First, the grain of salt. The American Geriatrics Society began recommending less aggressive treatment for diabetes in 2013. So, according to a study in the Journal of General Internal Medicine, the overtreatment researchers uncovered during the study period (January 2011 to June 2011) might have been corrected, at least somewhat.
That said, the study states that Medicare recipients are more frequently overtreated for diabetes than undertreated. Looking at CMS data from 10 states, researchers examined 78,792 patients with diabetes, finding that 10.9% (8,560 patients) were potentially overtreated, while 6.9% (5,487 patients) were undertreated.
But that “may in part reflect the fact that clinicians had not adopted to recent clinical guidelines for diabetes management….” Those guidelines include a relaxation of glycemic control targets for older adults with multiple chronic conditions, limited life expectancy or functional impairment.
Patients were identified as being potentially overtreated for diabetes if they had an HbA1c of less than 6.5% and had filled any diabetes medications other than for metaformin from 120 days before to 180 days after the index date. Researchers looked for generic drug names for these classes of medications: insulin, biguanides, sulfonylureas, thiazolidinediones, meglitinides, GLP-1 agonists, amylin analogs, DPP-4 inhibitors, and alpha-glycosidase inhibitors.
The benefits of aggressive glycemic control begin to be seen about eight years after start of treatment. The harms of that treatment, on the other hand, can happen at any time. Those include hypoglycemia, cognitive impairment, cardiovascular events, fractures, and death.
Those who were overtreated rarely had their regimens deintensified, the study states. Deintensification of treatment was less common for those over age 75. It was more common for those with six or more chronic conditions, more outpatient visits, or for those living in urban areas.
“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,” the study states. “It is encouraging that those with multiple chronic conditions were more likely to receive deintensification, because they often have complex medication regimens, and prior studies have shown that risk for hypoglycemia increases with age, comorbidity burden, and polypharmacy.”
Researchers examined fee-for-service claims data in New York, New Jersey, Maryland, Delaware, Virginia, North Carolina, South Carolina, Georgia, Florida, and Alabama.