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The Effect of Comorbid Illness and Functional Status on the Expected Benefits of Intensive Glucose Control in Older Patients with Type 2 Diabetes: A Decision Analysis
Open accessAbstract
BACKGROUND: Physicians are uncertain about when to pursue intensive glucose control among older patients with diabetes. OBJECTIVE: To assess the effect of comorbid illnesses and functional status, mediated through background mortality, on the expected benefits of intensive glucose control. DESIGN: Decision analysis. DATA SOURCES: Major clinical studies in diabetes and geriatrics. TARGET POPULATION: Patients 60 to 80 years of age who have type 2 diabetes and varied life expectancies estimated from a mortality index that was validated at the population level. TIME HORIZON: Patient lifetime. PERSPECTIVE: Health care system. INTERVENTION: Intensive glucose control (hemoglobin A1c [HbA1c] level of 7.0) versus moderate glucose control (HbA1c level of 7.9). OUTCOME MEASURES: Lifetime differences in incidence of complications and average quality-adjusted days. RESULTS OF BASE-CASE ANALYSIS: Healthy older patients of different age groups had expected benefits of intensive glucose control ranging from 51 to 116 quality-adjusted days. Within each age group, the expected benefits of intensive control steadily declined as the level of comorbid illness and functional impairment increased (mortality index score, 1 to 26 points). For patients 60 to 64 years of age with new-onset diabetes, the benefits declined from 106 days at baseline good health (life expectancy, 14.6 years) to 44 days with 3 additional index points (life expectancy, 9.7 years) and 8 days with 7 additional index points (life expectancy, 4.8 years). A similar decline in benefits occurred among patients with prolonged duration of diabetes. RESULTS OF SENSITIVITY ANALYSIS: With alternative model assumptions (such as Framingham models), expected benefits of intensive control declined as mortality index scores increased. LIMITATIONS: Diabetes clinical trial data were lacking for frail, older patients. The mortality index was not validated for use in predicting individual-level life expectancies. Adverse effects of intensive control were not taken into account. CONCLUSION: Among older diabetic patients, the presence of multiple comorbid illnesses or functional impairments is a more important predictor of limited life expectancy and diminishing expected benefits of intensive glucose control than is age alone.
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“individuals with shorter life expectancy, advanced diabetes complications, life-limiting comorbid illnesses, frailty, or substantial cognitive or functional impairments will have less benefit from glucose lowering”
From 13. Older Adults: Standards of Care in Diabetes—2026 (2026) · cites this paper as [72]
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“Based on concepts of competing mortality and time to benefit, some people in this category with shorter life expectancy will have less benefit from glucose lowering and should have less stringent glycemic goals (64).”
From 13. Older Adults: Standards of Care in Diabetes—2024 (2024) · cites this paper as [64]
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“Based on concepts of competing mortality and time to benefit, some people in this category with shorter life expectancy will have less benefit from glucose lowering and should have less stringent glycemic goals (66).”
From 13. Older Adults: Standards of Care in Diabetes—2025 (2025) · cites this paper as [66]
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Metadata
- Authors
- Huang, E. S., Zhang, Q., Gandra, N., Chin, M. H., & Meltzer, D. O.
- Affiliations
- Boston University (US)
- Venue
- Annals of Internal Medicine
- Publisher
- American College of Physicians
- Published
- 2008-07-01
- Volume
- 149
- Issue
- 1
- Pages
- 11-19
- ISSN
- 0003-4819 (ISSN-L)
- 1539-3704
- PMC
- PMC2562733
- OpenAlex
- W2144693872
- Cited by
- 165
- References
- 57
- Citations by year
- 2026: 3 · 2025: 7 · 2024: 9 · 2023: 10 · 2022: 7 · 2021: 5 · 2020: 4 · 2019: 5 · 2018: 6 · 2017: 11 · 2016: 13 · 2015: 9 · 2014: 10 · 2013: 11 · 2012: 14
- FWCI
- 9.68
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Annals of Internal Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute on Aging (K23AG021963)
- National Institute of Diabetes and Digestive and Kidney Diseases (P60DK20595, K24DK071933, P60DK020595)
- Eunice Kennedy Shriver National Institute of Child Health and Human Development (R03HD056073)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Keywords
- type 2 diabetes, older adults, tight glycemic control, glycemic control, comorbidities, functional status, mortality index, life expectancy, diabetes complications, HbA1c, frailty, decision analysis
- MeSH terms
- Aged, Aged, 80 and over, Blood Glucose, Decision Support Techniques, Diabetes Mellitus, Type 2, Female, Glycated Hemoglobin, Humans, Life Expectancy, Male, Middle Aged, Quality of Life, Sensitivity and Specificity, Diabetes Complications
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