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Physicians must debunk potentially erroneous ideas about diabetes treatment plans for older adults
Contrary to management guidelines, older adults with type 2 diabetes may overemphasize additional health conditions and complications when participating in decisions to enhance or de-intensify therapy, according to findings published in JAMA Internal Medicine.
“The take-home message is that the guidelines about individualized blood sugar targets are not intuitive to patients, and better communication is needed, as is more research to better understand patients’ perspectives and preferences,” Nancy L. Schoenborn, MD, MHS, associate professor in the division of geriatric medicine and gerontology at Johns Hopkins University School of Medicine, told Endocrine Today. “To our knowledge, there have not been prior studies about how patients perceive guidelines on individualized blood sugar targets in older adults, that was the reason we conducted this study. Better understanding patient perspectives allows doctors to provide more patient-centered care.”
Schoenborn and colleagues assessed which factors patients believed were most important in making treatment decisions based on responses to surveys completed by 818 adults aged at least 65 years with type 2 diabetes (mean age, 74 years; 46.3% women) who were participants in KnowledgePanel, an online survey platform. Participants completed a survey that asked about either adding diabetes medications (n = 410) or reducing diabetes medications (n = 408) between Dec. 13, 2018, and Jan. 3, 2019, based on random assignment. All participants were asked to rank each factor based on its importance and identify factors that should lead to more aggressive treatment. Participant responses allowed the researchers to rank each factor on a scale of 0 to 100 based on a conditional logistic regression model.
Among those asked about good reasons to add diabetes medications, 62.8% identified a short duration of diabetes, 54.6% identified a low chance of adverse effects due to the new medication, 53.4% identified minimal effort required for taking the medication, 51.9% identified having a long life expectancy, 51.2% identified low cost, 48.8% identified having no significant diabetes complications and 45.6% identified having a limited number of additional health conditions. The surveys also revealed that each factor was deemed a good reason to add a medication by 23.3% of respondents, and no factors provided a good enough reason for 14% of the respondents.
Among those asked about good reasons to discontinue a diabetes medication, 37.7% said increased odds of an adverse effect, 18.4% said the presence of diabetes complications, 15.1% said the presence of additional health conditions, 14.8% said high cost, 9.6% said a shorter life expectancy, 9.4% said longer diabetes duration and 8.4% said excessive effort required to take the medication. The surveys also revealed that all factors were deemed good reasons to discontinue a medication by 0.5% of respondents, and none of the factors were deemed a good reason by 46.9% of the respondents.
When including all respondents, the chance for adverse effects, life expectancy and the presence of additional health conditions were the highest ranked while how much effort and cost a treatment required were the lowest ranked for deciding whether to add or discontinue a medication. More respondents thought aggressive treatment was necessary for someone with diabetes for at least 15 years (60.1%) vs. someone with diabetes for 5 years or fewer (39.9%), for someone with more severe complications (75.6%) vs. someone with no complications (24.4%) and for someone with additional health conditions (67.5%) vs. someone with no additional health conditions (32.5%), which the researchers said was contrary to current guidelines. Respondents were in agreement with guidelines when it came to considering life expectancy and adverse effects, according to the researchers, with 78.2% saying aggressive treatment was needed for patients at lower risk for adverse events and 72.7% saying aggressive treatment was needed for someone with a life expectancy of at least 15 years.
“Clinicians need to be aware of the potential discrepancy between patient perspective and guideline recommendation,” Schoenborn said. “It would be important for clinicians to proactively elicit the patients' views and preferences when deciding about how aggressively to treat diabetes and explain the rationale behind individualized blood sugar targets.” – by Phil Neuffer
For more information:
Nancy L. Schoenborn, MD, MHS, can be reached at nancyli@jhmi.edu.
Disclosures: Schoenborn reports she has received grants from the National Institute on Aging and American Cancer Society. Please see the study for all other authors’ relevant financial disclosures.
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Schoenborn NL, et al. JAMA Intern Med. 2019;doi:10.1001/jamainternmed.2019.3806.
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