Treatment Deintensification in Older Patients With Diabetes

Study Questions:

What is the rate of blood pressure (BP)-lowering and blood glucose–lowering medicine deintensification among older patients with type 1 or 2 diabetes mellitus who potentially receive overtreatment?

Methods:

This was a retrospective cohort study conducted using data from the US Veterans Health Administration. Participants included 211,667 patients >70 years with diabetes mellitus who were receiving active treatment (defined as BP-lowering medications other than angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers, or glucose-lowering medications other than metformin hydrochloride) from January 1 to December 31, 2012. Data analysis was performed December 10, 2013, to July 20, 2015. Participants were eligible for deintensification of treatment if they had low BP or a low hemoglobin A1c (HbA1c) level in their last measurement in 2012.The investigators defined very low BP as <120/65 mm Hg, moderately low as systolic BP of 120-129 mm Hg, or diastolic BP <65 mm Hg, very low HbA1c as <6.0%, and moderately low HbA1c as 6.0-6.4%. All other values were not considered low. The main outcomes measure was medication deintensification, defined as discontinuation or dosage decrease within 6 months after the index measurement.

Results:

The actively treated BP cohort included 211,667 participants, more than half of whom had moderately or very low BP levels. Of 104,486 patients with BP levels that were not low, treatment in 15.1% was deintensified. Of 25,955 patients with moderately low BP levels, treatment in 16.0% was deintensified. Among 81,226 patients with very low BP levels, 18.8% underwent BP medication deintensification. Of patients with very low BP levels whose treatment was not deintensified, only 0.2% had a follow-up BP measurement that was elevated (BP ≥140/90 mm Hg). The actively treated HbA1c cohort included 179,991 participants. Of 143,305 patients with HbA1c levels that were not low, treatment in 17.5% was deintensified. Of 23,769 patients with moderately low HbA1c levels, treatment in 20.9% was deintensified. Among 12,917 patients with very low HbA1c levels, 27.0% underwent medication deintensification. Of patients with very low HbA1c levels whose treatment was not deintensified, <0.8% had a follow-up HbA1c measurement that was elevated (≥7.5%).

Conclusions:

The authors concluded that among older patients whose treatment resulted in very low levels of HbA1c or BP, 27% or fewer underwent deintensification, representing a lost opportunity to reduce overtreatment.

Perspective:

This study reports that in a cohort of older patients with diabetes mellitus receiving treatment for BP and blood glucose–level control, a patient’s BP or HbA1c level had only a weak association with the likelihood of deintensification. While underuse of therapies has been well-studied, the harms of overuse have rarely been integrated into guidelines, quality measures, and pay-for-performance efforts. Future performance management systems need to consider how to create incentives against both overuse and underuse to motivate appropriate treatment, including deintensification of treatment that is focused on optimal, appropriate, and individualized care.

Clinical Topics: Geriatric Cardiology, Prevention

Keywords: Blood Glucose, Blood Pressure, Blood Pressure Determination, Diabetes Mellitus, Diabetes Mellitus, Type 2, Diabetes Mellitus, Type 1, Hemoglobin A, Glycosylated, Geriatrics, Hypotension, Primary Prevention, United States Department of Veterans Affairs


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