Medicare Patients With Diabetes at Risk of Overtreatment

Kristin Jenkins

October 02, 2017

More Medicare recipients are overtreated than undertreated for diabetes, yet rarely have their regimens been scaled back or deintensified, leaving them at increased risk of potentially life-threatening complications, say researchers.

Analysis of claims data and prescription refills from 78,792 Medicare recipients with diabetes in 10 states shows that 8560 (10.9%) were potentially overtreated compared with 6.9% who were potentially undertreated, according to Matthew L Maciejewski, PhD, of Duke University and Durham Veterans Affairs Medical Center, NC, and colleagues, reporting in the Journal of General Internal Medicine.

Only 14% of those who were overtreated were taken off previously recommended treatments, the study authors say.

Major trials have shown that in older patients and in those with comorbidities, aggressive diabetes control carries substantial risks.

Severe hypoglycemia, cardiovascular events, cognitive impairment, fractures, and death associated with overtreatment of diabetes "can happen at any time," note Dr Maciejewski and colleagues. "Optimizing glucose control is clinically difficult, but it is a public-health imperative."

Over-75s Most Likely to Be Overtreated

To compare the rates and patient characteristics associated with overtreatment and undertreatment of diabetes in the same cohort of patients, the researchers examined records for Medicare patients with at least one HbA1c lab result available between January 1, 2011, and June 30, 2011.

Patients with an HbA1c of < 6.5% at a single point in 2011, with fills for any diabetes medications beyond metformin, were considered potentially overtreated; those with HbA1c > 9% were considered undertreated.

Overtreatment of diabetes was more common among Medicaid recipients older than 75 years of age (12%). It was also more common in those who qualified for both Medicare and Medicaid because of low incomes or serious disability (13.4%) and ranged from 11% for non-Hispanic blacks to 9.6% for those of "other" race/ethnicity.

Overtreatment was less likely and rates of deintensification were highest for Hispanic beneficiaries as well as for Medicare beneficiaries with six or more chronic conditions, those with more outpatient visits, those living in urban areas, and in 15% of those aged 65 to 70 years of age.

"Deintensification of diabetic therapy is often clinically appropriate for older adults, because the benefit of aggressive diabetes treatment declines with age, while the risks increase," the study authors note.

"It is troubling that the oldest Medicare beneficiaries were more likely to be overtreated and less likely to have their medication regimens deintensified, because these older adults are least likely to benefit from tight glycemic control and most likely to be harmed."

Individualize Treatment to Maximize Care While Avoiding Unnecessary Harm

Effective treatment of diabetes requires a major shift toward individualized treatment, and this study will help identify those who may benefit from more intensive treatment as well as those who may need less, they explain.

"By focusing at both the overtreatment and undertreatment ends of the diabetes quality spectrum, we can best begin to truly improve the quality of diabetes care, ensuring that patients get needed care while avoiding unnecessary potential harm."

Although this is the first study to examine overtreatment and deintensification in a Medicare population, the investigators acknowledge that clinical practice may have changed since 2011.

Several major studies as well as new clinical guidelines for diabetes management have followed with recommendations for relaxed glycemic-control targets in older adults with multiple chronic conditions, limited life expectancy, diabetic complications, or functional impairment.

For instance, the "Choosing Wisely" campaign has set out to reduce overtreatment by asking clinicians to focus on the risks and benefits of evidence-based tests and procedures.

And in 2013, the American Geriatrics Society (AGS) updated its guidelines for improving the care of older adults with diabetes, recommending that medications other than metformin be avoided in the older patient with an HbA1c of <7.5% (J Am Geriatr Soc. 2013;61:2020-2026).

"Current rates of overtreatment may be somewhat lower than what we report here," Dr Maciejewski and colleagues admit.

"Future studies should examine whether rates of overtreatment and deintensification of diabetes regimens have changed over the past 6 years and whether the disparities observed here have narrowed," they suggest.

More work is also needed to determine whether distinct subgroups of patients with both Medicaid and Medicare might benefit from specific approaches to diabetes management, they say.

Changing Prescribing Habits May Not Be Easy

In an interview, coauthor Jeremy Sussman, MD, MS, of Ann Arbor Veterans Affairs Medical Center and the University of Michigan Medical School, said that more attention to overtreatment is warranted but changing diabetes-care practices may be difficult.

"The first issue is simple awareness, he said, noting that clinical guidelines and performance measures for diabetes permit or encourage less aggressive care for older patients "because it's safer."

In 2008, the ACCORD trial showed that aggressive management of diabetes in elderly patients can be risky but "influenced care less than we'd hoped," Dr Sussman told Medscape Medical News.

Standards of medical care in diabetes issued by the American Diabetes Association have also stipulated less intensive treatment for patients at high risk of hypoglycemia, including those with a history of hypoglycemia, those with a lower life expectancy, and those with multiple comorbidities.

"This [current] study and others show that current clinical care does not have that nuance," Dr Sussman said. "Those factors had almost no influence on rates of overtreatment."

Results from a previous study by Dr Sussman and colleagues showed that only one in four of almost 400,000 older patients with diabetes had their prescriptions changed when deintensification was indicated.

Study limitations include the fact that glycemic control was based on a single cross-sectional measurement in 2011 and the fact that the investigators weren't able to examine whether potential overtreatment or lack of deintensification was associated with adverse outcomes. They also couldn't determine the reasons that patients were overtreated.

Funding for this study was provided by the Centers for Medicare & Medicaid Services and by the Department of Veterans Affairs. Dr Maciejewski reports a relationship with Amgen; Dr Sussman reports no potential conflicts of interest. Disclosures for the coauthors are listed inthe paper.

J Gen Intern Med . Published online on September 13, 2017. Article

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