individualization strategies for older patients with diabetes elbert s. huang, md mph facp...
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Individualization Strategies for Older Patients with Diabetes
Elbert S. Huang, MD MPH FACPUniversity of Chicago
Framework for Studying Individualization of Medical Decisions
General Framework for Glycemic Control Decision
A1C < 8%
A1C <7%
Course of Diabetes with A1C < 8%
Course of Diabetes with A1C < 7%
Health Outcomes
Health Outcomes
Individualization of Medical Decisions
A1C < 8%
A1C <7%
Course of Diabetes with A1C < 8%
Course of Diabetes with A1C < 7%
Health Outcomes
Health Outcomes
A1C < 8%
A1C <7%
Course of Diabetes with A1C < 8%
Course of Diabetes with A1C < 7%
Health Outcomes
Health Outcomes
Subgroup 1
Subgroup 2
Evidence Regarding the Presence of Key Subgroups
Trial in New Onset Diabetes (UKPDS)
Intervention TrialMedian follow-up 10.0 years
Intervention Trial + Post-trial monitoringMedian follow-up 16.8 years
RR=0.88 (0.79-0.99)P=0.029
Conventional
Sulfonylurea/Insulin
Conventional
Sulfonylurea/Insulin
Lancet 1998;352(9131):837-53; NEJM 2008; 359:1577-1589
Trials in Long-Duration of Diabetes ACCORD ADVANCE VADT
Age, mean 62.2 66 60.4
Duration of DM 10 yrs (median) 8 yrs (mean) 11.5 yrs (mean)
A1C comparison 7.5% vs. 6.4% 7.3% vs. 6.5% 8.4% vs. 6.9%
Follow-up time 3.5 years 5 years 5 years
Selected Mortality Results
257deaths/5128 (intensive)
203 deaths/5123
No excessive deaths
More sudden deaths in
intensive arm (11/4) but not
significantN Engl J Med. 2008;358(24):2545-59. N Engl J Med. 2008;358(24):2560-72. N Engl J Med. 2009;360(2):129-39.
Impact of intensive glucose-lowering therapy by coronary calcification (VADT)
Reaven P, et al. Diabetes. 2009 Nov;58(11):2642-8.
Implications of Being Sicker – Expected Benefits of Glucose Control Decline
A. New-onset diabetes
0
20
40
60
80
100
120
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
Level of comorbid illness/functional impairment
Dif
fere
nce i
n q
uali
ty-a
dju
ste
d
days
Huang ES, et al. Ann Intern Med. 2008; 149(1): 11-19.
Reduction in Cardiovascular Risk Associated with A1C≤6.5% by TIBI Subgroup
TIBI Score Unadjusted Hazard Ratio (95% CI)
Adjusted Hazard Ratio (95% CI)
P for interaction
<12 0.58
(0.41, 0.82)
0.60
(0.42, 0.85)
0.036
≥12 0.93
(0.68, 1.26)
0.92
(0.68, 1.25)
TIBI = Total Illness Burden Index
Models adjusted for age and sex
Greenfield S, et al. Ann Intern Med. December 2009;151(12):854-860
Classifying Older Adults with Diabetes by Comorbid Conditions (NSHAP)
0
10
20
30
40
50
0 1 2 3 4 5 6 7 8 9
No. of Comorbid Conditions
Per
cent
of P
artic
ipan
tsClass 1 (n = 326)
Class 2 (n = 149)
Class 3 (n = 33)
Laiteerapong N, Iveniuk J, John P, Das A, Laumann EO, Huang ES. Prev Chronic Dis. 2012 May;9:E100.
Clinical Complexity Groups (HRS)
Health Status Groups Description
A Relatively Healthy Group No comorbidities, or comorbidities constrained to osteoarthritis and hypertension, and with no impairments.
Difficulties with Diabetes Self-Management
Multiple comorbidities and/or any one of the following: mild cognitive impairment, poor vision, and 2 or more IADL impairments.
A Limited Benefit Group Poorest health status, with one or more of the following: moderate to severe cognitive impairment, 2 or more ADL dependencies, and/or residence in a long-term nursing facility.
Blaum CS, et al. Med Care. 2010 April; 48(4): 327-334.
Care Guidelines for Older Patients
California Healthcare Foundation/AGS - 2003
Preventive care Target goals
Non-Frail Frail
Glucose A1C<7% A1C8%
Blood pressure SBP<130 mm Hg
SBP<140 mm Hg
Cholesterol Goals unchanged
Aspirin prophylaxis Goal unchanged
Brown AF, et al. J Am Geriatr Soc 2003;51(Suppl. Guidelines): S265–S280
Kirkman et al, Diabetes Care and JAGS Dec 2012
Tools for Individualizing Diabetes Care in Clinical Practice
Variables/Tools for Guiding Individualization
Individual variables– Age– Duration of diabetes – Cardiovascular diseaseMortality prediction models– Comorbidity alone (TIBI, NSHAP)– Comorbidity and functional status (HRS)Diabetes simulation modelsDecision support tools for clinical practice
Comorbidity and Functional Status Index (JAMA 2006;295(7):801-808)
4-year Mortality Index in Older Adults
Risk Factor Assigned Score
Risk Factor Assigned score
Age Comorbidities (continued)
60-64 1 Heart failure 2
65-69 2 BMI<25 1
70-74 3 Current smoker 2
75-79 4 Functional measures
Male sex 2 Bathing 2
Comorbidities Managing finances 2
Diabetes mellitus 1 Walking several blocks 2
Cancer 2 Pushing/pulling heavy objects 1
Lung disease 2
JAMA. 2006;295(7):801-808
Probability of death in 4-years
0
10
20
30
40
50
60
70
0 5 10 15 20
Mortality index score
Per
cent
age
with
sco
re w
ho d
ie
in 4
-yea
rs
Traditional Model of Diabetes Complications
Assign initial patient characteristics
Simulate natural history of diabetes progression according to patient characteristics
Retinopathy Module
Neuropathy Module
Nephropathy Module
Coronary Heart Disease Module
Stroke Module
Mortality Module
Alive
Dead
Advance in disease progression one year
Select next patient
Clinical Decisions:Risk Factor Goals*
Patient Preferences
Clinical Factors**
B
Clinical Decisions: Treatment Selection
A
C D
Conceptual Framework for Personalized Decision Support
Wilkinson, Nathan, Huang. Curr Diab Rep. 2013 Apr;13(2):205-12
Future Directions
Individualization of diabetes care is frequently cited but what it means variesWhat is the best way to individualize care?– No clear consensus on categorization of older
patients– Numerous variables to consider (life expectancy,
duration of diabetes, pre-existing cardiovascular disease)
Need trials of competing algorithms and decision support tools
