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Zullo AR, Riester MR, Hayes KN, Munshi MN, Berry SD. Comparative safety of sulfonylureas among U.S. nursing home residents. J Am Geriatr Soc 2023; 71:1047-1057. [PMID: 36495141 PMCID: PMC10089954 DOI: 10.1111/jgs.18160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/23/2022] [Accepted: 10/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The comparative safety of sulfonylureas (SUs) in nursing home (NH) residents remains understudied despite widespread use. We compared the effects of three SU medications and initial SU doses on adverse glycemic and cardiovascular events among NH residents. METHODS This national retrospective cohort study linked Medicare claims with Minimum Data Set 2.0 assessments for long-stay NH residents aged ≥65 years between January 2008 and September 2010. Exposures were the SU medication initiated (glimepiride, glipizide, or glyburide) and doses (standard or reduced). One-year outcomes were hospitalizations or emergency department visits for severe hypoglycemia, heart failure (HF), stroke, and acute myocardial infarction (AMI). After the inverse probability of treatment and inverse probability of censoring by death weighting, we estimated hazard ratios (HR) using Cox regression models with robust 95% confidence intervals (CI). RESULTS The cohort (N = 6821) included 3698 new glipizide, 1754 glimepiride, and 1369 glyburide users. Overall, the mean (standard deviation) age was 81.4 (8.2) years, 4816 (70.6%) were female, and 5164 (75.7%) were White non-Hispanic residents. The rates of severe hypoglycemia were 30.3 (95% CI 22.3-40.1), 49.0 (95% CI 34.5-67.5), and 35.9 (95% CI 22.2-54.9) events per 1000 person-years among new glipizide, glimepiride, and glyburide users, respectively (glimepiride versus glipizide HR 1.6, 95% CI 1.0-2.4, p = 0.04; glyburide versus glipizide HR 1.2, 95% CI 0.7-1.9, p = 0.59). The rates of severe hypoglycemia were 27.1 (95% CI 18.6-38.0) and 42.8 (95% CI 33.6-53.8) events per 1000 person-years among new users of reduced and standard SU doses, respectively (HR 2.2, 95% CI 1.4-3.5, p < 0.01). Rates of HF, stroke, and AMI were similar between medications and doses. CONCLUSIONS Among long-stay NH residents, new use of glimepiride and standard SU doses resulted in higher rates of severe hypoglycemic events. Cardiovascular outcomes may not be affected by the choice of SU medication or dose.
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Affiliation(s)
- Andrew R. Zullo
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Department of Pharmacy, Lifespan—Rhode Island Hospital, Providence, RI, USA
| | - Melissa R. Riester
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kaleen N. Hayes
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Graduate Department of Pharmaceutical Sciences, University of Toronto Leslie Dan Faculty of Pharmacy, Toronto, Ontario, Canada
| | - Medha N. Munshi
- Joslin Diabetes Center, Boston, MA, USA
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Sarah D. Berry
- Beth Israel Deaconess Medical Center, Boston, MA, USA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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2
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Ouellet GM, O’Leary JR, Leggett CG, Skinner J, Tinetti ME, Cohen AB. Benefits and harms of oral anticoagulants for atrial fibrillation in nursing home residents with advanced dementia. J Am Geriatr Soc 2023; 71:561-568. [PMID: 36310367 PMCID: PMC9957933 DOI: 10.1111/jgs.18108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/04/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Approximately 20% of older persons with dementia have atrial fibrillation (AF). Nearly all have stroke risks that exceed the guideline-recommended threshold for anticoagulation. Although individuals with dementia develop profound impairments and die from the disease, little evidence exists to guide anticoagulant discontinuation, and almost one-third of nursing home residents with advanced dementia and AF remain anticoagulated in the last 6 months of life. We aimed to quantify the benefits and harms of anticoagulation in this population. METHODS Using Minimum Data Set and Medicare claims, we conducted a retrospective cohort study with 14,877 long-stay nursing home residents aged ≥66 between 2013 and 2018 who had advanced dementia and AF. We excluded individuals with venous thromboembolism and valvular heart disease. We measured anticoagulant exposure quarterly, using Medicare Part D claims. The primary outcome was all-cause mortality; secondary outcomes were ischemic stroke and serious bleeding. We performed survival analyses with multivariable adjustment and inverse probability of treatment (IPT) weighting. RESULTS In the study sample, 72.0% were female, 82.7% were aged ≥80 years, and 13.5% were nonwhite. Mean CHA2 DS2 VASC score was 6.19 ± 1.58. In multivariable survival analysis, anticoagulation was associated with decreased risk of death (HR 0.71, 95% CI 0.67-0.75) and increased bleeding risk (HR 1.15, 95% CI 1.02-1.29); the association with stroke risk was not significant (HR 1.08, 95% CI 0.80-1.46). Results were similar in models with IPT weighting. While >50% of patients in both groups died within a year, median weighted survival was 76 days longer for anticoagulated individuals. CONCLUSION Persons with advanced dementia and AF derive clinically modest life prolongation from anticoagulation, at the cost of elevated risk of bleeding. The relevance of this benefit is unclear in a group with high dementia-related mortality and for whom the primary goal is often comfort.
