Among Older Veterans with Diabetes, Few with Low Glucose or Blood Pressure Levels Undergo Treatment De-intensification
Clinical practice guidelines and quality of care initiatives for hemoglobin A1c and blood pressure (BP) control have long focused on intensifying therapy to achieve target risk factor levels, such as reducing A1c levels to under 7% or BP levels to under 140/90 mmHg. However, over the last decade research has shown that overly-intensive control can be harmful, and that the same clinical practice guidelines and quality of care measures that prevent under-treatment can lead to over-treatment. This study sought to describe the frequency and predictors of treatment de-intensification among potentially over-treated older Veterans with diabetes. Using VA data, investigators identified Veterans ages 70 or older who received BP- or glucose-lowering medications in the VA healthcare system during 2012 (n=211,667). Veterans were considered to have been de-intensified if they did not refill a previously prescribed BP- or A1c-lowering medication for 180 days after the index measurement, or if their next medication refill after the index measurement was at a lower dose. Patients' life expectancy was estimated based on their age and comorbidities.
- Among older Veterans with diabetes who were treated for BP or blood glucose control, Veterans' BP or A1c levels had only a weak relationship to the likelihood of de-intensification.
- Of the 104,486 Veterans with BP that was not low (130/65 mmHg or greater), 15% had a BP medication de-intensified; of the 25,955 Veterans with moderately low BP (120-129 mmHg systolic BP), 16% were de-intensified; and among the 81,226 Veterans with very low BP (systolic BP less than 120), 19% were de-intensified.
- Of the 143,305 Veterans whose A1c was not low (6.5% or greater), 18% had a diabetes medication de-intensified; of the 23,769 with moderately low A1c (6.0% to 6.4%), 21% were de-intensified; and of the 12,917 with very low A1c (less than 6.0%), 27% were de-intensified.
- There was a modest association between a patient's estimated life expectancy and de-intensification rates, but there was no consistent interaction between a patient's life expectancy, de-intensification rates, and BP or A1c levels.
- Although data are from just before VA efforts to reduce over-treatment began, among older Veterans with very low A1c and BP levels, 27% or fewer received medication de-intensification, representing a lost opportunity to reduce over-treatment. Authors suggest that practice guidelines and performance measures should focus more on reducing over-treatment through de-intensification. VA HSR&D's Quality Enhancement Research Initiative (QUERI) is also examining this issue in its newly funded program, "Improving Safety and Quality through Evidence-Based De-Implementation of Ineffective Diagnostics and Therapeutics."
- Pharmacy records underestimate medication intensity for Veterans who get medication outside VA; therefore some patients may have been missed who were eligible for de-intensification or who were de-intensified via pharmacies outside VA.
- Some Veterans with transiently low A1c or BP levels may not require de-intensification.
Sussman J, Kerr E, Saini S, et al. Rates of De-intensification of Blood Pressure and Glycemic Medication Treatment Based on Levels of Control and Life Expectancy in Older Patients with Diabetes Mellitus. JAMA Internal Medicine. December 1, 2015;175(12):1942-49.