Abstract
Objective
Our aim in this study was to assess potential overtreatment and overtesting among
older adults with type 2 diabetes across Canada.
Methods
An observational, population-based cohort study was conducted using data available
through the Canadian Primary Care Sentinel Surveillance Network. All patients included
in the study were seen by a primary care provider between 2010 and 2017, ≥65 years
with type 2 diabetes and had at least one glycated hemoglobin (A1C) measurement. Potential
overtreatment was defined as an index A1C of <7% and being prescribed antidiabetes
medications other than metformin within 1 year of the index A1C. Testing ≥3 times/year
in patients with A1C <7% was considered potential overtesting. Analyses were performed/compared
within 2 cross-sectional cohorts (2012 and 2016). A subcohort analysis was performed
on those with advanced age and dementia.
Results
An overall cohort of 41,032 patients (mean age, 76.6 years) was identified. Proportions
of potential overtreatment were 7.0% (2012) and 6.9% (2016) (difference in rate in
%: 0.1; 95% confidence interval [CI], −0.32 to 0.52]). Overall, 19.2% (2012) and 19.0%
(2016) of patients were potentially overtested (difference in rate in %: 0.2; 95% CI, −0.45
to 0.85), whereas 2.4% (2012) and 2.3% (2016) were potentially undertested (difference
in rate in %: 0.1; 95% CI, −0.15 to 0.35). Among patients with dementia and advanced
age, proportions of patients potentially overtreated were 14.5% and 12.1%, and those
overtested were 29.2% and 25.0% in 2012 and 2016, respectively.
Conclusions
Potential overtreatment and overtesting exists among older adults with diabetes in
Canadian primary care practices with minimal change over time. Higher proportions
of potentially unnecessary care were observed in those with advanced age and dementia.
Our study highlights an opportunity for primary care clinicians to improve testing
and treatment practices considering the individual patient, context and potential
for net benefit.
Résumé
Objectifs
Dans la présente étude, notre objectif était d’évaluer le surtraitement et la surévaluation
potentiels chez les personnes âgées atteintes du diabète de type 2 du Canada.
Méthodes
Nous avons réalisé une étude observationnelle en population générale à partir des
données disponibles dans le Réseau canadien de surveillance sentinelle de soins primaires.
Tous les patients de l’étude ont rencontré un prestataire de soins primaires entre
2010 et 2017, étaient des diabétiques de type 2 de ≥ 65 ans et avaient au moins une
mesure de l’hémoglobine glyquée (A1c). On a défini que le surtraitement potentiel
était le fait d’avoir une A1c de référence de < 7 % et de recevoir des ordonnances
de médicaments contre le diabète autres que la metformine dans l’année de l’A1c de
référence. Nous avons considéré les patients qui avaient une A1C < 7 % et qui étaient
évalués ≥3 fois/année comme étant en situation de surévaluation potentielle. Les analyses
ont été réalisées/comparées entre 2 cohortes transversales (2012 et 2016). Nous avons
réalisé une analyse auprès d’une sous-cohorte de patients qui avaient un âge avancé
et une démence.
Résultats
Nous avons recensé une cohorte globale de 41 032 patients (âge moyen, 76,6 ans). Les
pourcentages de surtraitement potentiel étaient de 7,0 % (2012) et de 6,9 % (2016)
(0,1; intervalle de confiance [IC] à 95 %, de −0,32 à 0,52]). Dans l’ensemble, 19,2
% (2012) et 19,0 % (2016) des patients étaient potentiellement en situation de surévaluation
(0,2; IC à 95 %, de −0,45 à 0,85), tandis que 2,4 % (2012) et 2,3 % (2016) étaient
potentiellement en situation de sous-évaluation (0,1; IC à 95 %, de −0,15 à 0,35).
Chez les patients qui avaient une démence et un âge avancé, les pourcentages de patients
potentiellement en situation de surtraitement étaient de 14,5 % et de 12,1 %, et ceux
qui étaient en situation de surévaluation étaient de 29,2 % et de 25,0 % en 2012 et
2016, et ce respectivement.