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Affiliation(s)
- Gregory M. Ouellet
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - John R. O’Leary
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Christopher G. Leggett
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH
| | - Jonathan Skinner
- The Dartmouth Institute for Health Policy & Clinical Practice, Dartmouth College, Hanover, NH
| | - Mary E. Tinetti
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
| | - Andrew B. Cohen
- Section of Geriatrics, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
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3
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Jeon SY, Shi Y, Lee AK, Hunt L, Lipska K, Boscardin J, Lee S. Fingerstick Glucose Monitoring in Veterans Affairs Nursing Home Residents with Diabetes Mellitus. J Am Geriatr Soc 2020; 69:424-431. [PMID: 33064879 DOI: 10.1111/jgs.16880] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/09/2020] [Accepted: 09/20/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND/OBJECTIVE Guidelines recommend less intensive glycemic treatment and less frequent glucose monitoring for nursing home (NH) residents. However, little is known about the frequency of fingerstick (FS) glucose monitoring in this population. Our objective was to examine the frequency of FS glucose monitoring in Veterans Affairs (VA) NH residents with diabetes mellitus, type II (T2DM). DESIGN AND SETTING National retrospective cohort study in 140 VA NHs. PARTICIPANTS NH residents with T2DM and older than 65 years admitted to VA NHs between 2013 and 2015 following discharge from a VA hospital. MEASUREMENTS NH residents were classified into five groups based on their highest hypoglycemia risk glucose-lowering medication (GLM) each day: no GLMs; metformin only; sulfonylureas; long-acting insulin; and any short-acting insulin. Our outcome was a daily count of FS measurements. RESULTS Among 17,474 VA NH residents, mean age was 76 (standard deviation (SD) = 8) years and mean hemoglobin A1c was 7.6% (SD = 1.5%). On day 1 after NH admission, 49% of NH residents were on short-acting insulin, decreasing slightly to 43% at day 90. Overall, NH residents had an average of 1.9 (95% confidence interval (CI) = 1.8-1.9) FS measurements on NH day 1, decreasing to 1.4 (95% CI = 1.3-1.4) by day 90. NH residents on short-acting insulin had the most frequent FS measurements, with 3.0 measurements (95% CI = 2.9-3.0) on day 1, decreasing to 2.6 measurements (95% CI = 2.5-2.7) by day 90. Less frequent FS measurements were seen for NH residents receiving long-acting insulin (2.1 (95% CI = 2.0-2.2) on day 1) and sulfonylureas (1.7 (95% CI = 1.5-1.8) on day 1). Even NH residents on metformin monotherapy had 1.1 (95% CI = 1.1-1.2) measurements on day 1, decreasing to 0.5 (95% CI = 0.4-0.6) measurements on day 90. CONCLUSION Although guidelines recommend less frequent glucose monitoring for NH residents, we found that many VA NH residents receive frequent FS monitoring. Given the uncertain benefits and potential for substantial patient burdens and harms, our results suggest decreasing FS monitoring may be warranted for many low hypoglycemia risk NH residents.
