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Cited by 185Diabetes Treatment and ManagementHealth Systems, Economic Evaluations, Quality of LifeDiabetes Management and Research

Effect of patients’ risks and preferences on health gains with plasma glucose level lowering in type 2 diabetes mellitus

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Vijan, Sandeep, Sussman, Jeremy B., Yudkin, John S., Hayward, Rodney A.·2014·JAMA Internal Medicine
DOI 10.1001/jamainternmed.2014.2894PMC PMC4299865
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Abstract

IMPORTANCE: Type 2 diabetes mellitus is common, and treatment to correct blood glucose levels is standard. However, treatment burden starts years before treatment benefits accrue. Because guidelines often ignore treatment burden, many patients with diabetes may be overtreated. OBJECTIVE: To examine how treatment burden affects the benefits of intensive vs moderate glycemic control in patients with type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS: We estimated the effects of hemoglobin A1c (HbA1c) reduction on diabetes outcomes and overall quality-adjusted life years (QALYs) using a Markov simulation model. Model probabilities were based on estimates from randomized trials and observational studies. Simulated patients were based on adult patients with type 2 diabetes drawn from the National Health and Nutrition Examination Study. INTERVENTIONS: Glucose lowering with oral agents or insulin in type 2 diabetes. MAIN OUTCOMES AND MEASURES: Main outcomes were QALYs and reduction in risk of microvascular and cardiovascular diabetes complications. RESULTS: Assuming a low treatment burden (0.001, or 0.4 lost days per year), treatment that lowered HbA1c level by 1 percentage point provided benefits ranging from 0.77 to 0.91 QALYs for simulated patients who received a diagnosis at age 45 years to 0.08 to 0.10 QALYs for those who received a diagnosis at age 75 years. An increase in treatment burden (0.01, or 3.7 days lost per year) resulted in HbA1c level lowering being associated with more harm than benefit in those aged 75 years. Across all ages, patients who viewed treatment as more burdensome (0.025-0.05 disutility) experienced a net loss in QALYs from treatments to lower HbA1c level. CONCLUSIONS AND RELEVANCE: Improving glycemic control can provide substantial benefits, especially for younger patients; however, for most patients older than 50 years with an HbA1c level less than 9% receiving metformin therapy, additional glycemic treatment usually offers at most modest benefits. Furthermore, the magnitude of benefit is sensitive to patients' views of the treatment burden, and even small treatment adverse effects result in net harm in older patients. The current approach of broadly advocating intensive glycemic control should be reconsidered; instead, treating patients with HbA1c levels less than 9% should be individualized on the basis of estimates of benefit weighed against the patient's views of the burdens of treatment.

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  • Tight glycemic control with a target A1C of 6.0% may not be ideal for older/frail individuals, those with longer duration of diabetes, advanced coronary artery disease (CAD) and a known history of severe hypoglycemia.

    “Therefore, it has been suggested that a tight glycemic control with a target A1C of 6.0% may not be ideal for older/frail individuals, those with longer duration of diabetes, advanced coronary artery disease (CAD) and a known history of severe hypoglycemia (32,33)”

    From Targets for Glycemic Control (2018) · cites this paper as [32]

    The Results and Discussion (page numbers unavailable) report smaller benefits from A1c lowering in older patients and argue against a single intensive target for everyone. The copy does not specifically evaluate a 6.0% target or identify frailty, longer diabetes duration, advanced CAD, or a history of severe hypoglycemia as the listed reasons to avoid it. (LLM, conf=0.87)

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  • Individuals with a long duration of diabetes, a known history of hypoglycemia, advanced atherosclerosis, or advanced age/frailty may benefit from less aggressive glycemic targets.

    “Individuals with a long duration of diabetes, a known history of hypoglycemia, advanced atherosclerosis, or advanced age/frailty may benefit from less aggressive targets (67,68).”

    From 6. Glycemic Targets: <i>Standards of Care in Diabetes—2023</i> (2023) · cites this paper as [68]

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Research works printed but not linked: 2

  1. [38]Humphrey LL Ballard DJ Frohnert PP Chu CP O’Fallon WM Palumbo PJ Chronic renal failure in non-insulin-dependent diabetes mellitus. A population-based study in Rochester Minnesota Ann Intern Med 1989 111 788 96 2817626
  2. [44]Lifetime benefits and costs of intensive therapy as practiced in the diabetes control and complications trial The Diabetes Control and Complications Trial Research Group JAMA: the journal of the American Medical Association 1996 276 1409 15 8892716

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Authors
Vijan, S., Sussman, J. B., Yudkin, J. S., & Hayward, R. A.
Affiliations
  • University of Michigan (US)
  • University College London (GB)
ORCID
Venue
JAMA Internal Medicine
Publisher
American Medical Association (AMA)
Published
2014-08-01
Volume
174
Issue
8
Pages
1227
ISSN
2168-6106 (ISSN-L)
DOI
10.1001/jamainternmed.2014.2894
PMC
PMC4299865
OpenAlex
W2131347767
Cited by
185
References
75
Citations by year
2026: 4 · 2025: 6 · 2024: 8 · 2023: 9 · 2022: 10 · 2021: 16 · 2020: 11 · 2019: 22 · 2018: 18 · 2017: 16 · 2016: 28 · 2015: 27 · 2014: 10
FWCI
21.61
Type
journal article
Language
en
Open access
Locations
  • JAMA Internal Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • UCL Discovery (University College London) (submittedVersion)
Funders
National Institute of Diabetes and Digestive and Kidney Diseases (P60DK020572, P30DK092926)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Health Systems, Economic Evaluations, Quality of Life
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
Keywords
type 2 diabetes, glycemic control, tight glycemic control, treatment burden, patient preferences, quality-adjusted life years, HbA1c, metformin, microvascular complications, cardiovascular complications, overtreatment, elderly patients, personalized treatment, oral antidiabetic drugs, insulin
MeSH terms
Aged, Diabetes Mellitus, Type 2, Glycated Hemoglobin, Humans, Hypoglycemic Agents, Insulin, Markov Chains, Middle Aged, Models, Statistical, Treatment Outcome, Cost of Illness, Risk Assessment, Quality-Adjusted Life Years, Diabetes Complications, Patient Preference

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