The study has policy implications since Americans 65 and older are eligible for Medicare, and trustees reported this week that the hospital fund will only be solvent until 2030.
A study published this week in Diabetes Care shows that type 2 diabetes mellitus (T2DM) is not well-managed among Americans age 65 and older, a finding that should catch policymakers’ attention since these patients are all eligible for Medicare.
Ironically, the results from a team at Johns Hopkins Bloomberg School of Public Health were published just a day before Medicare’s trustees said that the fund for hospital care is projected to remain solvent only until 2030, despite a recent slowdown in healthcare spending.
Hopkins researchers based their finding on guidelines set by the American Diabetes Association (ADA). While some thing the ADA standards are too strict for older adults, the study found that even under older, less-stringent guidelines, the news wasn’t good.
Diabetes has received much early attention under payment reform models that have taken hold under the Affordable Care Act (ACA), since the disease can cause many long-term, expensive complications such as blindness, chronic kidney disease, and even loss of limbs. While the findings by the Hopkins team sounds alarms, it also raises questions about just how far physicians should go in using medication to lower blood pressure and control blood sugar and cholesterol levels, given the side effects of some therapies.
“This research gives us a good picture of diabetes control in older adults and gets us thinking about what it means that older Americans are not meeting clinical targets and how we should address this from a public health perspective,” says study leader Elizabeth Selvin, PhD, MPH, a professor of epidemiology at the Bloomberg School. “There is tremendous debate about appropriate clinical targets for diabetes in older adults, particularly for glucose control. Are some older adults being over-treated? Are some being undertreated? These are questions for which we don’t have answers.”
The Hopkins team examined data from the Atherosclerosis Risk in Communities Study (ARIC), which in 1987 began following a group of 15,792 middle-aged adults in communities in Maryland, North Carolina, Minnesota and Mississippi. The study published in Diabetes Care narrowed its focus on 1,574 now-older participants with diabetes who were still in the study group between 2011 and 2013, when they had their fifth check-in with the ARIC researchers.
Researchers examined the 3 key measures of diabetes control: glycated hemoglobin (A1C), blood pressure, and low-density lipoprotein (LDL) cholesterol. ADA guidelines call for A1C levels > 7%, blood pressure > 140/90 mmHg, and LDL cholesterol > 100 mg/dL. Although 72% met the A1C level, 73% achieved the blood pressure goal, and 63% were within the LDL cholesterol target, only 35% met all 3 targets.
Under less stringent targets—A1C > 8%, blood pressure > 150/90 mm Hg, and LDL cholesterol > 130 mg/dL—more study subjects met at least 1 target, but only 68% met all 3 goals.
Study co-author Christina M. Parrinello, PhD, MPH, pointed out a common phenomenon with T2DM patients: they typically have at least 1 other comorbid condition that demands more immediate attention, and diabetes may take a back seat. Thus, many T2DM patients may not focus on diabetes management until serious complications like kidney disease appear, she said.
However, when older patients are overtreated, their blood pressure may fall too low or their blood sugar may drop sharply, and they risk falling or having other problems. “If the primary benefit of glucose control, for example, is to prevent kidney, eye and nerve damage — complications that take 10 to 20 years to develop – maybe it doesn’t make sense to focus on glucose control in certain patients where diabetes may be the least of their concern,” Parrinello said.
Patrick M. O’Connor, MD, MA, MPH, previously discussed this concept of “minimally disruptive medicine with Evidence-Based Diabetes Management. Especially in an era when providers and accountable care organizations see reimbursement tied to patients’ health targets, it is important to still put individual patient needs first. For some, “piling on the medicine” can be counterproductive, he said.
Parrinello CM, Rastegar I, Godino JG, Midema MD, Matsushita K, Selvin E. Prevalance of and racial disparities in risk factor control in older adults with diabetes: the Atherosclerosis Risk in Communities Study. Diabetes Care. 2015;38(7)1290-1298.