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Affiliation(s)
- Sun Y Jeon
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Alexandra K Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Lauren Hunt
- San Francisco Veterans Affairs Medical Center, San Francisco, California, USA.,Department of Physiological Nursing, University of California, San Francisco, San Francisco, California, USA
| | - Kasia Lipska
- Department of Internal Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut, USA
| | - John Boscardin
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
| | - Sei Lee
- Division of Geriatrics, University of California, San Francisco, San Francisco, California, USA.,San Francisco Veterans Affairs Medical Center, San Francisco, California, USA
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Niznik JD, Hunnicutt JN, Zhao X, Mor MK, Sileanu F, Aspinall SL, Springer SP, Ersek MJ, Gellad WF, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes. J Am Geriatr Soc 2020; 68:736-745. [PMID: 32065387 DOI: 10.1111/jgs.16360] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]). DESIGN Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments. SETTING VA CLCs. PARTICIPANTS A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission. MEASUREMENTS We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7-day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90-day cumulative incidence of deintensification. RESULTS More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0-7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50-.66). Compared with non-sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31-1.88), except for basal insulin (aRR = .59; 95% CI = .52-.66). The only resident factor associated with increased likelihood of deintensification was documented end-of-life status (aRR = 1.12; 95% CI = 1.01-1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75-.96), obesity (aRR = .88; 95% CI = .78-.99), and peripheral vascular disease (aRR = .90; 95% CI = .81-.99) were associated with decreased likelihood of deintensification. CONCLUSION Deintensification of treatment regimens occurred in less than one-half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics. J Am Geriatr Soc 68:736-745, 2020.
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Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Jacob N Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Florentina Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sydney P Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Portland, Maine
| | - Mary J Ersek
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Veterans Experience Center; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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Nagaraj SB, Sidorenkov G, van Boven JFM, Denig P. Predicting short- and long-term glycated haemoglobin response after insulin initiation in patients with type 2 diabetes mellitus using machine-learning algorithms. Diabetes Obes Metab 2019; 21:2704-2711. [PMID: 31453664 PMCID: PMC6899933 DOI: 10.1111/dom.13860] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/30/2019] [Accepted: 08/20/2019] [Indexed: 01/04/2023]
Abstract
AIM To assess the potential of supervised machine-learning techniques to identify clinical variables for predicting short-term and long-term glycated haemoglobin (HbA1c) response after insulin treatment initiation in patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS We included patients with T2DM from the Groningen Initiative to Analyse Type 2 diabetes Treatment (GIANTT) database who started insulin treatment between 2007 and 2013 and had a minimum follow-up of 2 years. Short- and long-term responses at 6 (±2) and 24 (±2) months after insulin initiation, respectively, were assessed. Patients were defined as good responders if they had a decrease in HbA1c ≥ 5 mmol/mol or reached the recommended level of HbA1c ≤ 53 mmol/mol. Twenty-four baseline clinical variables were used for the analysis and an elastic net regularization technique was used for variable selection. The performance of three traditional machine-learning algorithms was compared for the prediction of short- and long-term responses and the area under the receiver-operating characteristic curve (AUC) was used to assess the performance of the prediction models. RESULTS The elastic net regularization-based generalized linear model, which included baseline HbA1c and estimated glomerular filtration rate, correctly classified short- and long-term HbA1c response after treatment initiation, with AUCs of 0.80 (95% CI 0.78-0.83) and 0.81 (95% CI 0.79-0.84), respectively, and outperformed the other machine-learning algorithms. Using baseline HbA1c alone, an AUC = 0.71 (95% CI 0.65-0.73) and 0.72 (95% CI 0.66-0.75) was obtained for predicting short-term and long-term response, respectively. CONCLUSIONS Machine-learning algorithm performed well in the prediction of an individual's short-term and long-term HbA1c response using baseline clinical variables.
