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Invited Commentary | Less Is More

Deintensification of Routine Medical Services The Next Frontier for Improving Care Quality

Eve A. Kerr, MD, MPH1; Timothy P. Hofer, MD, MS1
[+] Author Affiliations
1Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, University of Michigan Medical School, and Institute for Healthcare Policy and Innovation, Ann Arbor
JAMA Intern Med. 2016;176(7):978-980. doi:10.1001/jamainternmed.2016.2292.
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The study by McCoy and colleagues1 in this issue of JAMA Internal Medicine adds to an increasing body of research24 that older patients with type 2 diabetes mellitus often receive unnecessarily intensive treatment. The authors found that nearly 20% of patients with clinical complexity (75 years or older or with multiple comorbidities) with a hemoglobin A1c (HbA1c) level less than 7.0% are receiving intensive oral treatment regimens (they excluded patients taking insulin at baseline). Furthermore, patients with clinical complexity had a higher likelihood of severe hypoglycemia, even if their treatments did not meet the definition of high intensity. The results were consistent regardless of medications used, although one-third of patients with clinical complexity were treated with sulfonylureas, despite guidelines advising against their use. Moreover, more than three-quarters of intensively treated patients did not have their treatments deintensified after testing revealed a low HbA1c level. This finding is consistent with research by Sussman et al,5 who found that once intensive treatments are started, even older patients with very tight control (eg, HbA1c level <6.0%) rarely have medications deintensified.

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