Conclusions
Dans la pratique canadienne en soins primaires, les personnes âgées diabétiques sont
en situation de surtraitement et de surévaluation potentiels. De plus, peu de changements
ont été observés dans le temps. Les pourcentages plus élevés de soins potentiellement
non nécessaires étaient observés chez ceux qui avaient un âge avancé et une démence.
Notre étude présente la possibilité aux cliniciens en soins primaires d’améliorer
les pratiques d’évaluation et de traitement qui considèrent le patient individuellement,
le contexte et le potentiel d’un avantage net.
Keywords
Mots clés
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References
- IDF Diabetes Atlas, 7th ed. 2015.
- Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): Prospective observational study.BMJ. 2000; 321: 405-412
- Glucose control and vascular complications in veterans with type 2 diabetes.N Engl J Med. 2009; 360: 129-139
- The Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes.N Engl J Med. 2008; 358: 2545-2559
- Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes.N Engl J Med. 2008; 358: 2560-2572
- The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.N Engl J Med. 1993; 329: 977-986
- Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).Lancet. 1998; 352: 837-853
- Follow-up of glycemic control and cardiovascular outcomes in type 2 diabetes.N Engl J Med. 2015; 372: 2197-2206
- The effect of comorbid illness and functional status on the expected benefits of intensive glucose control in older patients with type 2 diabetes.Ann Intern Med. 2008; 149: 11-19
- Assessing potential glycemic overtreatment in persons at hypoglycemic risk.JAMA Intern Med. 2014; 174: 259-268
- Potential overtreatment of diabetes mellitus in older adults with tight glycemic control.JAMA Intern Med. 2015; 175: 356-362
- Tight glycemic control and use of hypoglycemic medications in older veterans with type 2 diabetes and comorbid dementia.Diabetes Care. 2015; 38: 588-595
- Public health implications of recommendations to individualize glycemic targets in adults with diabetes.Diabetes Care. 2013; 36: 84-89
- Intensive treatment and severe hypoglycemia among adults with type 2 diabetes.JAMA Intern Med. 2016; 176: 969-978
- Patient age, ethnicity, medical history, and risk factor profile, but not drug insurance coverage, predict successful attainment of glycemic targets: Time 2 Do More Quality Enhancement Research Initiative (T2DM QUERI).Diabetes Care. 2010; 33: 2558-2560
- Rates of deintensification of blood pressure and glycemic medication treatment based on levels of control and life expectancy in older patients with diabetes mellitus.JAMA Intern Med. 2015; 175: 1942-1949
- Is there evidence of potential overtreatment of glycaemia in elderly people with type 2 diabetes? Data from the GUIDANCE study.Acta Diabetol. 2017; 54: 209-214
- Potential glycemic overtreatment in patients >/=75 years with type 2 diabetes mellitus and renal disease: Experience from the observational OREDIA study.Diabetes Metab Syndr Obes. 2015; 8: 303-313
- The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988–2010.Diabetes Care. 2013; 36: 2271-2279
- Older adults: Standards of medical care in diabetes.Diabetes Care. 2019; 42: S139-S147
- Hemoglobin A1c targets for glycemic control with pharmacologic therapy for nonpregnant adults with type 2 diabetes mellitus: A guidance statement update from the American College of Physicians.Ann Intern Med. 2018; 168: 569-576
- Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.Can J Diabetes. 2018; 42: S1-S325
- European Association for the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: A patient-centered approach: Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).Diabetes Care. 2012; 35: 1364-1379
