Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries
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.
We examined rates of overtreatment and deintensification of therapy for older adults with diabetes, and whether these rates differed by medical, demographic, and socioeconomic characteristics.
Design, Subjects, and Main Measures
We analyzed Medicare claims data from 10 states, linked to outpatient laboratory values to identify patients potentially overtreated for diabetes (HbA1c < 6.5% with fills for any diabetes medications beyond metformin, 1/1/2011–6/30/2011). We examined characteristics associated with deintensification for potentially overtreated diabetic patients. We used multinomial logistic regression to examine whether patient characteristics associated with overtreatment of diabetes differed from those associated with undertreatment (i.e. HbA1c > 9.0%).
Of 78,792 Medicare recipients with diabetes, 8560 (10.9%) were potentially overtreated. Overtreatment of diabetes was more common among those who were over 75 years of age and enrolled in Medicaid (p < 0.001), and was less common among Hispanics (p = 0.009). Therapy was deintensified for 14% of overtreated diabetics. Appropriate deintensification of diabetic therapy was more common for patients with six or more chronic conditions, more outpatient visits, or living in urban areas; deintensification was less common for those over age 75. Only 6.9% of Medicare recipients with diabetes were potentially undertreated. Variables associated with overtreatment of diabetes differed from those associated with undertreatment.
Medicare recipients are more frequently overtreated than undertreated for diabetes. Medicare recipients who are overtreated for diabetes rarely have their regimens deintensified.
KEY WORDSMedicare beneficiary diabetes potential overtreatment deintensification
We thank the editor and two reviewers for helpful comments. The research in this article was supported by the Centers for Medicare & Medicaid Services under contract number HHSM-500-2014-00442G with the National Committee for Quality Assurance. This work was also supported by the Office of Research and Development, Health Services Research and Development Service, Department of Veterans Affairs, and Dr. Maciejewski was also supported by a Research Career Scientist award from the Department of Veterans Affairs (RCS 10-391). The National Committee for Quality Assurance and the Centers for Medicare & Medicaid Services provided feedback on interpretation of the data when the manuscript was reviewed and approved, but had no role in the design, conduct, collection, management, or analysis of the data. This work was presented at the 2017 AcademyHealth Annual Research Meeting. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, Duke University, the National Committee for Quality Assurance, the Centers for Medicare & Medicaid Services, or the US Department of Health and Human Services. We acknowledge helpful review by Sarah Scholle, Michael Barr, and Mary Barton at the National Committee for Quality Assurance.
Compliance with Ethical Standards
Conflict of Interest
Dr. Maciejewski has received institutional grants from the VA HSR&D, the Agency for Healthcare Research and Quality, the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Cancer Institute, and an institutional contract from the Centers for Medicare & Medicaid Services; and reports ownership of Amgen stock due to his spouse’s employment. Dr. Maciejewski received honoraria for speaking at a workshop held at the University of Alabama-Birmingham. Dr. Sussman has received research support from VA HSR&D in the form of a career development award. Dr. Curtis has received research support from the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, Boston Scientific, Bristol-Myers Squibb, GE Healthcare, GlaxoSmithKline, Johnson & Johnson, Medtronic, Merck, and Novartis. Dr. Kerr has received research support from VA HSR&D to examine deintensification of medical services. All other authors declare that they have no conflict of interest.
- 2.Canada Choosing Wisely website. http://www.choosingwiselycanada.org. Accessed 5 March 2017.
- 3.UK Choosing Wisely website. http://www.choosingwisely.co.uk/. Accessed 5 March 2017.
- 6.American Geriatrics Society Expert Panel on Care of Older Adults with Diabetes Mellitus, Moreno G, Mangione CM, Kimbro L, Vaisberg E. Guidelines abstracted from the American Geriatrics Society Guidelines for Improving the Care of Older Adults with Diabetes Mellitus: 2013 update. J Am Geriatr Soc 2013;61(11):2020-2026.CrossRefGoogle Scholar
- 7.National Institute for Health and Care Excellence (NICE). Type 2 diabetes in adults: management. https://www.nice.org.uk/guidance/ng28/chapter/1-Recommendations. Accessed 1 December 2018.
- 8.Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131):854–865.Google Scholar
- 9.Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352(9131):837–853.Google Scholar
- 21.McCoy RG, Lipska KJ, Yao X, Ross JS, Montori VM, Shah ND. Intensive Treatment and Severe Hypoglycemia Among Adults With Type 2 Diabetes. JAMA Intern Med 2016;176(7):969-978.Google Scholar
- 33.National Committee for Quality Assurance. HEDIS 1999, Volume 2: Technical Specifications for Health Plans. Washington DC: National Committee for Quality Assurance; 1999.Google Scholar
- 35.US Department of Agriculture ERS. Rural urban commuting area codes. https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/. Accessed 31 March 2011.
- 36.Center WWAMI Rural Health Research Center. RUCA data: using RUCA data. http://depts.washington.edu/uwruca/ruca-data.php. Accessed 31 March 2011.