Patient-Centered Guidelines for Geriatric Diabetes Care: Potential Missed Opportunities to Avoid Harm

Ellen M. McCreedy, PhD; Robert L. Kane, MD; Sarah E. Gollust, PhD; Nathan D. Shippee, PhD; Kirby D. Clark, MD

Disclosures

J Am Board Fam Med. 2018;31(2):178-180. 

In This Article

Abstract and Introduction

Abstract

Background: Clinicians strive to deliver individualized, patient-centered care. However, these intentions are understudied. This research explores how patient characteristics associated with an high risk-to-benefit ratio with hypoglycemia medications affect decision making by primary care clinicians.

Methods: Using a vignette-based survey, we queried primary care clinicians on their intended management of geriatric patients with diabetes. The patients' ages, disease durations, and comorbidities were systematically varied. Clinicians indicated whether they would intensify glycemic control by adding a second-line hypoglycemia medication.

Results: A convenience sample of 336 primary care clinicians completed the survey. Despite the recommendations for HbA1c targets <8% for more complex patients, an 80-year-old woman with an HbA1c of 7.5%, longstanding diabetes, coronary disease, and cognitive impairment and with instrumental activity of daily living dependencies, had a predicted probability of treatment intensification of 35%. Internists were 11% and nurse practitioners were 14% more likely to intensify treatment than family physicians (P < .01). These provider differences remained significant after controlling for geographic differences in treatment intensification. Providers in Florida were more likely to intensify treatment (P < .01).

Conclusions: Primary care clinicians often chose to intensify glycemic control despite individual patient factors that warrant higher glycemic targets based on existing guidelines. This research identifies possible missed opportunities for patient-centered goal setting and raises questions about the influence of training and practice environment on clinical decision making.

Introduction

Older adults with diabetes are at greater risk for adverse consequences of the disease, notably hypoglycemia, with tight glycemic control.[1–3] This is particularly true for older adults with long-standing diabetes, coexisting cardiovascular disease, or cognitive impairment. This iatrogenic risk also increases with age. The rate of hospitalization for hypoglycemia in diabetic patients aged ≥75 years is twice that of those aged 65 to 74, and rates of hospitalization for hypoglycemia now exceed those for hyperglycemia among the Medicare population.[4]

To avoid this harm, the American Diabetes Association (ADA)[5,6] and the American Geriatric Society[7,8] recommend tailoring glycemic targets based on a patient's life expectancy, number and severity of comorbid chronic diseases, and cognitive and physical functioning. According to the ADA guidelines for older adults,[6] glycohemoglobin (HbA1c) targets <7.5% are appropriate for older adults with few comorbid conditions and intact cognitive and physical functioning (healthy); targets <8% are appropriate for older adults with comorbid chronic diseases, impaired instrumental activities of daily living (IADLs), or mild to moderate cognitive impairment (complex/intermediate); and targets <8.5% are appropriate for patients with end-stage illness receiving long-term care, with moderate to severe cognitive impairment, or with impaired activities of daily living (very complex/poor health). The American Geriatric Society endorses this 3-tiered approach to glycemic management with a lower bound of 7% for all older adults and an upper bound of 9% for those with poor health and limited life expectancy.[8]

Despite all the effort that has gone into creating these consensus statements, a paucity of the literature examines how clinicians respond to these recommendations in practice when tailoring treatment for individual patients with diabetes. In this study we focus on community-dwelling older adults with diabetes who fit into the healthy and intermediate categories of clinical complexity and, per existing guidelines, should have HbA1c targets <7.5% (healthy) or <8% (complex/intermediate). We presented common patient scenarios to primary care clinicians, who most often manage older adults with diabetes, in order to investigate the effect of certain patient characteristics on their decision making. We specifically measured whether clinicians would chose to intensify treatment (defined as adding a second agent) and how this intensification varied by patient characteristics. We hypothesized that clinicians would treat more aggressively younger patients without cognitive impairment or a history of heart disease.

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