MedicalResearch.com Interview with:
Matthew L. Maciejewski, PhD
Professor in Medicine
Division of General Internal Medicine, Department of Medicine
Center for Health Services Research Primary Care
Durham VA Medical Center
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: Treating diabetes requires balancing the risks of long-term harm from under-treatment with the short-term and long-term harm from potential over-treatment. Randomized trials have shown that the benefits of aggressive glycemic control only begin after at least 8 years of treatment. Yet, the harms of aggressive glycemic control – hypoglycemia, cardiovascular events, cognitive impairment, fractures, and death – can happen at any time.
In some older people, “deintensification” of diabetes treatment may be the safer route, because of the risks that come with too-low blood sugar. The American Geriatrics Society (AGS) specifically states that medications other than metformin should be avoided when an older patient’s hemoglobin A1c is less than 7.5%, because the risks of hypoglycemia are larger and the potential benefits of treatment are smaller for older adults with diabetes. Most attention in prior work has focused on undertreatment of diabetes and there has been only limited investigation of patient characteristics associated with overtreatment of diabetes or severe hypoglycemia.
Since the elderly are therefore at greatest risk of overtreatment and Medicare is the primary source of care of the elderly, we examined rates of overtreatment and deintensification of therapy for Medicare beneficiaries, and whether there were any disparities in these rates. We found that almost 11 percent of Medicare participants with diabetes had very low blood sugar levels that suggested they were being over-treated. But only 14 percent of these patients had a reduction in blood sugar medication refills in the next six months.
MedicalResearch.com: What should readers take away from your report?
Response: The medical community’s focus on undertreatment has resulted in dramatic improvements in glycemic control, on average, but has apparently also encouraged overtreatment. Effective treatment of diabetes requires a major shift in approach towards greater personalization of treatments based on potential for individual risk and benefit. Our study points the way for how to identify patients who may benefit not only from more intensive treatment, but also those who may need deintensification.
MedicalResearch.com: What recommendations do you have for future research as a result of this study?
Response: It will be critical to examine how over-treatment and deintensification have changed since 2011 on which these results are based. We also need to find ways to help providers and patients make sure that diabetes care is effective, but safe.
MedicalResearch.com: Thank you for your contribution to the MedicalResearch.com community.
Matthew L. Maciejewski, Xiaojuan Mi, Jeremy Sussman, Melissa Greiner, Lesley H. Curtis, Judy Ng, Samuel C. Haffer, Eve A. Kerr. Overtreatment and Deintensification of Diabetic Therapy among Medicare Beneficiaries. Journal of General Internal Medicine, 2017; DOI: 1007/s11606-017-4167-y
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