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Affiliation(s)
- Sunil B. Nagaraj
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
| | - Grigory Sidorenkov
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
- Department of Epidemiology, University of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
| | - Job F. M. van Boven
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and Pharmacology, University of GroningenUniversity Medical Centre GroningenGroningenThe Netherlands
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Raval AD, Vyas A. National Trends in Diabetes Medication Use in the United States: 2008 to 2015. J Pharm Pract 2018; 33:433-442. [DOI: 10.1177/0897190018815048] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Data on trends of diabetes medications use are sparse, outdated, and limited to prescription data. We determined trends in diabetes medication use among US individuals with diabetes during 2008-2015. Methods We used 2008-2015 Medical Expenditure Panel Survey to examine diabetes medication utilization among individuals aged ≥18 years with diabetes. Prescription medications were classified based on therapeutic class and subclass using Multum Lexicon database. Results From 2008 to 2015, use of any diabetes medication (81.4% vs. 87%), metformin (47.8% vs. 59.0%), and insulin (23.0% vs. 31.0%) increased, whereas, use of sulfonylurea (36.0% vs. 29.0%) and thiazolidinedione (21% vs. 9.0%) declined. A linear increase was observed in the uptake of dipeptidyl peptidase-4 (DPP-4) inhibitors from 6.2% in 2008 to 12.4% in 2015; glucagon-like peptide-1 (GLP-1) receptor agonists from 2.5% in 2008 to 4.4% in 2015 and sodium glucose transporter-2 (SGLT2) inhibitors from 0.8% in 2014 (the first SGLT2 inhibitors approval year) to 4.4% in 2015. Monotherapy use increased from 50.6% to 56.4% during 2008-2015, while triple therapy use declined. Conclusions Metformin, insulin and sulfonylureas remained the top-three prescribed classes of diabetes medications. Increased use of DPP-4 inhibitors, GLP-1 receptor agonists and SGLT2 inhibitors was offset by decline in TZDs use.
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Affiliation(s)
| | - Ami Vyas
- Department of Pharmacy Practice, College of Pharmacy, University of Rhode Island, Kingston, RI, USA
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Sidorenkov G, van Boven JFM, Hoekstra T, Nijpels G, Hoogenberg K, Denig P. HbA1c response after insulin initiation in patients with type 2 diabetes mellitus in real life practice: Identifying distinct subgroups. Diabetes Obes Metab 2018; 20:1957-1964. [PMID: 29687577 PMCID: PMC6055847 DOI: 10.1111/dom.13332] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 04/06/2018] [Accepted: 04/19/2018] [Indexed: 12/30/2022]
Abstract
AIMS To identify subgroups of patients with type 2 diabetes mellitus (T2DM) following distinct trajectories of HbA1c after insulin initiation and explore underlying differences in clinical characteristics. MATERIALS AND METHODS A cohort study was conducted in patients with T2DM initiating insulin in 2007-2013 with a follow-up of 2 to 4 years. Data were collected from the Groningen Initiative to Analyze Type 2 Diabetes Treatment (GIANTT) database. The primary outcome was subgroups with different trajectories of HbA1c patterns after insulin initiation, as identified by latent class growth modeling. Differences between subgroups were tested using one-way ANOVA, Kruskal-Wallis or chi-square tests, where appropriate. RESULTS From 1459 patients, three subgroups with distinct HbA1c patterns were identified. Group 1 (8%) initially showed a moderate decrease followed by an increase in HbA1c 2 years later, despite receiving more comedication. Group 2 (84%) showed a stable decrease. Group 3 (8%) had a high initial level of HbA1c and a rapid decline within the first year, followed by a slow increase thereafter. Group 1 patients were on average 6-7 years younger than patients in groups 2 and 3 and were more likely to receive sulfonylureas than Group 3 patients. Group 3 patients had a shorter diabetes duration and were less well-controlled for HbA1c, systolic blood pressure and LDL-cholesterol at insulin initiation. CONCLUSIONS Most patients showed a stable HbA1c response, but one out of six patients showed either a poor response, or a rapid initial response only after insulin initiation. Response patterns were associated with age, diabetes duration and risk-factor controls at the time of insulin initiation.
