November 4, 2015
De-Intensification of Diabetes, BP Treatment Underused in Older Patients

Ann Arbor, MI—Too many older patients with very low hemoglobin A1c (HbA1c) or blood pressure levels continue to be over-treated, according to a new article decrying the missed opportunity to de-intensify treatment.

The article published online recently by JAMA Internal Medicine found that only 27% or fewer of older patients treated at the Veterans Health Administration (VHA) had their medications reduced, despite very low HbA1c or blood pressure levels.

Background information in the report notes that new guidelines and the Choosing Wisely campaign recommend less aggressive treatment for older patients and those with limited life expectancy, such as a target HbA1c level of 7.5% or 8%, while another report recommends older patients seek to achieve a systolic blood pressure (SBP) of 150 mm Hg and no longer try to reach a level below 140 mm Hg.

The researchers, led by Jeremy B. Sussman, MD, MS, of the Veterans Affairs Center for Clinical Management Research in Ann Arbor, note that little research has been done on the process of medication de-intensification, including how often it happens and for whom.

The VHA study looked at data from 2012 and included 211,667 patients older than age 70 years receiving blood pressure–lowering medications other than angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or glucose-lowering medications other than metformin hydrochloride.

More than half of the 211,667 participants actively treated for blood pressure had moderately low SBP of 120 to 129 mm Hg or diastolic blood pressure [DBP] less than 65 mm Hg, or very low BP levels, less than 120 mm Hg or DBP less than 65 mm Hg. Treatment was de-intensified in 16% of the 25,955 patients with moderately low blood pressure levels and in 18.8% of the 81,226 patients with very low blood pressure levels.

For the 179,991 patients in the actively treated HbA1c group, medication was reduced in 20.9% of the 23,769 patients with moderately low HbA1c—6.0% to 6.4%—levels and in 27% of the 12,917 patients with very low HbA1c—less than 6.0%.

Results indicate that, of patients with very low BP levels whose treatment was not de-intensified, only 0.2% had a follow-up BP measurement that was elevated. Of patients with very low HbA1c levels whose treatment was not de-intensified, meanwhile, fewer than 0.8% had a follow-up HbA1c measurement that was 7.5% or greater.

“Future performance management systems should consider how to create incentives against both overuse and underuse to motivate appropriate treatment, including de-intensification of treatment that is personalized to individual needs, risks and benefits,” according to the researchers. “In addition, healthcare professionals should assess the harms of intensive therapy just as they do the benefits. These changes may require new clinical decision support tools, new performance measures and, most important, a new perspective focusing on personalized, appropriate care.”

A research letter published online concurrently reports that a survey of Veterans Affairs primary care providers indicate that almost half of the clinicians said they would they would not be concerned about the harms of tight glycemic control for a hypothetical 77-year-old man with diabetes at risk for hypoglycemia. In fact, nearly a quarter of the respondents said they were more worried that de-intensifying medication for the man in the hypothetical situation could leave them vulnerable to future malpractice claims.

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