- Management of Diabetes Mellitus Update Working Group. VA/DoD Clinical Practice Guideline: Management of Diabetes Mellitus. Version 4.0. 2010.http://www.healthquality.va.gov/guidelines/cd/diabetes/dm2010_sum-v4.pdfDate: 2010Date accessed: June 4, 2021
- California Healthcare Foundation/American Geriatrics Society Panel on Improving Care for Elders with Diabetes. Guidelines for improving the care of the older person with diabetes mellitus.J Am Geriatr Soc. 2003; 51: S265-S280
- Choosing Wisely initiative: American Geriatrics Society ten things clinicians and patients should question. 2019.http://www.choosingwisely.org/societies/american-geriatrics-societyDate: 2019Date accessed: July 30, 2020
- http://www.choosingwiselycanada.orgDate accessed: June 23, 2021
- Inappropriate requesting of glycated hemoglobin (Hb A1c) is widespread: Assessment of prevalence, impact of national guidance, and practice-to-practice variability.Clin Chem. 2012; 58: 906-915
- Temporal trends of hemoglobin A1c testing.J Am Med Inform Assoc. 2014; 21: 1038-1044
- The inappropriate use of HbA1c testing to monitor glycemia: Is there evidence in laboratory data?.J Eval Clin Pract. 2007; 13: 21-24
- Hemoglobin A1c testing in diabetes: A rapid review. 2014.https://www.hqontario.ca/portals/0/documents/evidence/reports/hemoglobin-a1c-testing-1407-en.pdfDate: 2014Date accessed: June 6, 2021
- Global guidelines for type 2 diabetes.Diabetes Res Clin Pract. 2014; 104: 1-52
- Standards of medical care in diabetes---2018.Diabetes Care. 2018; 41: S1-156
- AACE/ACE comprehensive diabetes management algorithm 2015.Endocrine Pract. 2020; 26: 127-129
- Type 2 diabetes in adults: Management. 2015.https://www.nice.org.uk/guidance/ng28/chapter/recommendations#hba1c-measurement-and-targetsDate: 2015Date accessed: June 23, 2021
- VA/DoD clinical practice guideline for the management of diabetes mellitus. Department of Veteran Affairs, Department of Defense. 2010.www.healthquality.va.gov/guidelines/cd/diabetes/dm2010_ful-v4e.pdfDate: 2010Date accessed: June 4, 2021
- CPCSSN for Researchers.http://cpcssn.ca/join-cpcssn/for-researchers/Date accessed: June 4, 2021
- Validating the 8 CPCSSN case definitions for chronic disease surveillance in a primary care database of electronic health records.Ann Fam Med. 2014; 12: 367-372
- Canadian Diabetes Association 2013 clinical practice guidelines for the prevention and management of diabetes in Canada.Can J Diabetes. 2013; 37: S1-S212
- Overtreatment and deintensification of diabetic therapy among medicare beneficiaries.J Gen Intern Med. 2018; 33: 34-41
- Deprescribing: Future directions for research.Res Social Adm Pharm. 2019; 15: 801-805
- Hemoglobin A1c testing frequency: A review of the clinical evidence and guidelines. 2014.https://www.ncbi.nlm.nih.gov/books/nbk253480/pdf/bookshelf_nbk253480.pdfDate: 2014Date accessed: June 23, 2021
- LIPID Study Investigators. Monitoring cholesterol levels: Measurement error or true change?.Ann Intern Med. 2008; 148: 656-661
- Patient safety in the ambulatory setting. A clinician-based approach.J Gen Intern Med. 2004; 19: 719-725
- Diagnostic error in medicine: Analysis of 583 physician-reported errors.Arch Intern Med. 2009; 169: 1881-1887
- HbA1c overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001–13: Observational population-based study.BMJ. 2015; 351: h6138
- Repeated hemoglobin A1C ordering in the VA Health System.Am J Med. 2011; 124: 342-349
- Is glycemia control in Canadians with diabetes individualized? A cross-sectional observational study.BMJ Open Diabetes Res Care. 2017; 5e000316
- Polypharmacy in the aging patient: A review of glycemic control in older adults with type 2 diabetes.JAMA. 2016; 315: 1034-1045
Article Info
Publication History
Published online: March 06, 2022
Accepted:
February 24,
2022
Received in revised form:
December 23,
2021
Received:
June 30,
2021
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2022 Canadian Diabetes Association.
