MedicalResearch: What are the main findings of the study?
Dr. Vijan: The main finding was that the burdens and side effects of intensive glycemic treatment significantly detract from the overall benefit of lower risks of diabetes complications, often to the point where the treatments cause more loss than gain in quality of life. It takes many (often 15-20) years to gain benefit from treatment, but the burdens begin right away and continue throughout treatment. By the time you might experience treatment benefit in terms of reduced complication risk, you’ve had a lot of years to have the downsides of treatment – which commonly include significant weight gain, low blood sugars, gastrointestinal symptoms, not to mention having to take multiple pills or injections on a daily basis.
MedicalResearch: Were any of the findings unexpected?
Dr. Vijan: The most surprising and significant finding was the degree to which this was true. In fact, the single most important factor in determining whether a patient should take a treatment was their view of the burden of the treatment.
MedicalResearch: What should clinicians and patients take away from your report?
Dr. Vijan: Providers should sit down with patients and ensure that both the patient and provider understand the likelihood that the patient will have any benefit from treatment, but more importantly that providers understand how patients feel about the burdens of the various treatment options – in other words, take a patient-centered approach to deciding on treatment. Far too often, the pattern is for the provider to dictate treatment goals from a set standard from a guideline (e.g., an A1c goal < 7%) and simply prescribe a drug without involving patients in the decision-making process. The findings do have very important implications for broader health policy as well. Since our research shows that patient views of treatment burden are the single most important factor in determining whether a treatment is likely to be beneficial or harmful, guidelines need to advocate a far more patient-centered approach to diabetes management, and there should be no universal treatment targets. Further, many organizations are actually profiled or graded on the proportion of patients they have under a specific A1c level. Our research strongly suggests that such approaches are misguided, since many patients will be encouraged to adopt treatments that cause more harm than benefit.
MedicalResearch: What recommendations do you have for future research as a result of this study?
Dr. Vijan: Ultimately we would like to try and design tools that help providers and patients make better, personalized decisions about diabetes treatment goals and management options. Understanding the best way to foster communication between patients and providers, particularly around the area of how to assess patient views of treatment burden and benefit is essential if we are to help people make the right decisions about their treatment goals. Finally, we would like to develop better ways to measure quality of care that take into account the fact that these types of discussion are happening, rather than setting specific performance targets that provide incentives that may cause unwanted treatment.
Vijan S, Sussman JB, Yudkin JS, Hayward RA. Effect of Patients’ Risks and Preferences on Health Gains With Plasma Glucose Level Lowering in Type 2 Diabetes Mellitus. JAMA Intern Med. Published online June 30, 2014. doi:10.1001/jamainternmed.2014.2894.