Survey reveals wariness about treatment deintensification in older patients
Primary care providers (PCPs) reported that they were more comfortable with tight glucose control in a older patient with type 2 diabetes, despite treatment-related risks, than they were with deintensification of treatment, according to a survey-based study.
Out of the 594 PCPs who worked at a Veterans Affairs (VA) facility, 42% said they'd be worried to initiate deintensification in case the patient's HbA1c elevated to 7.0% or higher, nearly half said they would not worry about potential harm from tight control, and one-quarter said they'd be afraid of malpractice litigation if they initiated deintensification of treatment, reported Tanner J. Caverly, MD, MPH, of the Veterans Affairs Center for Clinical Management Research in Ann Arbor, Mich., and colleagues in a research letter in JAMA Internal Medicine.
In 2014, Caverly's team solicited 1,222 nontrainee PCPs practicing in VA facilities across the U.S., including nurse practitioners (NPs) and physician assistants (PAs), about their prescribing practices and beliefs for patients with type 2 diabetes.
Of the 594 who returned usable surveys, 53% were women, 67% were MDs or DOs, 23% were NPs, and 7% were PAs.
Along with the survey, the researchers were presented with a clinical scenario of a patient. The man, age 77, had long-term type 2 diabetes and was a high-risk for hypoglycemia. He had a HbA1c of 6.5%, severe kidney disease, and was receiving 10 mg of glipizide (Glucotrol) twice a day.
The participants were asked 10 questions designed to identify barriers to and facilitators of medication deintensification by responding on a 4-point scale, from strongly agree to strongly disagree.
The PCPs were also asked to rate the level of difficulty they thought healthcare providers might have following the "Choosing Wisely" recommendation to "avoid using medications other than metformin to achieve HbA1c less than 7.5% in most adults."
When asked about tight glucose control (<7.0%) for the patients in the clinical scenario, 34% said they thought the patient would benefit from an HbA1c maintained below 7.0%, and 45% said they wouldn't worry about potential harms from tight control.
Also, 42% said they would worry that treatment deintensification would put the patient at risk for elevated glucose levels outside current performance measures, and 24% said they feared that deintensification would expose them to future malpractice claims.
"This approach to therapy was largely explained by the concern of making the patient's HbA1c level fall out of Department of Veterans Affairs performance measures, which, as the authors point out, have never targeted values less than 7.0%," commented Enrico Mossello, MD, PhD, of the University of Florence, in an accompanying editorial.
Out of 562 responders, 29% said they thought it would be difficult to follow the "Choosing Wisely" HbA1c recommendations for older adults. The PCPs who agreed it would be beneficial for the patient in the scenario to maintain an HbA1c level below 7.0%, and who also reported that they would worry about malpractice claims after initiating deintensification, were more likely to report difficulty following the HbA1c recommendations, compared to the other PCPs (P=0.02).
On the other hand, PCPs who reported concerns over harming the patient with tight glucose control were less likely to report difficulty following the "Choosing Wisely" recommendations (P=0.04).
"In type 2 diabetes mellitus, data from randomized clinical trials have shown uncertain or negative benefit-risk trade-offs associated with aggressive treatment of hypertension and hyperglycemia," Mossello pointed out. "According to the limited evidence available, a less-stringent HbA1c target level in the treatment of diabetes might be associated with a better prognosis in patients with [type 2 diabetes] with overt disability, older age, and more severe comorbidity, especially if they are receiving insulin."
The authors noted that "to overcome provider misperceptions about the benefits of stringent blood glucose control and concerns about negative repercussions following deintensification of therapy, safety initiatives should be national and span multiple practice settings."
Another group of researchers at the same institution looked at deintensification rates among a large population of seniors on medication to treat blood pressure and, in most cases, also type 2 diabetes, and published their results in the same issue of JAMA Internal Medicine. These researchers concluded that the VA health system had many missed opportunities for deintensificaiton of treatment, especially in patients with low or very low blood pressure and/or blood glucose levels.
Caverly disclosed support from the VA Advanced Fellowship Program in Health Services Research and Development (HSR&D). Two co-authors disclosed support from VA PACT Demonstration Laboratory, the VA Diabetes Quality Enhancement Research Initiative, and the HSR&D Career Development award at the VA Medical Center.
Caverly and most co-authors disclosed no relevant relationships with industry. One co-author disclosed relevant relationships with SeeChange Health and HealthMine.
This article was first published on MedPage Today and reprinted with permission from UBM Medica. Free registration is required.
Mossello disclosed no relevant relationships with industry.
Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner
last updated 10.28.2015
Primary Source JAMA Internal Medicine
Caverly TJ, et al "Appropriate prescribing for patients with diabetes at high risk for hypoglycemia: national survey of veterans affairs health care professionals" JAMA Intern Med 2015; DOI: 10.1001/jamainternmed.2015.5950.
Secondary Source: JAMA Internal Medicine