Department of Medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA.
J Gen Intern Med. 2024 May;39(6):992-1001. doi: 10.1007/s11606-023-08506-8. Epub 2023 Nov 8.
Guidelines recommend deintensifying hypoglycemia-causing medications for older adults with diabetes whose hemoglobin A1c is below their individualized target, but this rarely occurs in practice.
To understand physicians' decision-making around deintensifying diabetes treatment.
National physician survey.
US physicians in general medicine, geriatrics, or endocrinology providing outpatient diabetes care.
Physicians rated the importance of deintensifying diabetes medications for older adults with type 2 diabetes, and of switching medication classes, on 5-point Likert scales. They reported the frequency of these actions for their patients, and listed important barriers and facilitators. We evaluated the independent association between physicians' professional and practice characteristics and the importance of deintensifying and switching diabetes medications using multivariable ordered logistic regression models.
There were 445 eligible respondents (response rate 37.5%). The majority of physicians viewed deintensifying (80%) and switching (92%) diabetes medications as important or very important to the care of older adults. Despite this, one-third of physicians reported deintensifying diabetes medications rarely or never. While most physicians recognized multiple reasons to deintensify, two-thirds of physicians reported barriers of short-term hyperglycemia and patient reluctance to change medications or allow higher glucose levels. In multivariable models, geriatricians rated deintensification as more important compared to other specialties (p=0.027), and endocrinologists rated switching as more important compared to other specialties (p<0.006). Physicians with fewer years in practice rated higher importance of deintensification (p<0.001) and switching (p=0.003).
While most US physicians viewed deintensifying and switching diabetes medications as important for the care of older adults, they deintensified infrequently. Physicians had ambivalence about the relative benefits and harms of deintensification and viewed it as a potential source of conflict with their patients. These factors likely contribute to clinical inertia, and studies focused on improving shared decision-making around deintensifying diabetes medications are needed.
指南建议为糖化血红蛋白低于个体化目标的老年糖尿病患者减少导致低血糖的药物，但在实践中很少发生这种情况。
了解医生在减少糖尿病治疗方面的决策。
全国医生调查。
提供门诊糖尿病护理的普通内科、老年病学或内分泌学的美国医生。
医生对为 2 型糖尿病老年患者减少糖尿病药物以及改变药物种类的重要性进行了 5 分李克特量表评分。他们报告了这些行动在他们的患者中的频率，并列出了重要的障碍和促进因素。我们使用多变量有序逻辑回归模型评估了医生的专业和实践特征与减少和改变糖尿病药物的重要性之间的独立关联。
共有 445 名符合条件的受访者（应答率 37.5%）。大多数医生认为减少（80%）和改变（92%）糖尿病药物对老年患者的护理很重要或非常重要。尽管如此，三分之一的医生报告说很少或从不减少糖尿病药物。虽然大多数医生认识到有多种理由减少药物剂量，但三分之二的医生报告说存在短期高血糖的障碍以及患者不愿改变药物或允许更高的血糖水平。在多变量模型中，老年病医生认为减少药物剂量比其他专业更重要（p=0.027），而内分泌医生认为改变药物剂量比其他专业更重要（p<0.006）。执业年限较短的医生对减少药物剂量的重要性评价更高（p<0.001）和改变药物剂量（p=0.003）。
虽然大多数美国医生认为减少和改变糖尿病药物对老年患者的护理很重要，但他们很少减少药物剂量。医生对减少药物剂量的相对益处和危害存在矛盾看法，并认为这可能是与患者产生冲突的一个潜在来源。这些因素可能导致临床惰性，需要开展研究以改善减少糖尿病药物的共同决策。
