medwireNews: Clinical complexity and treatment burden have both increased over recent years among people with diabetes in the USA, say researchers.
They found that, in one of the two cohorts studied, almost two-thirds of participants had 10 or more actively managed health conditions by the end of the study period in 2018.
“[O]ur findings underscore the urgent need for expansion of accessible disease management programs to provide increasingly complex care for patients,” write Tyler Benning (Mayo Clinic, Rochester, Minnesota, USA) and co-researchers in Diabetes Care.
The team studied healthcare records contained in the OptumLabs Data Warehouse of 1,470,799 people with diabetes (6.3% with type 1) from across the USA who had commercial healthcare insurance and 1,311,903 (3.1% with type 1) enrolled in Medicare Advantage.
At baseline in 2006, the commercial cohort was an average age of 51.9 years and had an average of 8.59 actively managed health conditions per patient, with 33.3% having 10 or more. By the end of follow-up in 2018, the average age was 54.5 years and the average number of health conditions was 9.37, with 38.9% having at least 10.
The Medicare cohort was older, at an average of 70.1 years in 2006, increasing to 72.6 years during the study period. The average number of health conditions per person rose from 12.3 to 15.2 and the proportion with at least 10 health conditions increased from 51.6% to 65.1%.
“This clinical complexity increases treatment burden, may diminish [the] patient’s capacity for self-management, and predisposes patients to treatment-related severe hypoglycemia,” say Benning and team.
Indeed, treatment burden also increased over time. In the commercial cohort, although the average number of medication classes prescribed remained stable, the proportion of people taking at least 10 medication classes increased from 12.6% to 26.9%, with most of the increase occurring by 2009.
In the Medicare cohort, the proportion of people prescribed 10 or more classes rose from 37.6% to 48.5%.
“Polypharmacy poses multiple risks to patients, particularly those who are older and clinically complex, and pharmaceutical treatment comes with medical, logistical, and financial burdens,” say the researchers.
“It is therefore imperative for clinicians to individualize therapy to ensure evidence-based and goal-concordant care for patients, especially those with significant comorbidities and limited life expectancy.
“As the population of patients with diabetes grows older and more complex, clinicians should regularly reassess patients’ glycemic and other treatment targets and adjust regimens to align with the anticipated benefits and potential harms of treatment.”
Glycemic control worsened over time in both cohorts, although the team notes that this “may be showing signs of improvement after peaking in 2014–2015,” which approximately coincided with an increase in prescriptions for glucose-lowering medications, suggesting improved treatment intensification.
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