Study Examines Factors Driving Diabetes Overtreatment

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.

Misconceptions and misplaced concerns held by a significant minority of care providers will likely exacerbate the challenge of addressing costly, potentially dangerous drug overutilization in certain high-risk populations of older diabetic patients, according to research published online Oct. 26 in JAMA Internal Medicine (doi: 10.1001/jamainternmed.2015.5950).

The study surveyed a randomized sample of 594 practicing non-trainee Department of Veterans Affairs primary care professionals (physicians, nurses, physician assistants).

Dr. Tanner J. Caverly of the University of Michigan, Ann Arbor, and colleagues identified provider resistance as a key hurdle to broader acceptance of hemoglobin A_1c recommendations from the American Geriatrics Society’s Choosing Wisely diabetes treatment guidelines. The guidelines, revised in 2015,^, reflect an emerging clinical consensus that it is safe to ease stringent blood glucose control for older type 2 diabetes patients with an HbA_1c level lower than 7.5%, renal disease, or dementia.

Subjects answered a series of questions regarding a hypothetical scenario (77-year-old man with long-standing type 2 diabetes at high risk for hypoglycemia, 6.5% HbA_1c, severe kidney disease, taking 10 mg of glipizide twice-daily) in which, according to the Choosing Wisely recommendation, racheting down the intensity of treatment is advised. Findings, however, indicated that 38.6% of respondents expressed the belief that continued strict blood glucose control would be beneficial to the theoretical patient, 44.9% did not associate strict control with any increased risk of danger or harm, 42.1% cited concerns that lessening treatment intensity would result in HbA_1c levels outside of those stipulated by current performance metrics, and 23.5% feared that easing back on treatment intensity would open them to future malpractice claims.

As a result of the above-mentioned and other factors, 28.7% of PCPs surveyed characterized the adherence to Choosing Wisely’s HbA_1c recommendation as “difficult” or “very difficult.” Researchers then assessed which provider concerns were associated with the greatest likelihood of noncompliance. Providers who linked tight glucose control with patient benefit (P = .009) and those who worried about the danger of increased malpractice claims (P = .02) were most likely to report having difficulties following the Choosing Wisely recommendations.

The investigators suggested a number of possible measures that could “improve prescribing practices and prevent many adverse events in older patients with diabetes,” including national multidisciplinary safety initiatives (such as the Million Hearts Campaign), establishment of national guidelines, and creation of performance measures which incentivize adoption of less intense treatment where appropriate.