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Affiliation(s)
- Grigory Sidorenkov
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
- Department of EpidemiologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Job F. M. van Boven
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
| | - Trynke Hoekstra
- Center for Human Movement SciencesUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
- Department of Health Sciences, Faculty of ScienceAmsterdam Public Health Research Institute, VU University Medical CenterAmsterdamThe Netherlands
| | - Giel Nijpels
- Department of General Practice and Elderly Care MedicineAmsterdam Public Health Research Institute, VU University Medical CenterAmsterdamThe Netherlands
| | - Klaas Hoogenberg
- Department of Internal MedicineMartini HospitalGroningenThe Netherlands
| | - Petra Denig
- Department of Clinical Pharmacy and PharmacologyUniversity of Groningen, University Medical Center GroningenGroningenThe Netherlands
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8
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Morley JE. The Complexities of Diabetes in Older Persons. J Am Med Dir Assoc 2016; 17:872-4. [PMID: 27590405 DOI: 10.1016/j.jamda.2016.07.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 07/22/2016] [Indexed: 12/25/2022]
Affiliation(s)
- John E Morley
- Division of Geriatric Medicine and Endocrinology, Saint Louis University School of Medicine, St. Louis, MO.
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Zullo AR, Dore DD, Daiello L, Baier RR, Gutman R, Gifford DR, Smith RJ. National Trends in Treatment Initiation for Nursing Home Residents With Diabetes Mellitus, 2008 to 2010. J Am Med Dir Assoc 2016; 17:602-8. [PMID: 27052559 DOI: 10.1016/j.jamda.2016.02.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Revised: 02/17/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Diabetes mellitus is common in the nursing home (NH) population, yet little is known about prescribing of glucose-lowering medications in the NH setting. We describe trends in initiation of glucose-lowering medications in a national cohort of NH residents. DESIGN AND SETTING Retrospective cohort study using Part A and D claims for a random 20% of Medicare enrollees linked to NH Minimum Data Set (MDS) and Online Survey, Certification, and Reporting (OSCAR) databases in 7158 US NHs. PARTICIPANTS A total of 11,531 long-stay (continuous residence of ≥90 days) NH residents 65 years or older with diabetes who received a glucose-lowering medication between 2008 and 2010 after 4 months of nonuse. MEASUREMENTS Medicare Part D drug dispensing of glucose-lowering treatments; resident and facility characteristics preceding medication initiation. RESULTS We observed decreasing sulfonylurea initiation from 25.4% of initiations in 2008 to 11.7% in 2010, an average decrease of 1% per quarter (95% CLs -1.5 to -0.5). Thiazolidinedione initiation decreased from 4.7% to 1.9%, an average decrease of 0.3% per quarter (95% CLs -0.4 to -0.2), and meglitinide initiation from 1.5% to 0.3%. No appreciable linear trends were observed for metformin (range 12.0%-18.8%) and dipeptidyl peptidase-4 (DPP-4) inhibitors (range 0.9%-2.7%). In contrast, insulin use increased from 51.7% to 68.3% during the same time period, driven by a marked increase in initiation of rapid-acting insulin (11.0% to 29.4%; average increase of 1.4% per quarter, 95% CLs 0.9-1.9) and a modest increase in short-acting insulin (22.6% to 30.3%; an average increase of 0.6% per quarter, 95% CLs -0.1 to 1.3). CONCLUSIONS Between 2008 and 2010, there were substantial decreases in the use of oral glucose-lowering agents and corresponding increases in the use of insulin among long-term residents of US NHs.
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Affiliation(s)
- Andrew R Zullo
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI.
| | | | - Lori Daiello
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI
| | - Rosa R Baier
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI; Center for Long-Term Care Quality and Innovation, School of Public Health, Brown University, Providence, RI
| | - Roee Gutman
- Department of Biostatistics, School of Public Health, Brown University, Providence, RI
| | - David R Gifford
- Quality and Regulatory Affairs, American Health Care Association, Washington, DC
| | - Robert J Smith
- Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, RI; Department of Medicine, Alpert Medical School, Brown University, Providence, RI
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