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‘Missed opportunity’ to provide ADA compliant care

Internists and nurse practitioners were more likely than family physicians to intensify glycemic treatment in older patients in a way that was inconsistent with American Diabetes Association guidelines, according to findings recently published in the Journal of the American Board of Family Medicine.

The ADA guidelines for older adults recommend HbA1c targets of 7.5% or less for older adults with several comorbid conditions and intact cognitive and physical functioning. The target is 8% or less in those older adults with impaired ability to complete activities of daily living, mild to moderate cognitive impairment or comorbid chronic diseases.

“We know very little about how these standards affect the decision-making of primary care clinicians who provide most of the diabetes management for older adults,” Ellen McCreedy, PhD, of the Center for Gerontology and Healthcare Research at Brown University told Healio Family Medicine.

Researchers developed patient vignettes based on random selection of the following characteristics: age, HbA1c level of either 7.5% or 8.5%, presence of cognitive impairment with instrumental activities of daily living dependencies, history of coronary artery disease with previous coronary artery bypass graft and disease duration.

All the vignettes portrayed a theoretical patient with the same ability to pay for medications, kidney function, sex and weight. The patient had neither activity of daily living dependencies nor comorbid depression but did have mild neuropathic symptoms and hypertension. By using two different HbA1c levels, 16 different patient vignettes were developed. Each medical professional in the study viewed four randomly chosen vignettes. Therefore, every clinician did not receive the same survey, according to researchers.

McCreedy and colleagues analyzed responses from 336 medical professionals (73 internal medicine physicians, 108 family medicine physicians, and 155 nurse practitioners) They found that a vignette involving an 80-year-old woman with cognitive impairment, coronary disease, an HbA1c of 7.5%, longstanding diabetes and with instrumental activity of daily living dependencies had her treatment intensified 35% of the time.

“This 35% represents potential over-treatment, or a missed opportunity to provide guideline compliant care,” McCreedy said. “Our research [also] raises questions about the influence of training and practice environment on clinical decision making.”

Researchers also found internists were 11% and nurse practitioners were 14% more likely to intensify treatment than family physicians (P < .01).

McCreedy also explained the relevance of the findings and also offered suggestions on ways to improve patient care.

“The benefits of tight glycemic control on long-term vascular outcomes likely take 8 to 10 years to be realized [in Medicare patients]. This is a population for which we need to think carefully about the risks and benefits associated with aggressive treatment,” she said.

“Physicians can use the ADA Standards of Medical Care in Diabetes as a starting point. When you are treating an older adult with multiple chronic conditions and cognitive decline, explain to the patient and the caregiver why a higher A1c target is recommended. This should include a discussion of the potential harms associated with tight control,” McCreedy said. – by Janel Miller

Disclosure: The authors report no relevant financial disclosures.