Study Finds 1 in 10 Patients With Diabetes May Be Overtreated

Investigators found that 1 in 10 patients with diabetes initially hospitalized for treatment of common medical conditions was discharged with intensified diabetes medications, with nearly half unlikely to benefit due to limited life expectancy or already having an optimal blood glucose level.

Authors of a study published today in JAMA Network Open highlight that measurements of blood glucose levels in patients with diabetes, similar to blood pressure levels in patients with hypertension, are monitored frequently by inpatient clinicians during hospitalization.

While medication changes are often related to the condition that led to hospitalization, patients with chronic diseases such as diabetes or hypertension may be at a higher risk of having their medications altered even when hospitalized with unrelated common medical conditions. If the patients are discharged with these intensified treatments, medication confusion and adverse drug events may occur.

In prior research, intensifications of hypertension regimens were found to be common in hospitalized older adults and were driven by inpatient measurements. Researchers sought to examine whether this additionally applied to patients with diabetes, particularly older adults who account for more than 25% of diabetes cases and have higher risks of overtreatment. “Older adults are the most frequently hospitalized age group, and the balance of risks and benefits from strict blood glucose control may vary owing to limited life expectancy and elevated risks of hypoglycemia, polypharmacy, and adverse drug events,” said the study authors.

The study examined a retrospective national cohort of hospitalized older adults with diabetes not previously requiring insulin (n = 16,178; mean age = 73 years; 98% men), admitted to Veterans Health Administration (VHA) hospitals using VHA clinical and pharmacy data merged with VHA and Medicare claims data. Participants were assessed by how often their outpatient diabetes medications were intensified at hospital discharge, which medications were most commonly intensified, and whether life expectancy or prior outpatient diabetes control were associated with intensification decisions.

During preadmission, 8535 patients (53%) had a glycated hemoglobin (A1C) level less than 7.0% and 6199 (38%) had an A1C level between 7.0% and 8.9%. Conversely, 1044 (6%) had an A1C level greater than 9.0%, indicating severely uncontrolled diabetes, and 400 (2%) did not have their A1C measured. Nearly 70% of patients were taking 1 or more diabetes medications prior to hospitalization, and more than one-fourth of patients had an estimated life expectancy less than 5 years.

In the study findings, 10% of patients (n = 1626) were found to be discharged with intensified diabetes medications, including 781 (5%) with new insulins and 557 (3%) with intensified sulfonylureas. For those receiving these altered medications, 49% (n = 791) were classified as being unlikely to benefit owing to limited life expectancy or already being at goal A1C, whereas 20% (n = 329) were classified as having potential to benefit.

Among patients with a preadmission A1C level less than 7.0%, 37% experienced elevated inpatient blood glucose levels. Predicted probability of receiving an intensification was 4% (95% CI, 3%-4%) for patients without elevated inpatient blood glucose levels and 21% (95% CI, 15%-26%) for those with severely elevated inpatient blood glucose levels.

The study’s limitations, such as a lack of female representation in the VHA and its focus on an older patient cohort, may affect the generalizability of the findings. Researchers noted the necessity of a more value-based approach in practices, especially when treating patients with chronic diseases.

“Improving diabetes care for hospitalized older adults will require efforts to move beyond treating elevated inpatient numbers and toward patient-centered decision-making that considers long-term benefits and the risks of potentially unnecessary medication intensifications,” said the study authors.

Reference

Anderson TS, Lee S, Jing B, et al. Prevalence of diabetes medication intensifications in older adults discharged from US Veterans Health Administration hospitals [published online March 24, 2020]. JAMA Netw Open. doi: 10.1001/jamanetworkopen.2020.1511.