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De-Intensification Of Blood Glucose Lowering Medication In People Identified As Being Over-Treated: A Mixed Methods Study

Authors Hart HE, Ditzel K, Rutten GE, de Groot E, Seidu S, Khunti K, Vos RC

Received 16 March 2019

Accepted for publication 6 September 2019

Published 18 October 2019 Volume 2019:13 Pages 1775—1783

DOI https://doi.org/10.2147/PPA.S208947

Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Nicola Ludin

Peer reviewer comments 2

Editor who approved publication: Dr Johnny Chen


Huberta E Hart,1,2,* Kim Ditzel,1,* Guy E Rutten,1 Esther de Groot,1 Samuel Seidu,3 Kamlesh Khunti,3 Rimke C Vos1,4

1Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, The Netherlands; 2Leidsche Rijn Julius Health Centers, Utrecht, The Netherlands; 3Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK; 4Department of Public Health and Primary Care/lumc-Campus the Hague, Leiden University Medical Center, The Hague, The Netherlands

*These authors contributed equally to this work

Correspondence: Huberta E Hart
Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Erasmuslaan 68, Zeist 3707 ZE, The Netherlands
Tel +31 6 1695 0844
Email h.e.hart@umcutrecht.nl

Aim: To evaluate if, one year after notification of possible overtreatment, diabetes care providers de-intensified glucose-lowering medications and to gain insight into the opinions and beliefs of both care providers and patients regarding de-intensification.
Methods: Mixed methods using routine care data from five health-care centres in the Netherlands. Patient characteristics and medication prescription of patients, previously identified as possibly over-treated, were extracted from patients’ medical records. Opinions of care providers were obtained through interviews. Patients received questionnaires about their diabetes treatment and were asked to participate in focus groups.
Results: A total of 64 elderly patients with type 2 diabetes were previously identified as possibly over-treated and included; 57.8% male, median age 75 years (IQR=72–82), median diabetes duration 12 years (IQR=8–18). De-intensification was implemented in more than half (n=36) of them. Care providers preferred person-centred care above just setting general HbA1c target values, considering patient characteristics (such as comorbidity) and patient’s preference. Patients valued glucose levels as most important in determining their treatment. Both patients and care providers felt that de-intensification should occur gradually.
Conclusion: Treatment had been de-intensified in more than half of the patients (56.3%). Insight in reasons for not de-intensifying elderly patients is important since treatment for them can be “person-centred care”. De-intensification is an iterative and time-intensive process.

Keywords: elderly, overtreatment, hypoglycaemia, insulin therapy, primary care, type 2 diabetes

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