Over and Under-Treatment of Diabetes

Much of the discussion of excessive health spending in the US has focused on supposed inappropriate or unnecessary medical treatments.  But under-treatment clearly also exists.  Diabetes is an interesting case study because over-treatment can lead to serious adverse events, as can under-treatment.  Research in the Journal of General Internal Medicine used data on Medicare beneficiaries to identify rates of under and over-treatment of diabetes and to examine whether over-treatment was frequently de-intensified.   (JGIM Article)   The data was from 2010 and 2011 and included actual lab values from tests as well as all drugs prescribed, the most common treatment for diabetes.  Over-treatment was defined by use of certain medications by patients with HbA1c values under a certain level (the level was set very conservatively, so over-treatment was likely under-identified).  Under-treated patients were those with an HbA1c value over a certain level, regardless of medications used.  For patients who were initially categorized as over-treated, a further analysis was done to see if their medications were adjusted to prevent this over-treatment.  The final study group consisted of about 79,000 beneficiaries.

Of these, 10.8% were categorized as over-treated and 6.9% as under-treated.  Over-treatment was most likely for dual eligibles and beneficiaries over 75.  Among the over-treated group, only 14% had their therapies de-intensified.  Guidelines for diabetes treatment are a work in progress, and in recent years, they have been adjusted to encourage less aggressive blood sugar control in many cases.  There may be less over-treatment now than there was during the study period.  No specific cost analysis was performed by the authors, but if the rates of over-treatment and under-treatment found in the study are close to accurate, then if all patients got treatment by the guidelines, you would suspect that their would be a net savings to the system, both from lower drug costs and treatment of fewer adverse events.  This is encouraging. Diabetes accounts for a fair amount of health spending, so the savings could be meaningful.