Parker Melissa M, Lipska Kasia J, Gilliam Lisa K, Grant Richard W, Haider Shanzay, Huang Elbert S, Jain Rajesh K, Laiteerapong Neda, Liu Jennifer Y, Moffet Howard H, Karter Andrew J
Division of Research, Kaiser Permanente, Pleasanton, California, USA.
Department of Medicine, Section of Endocrinology, Yale School of Medicine, New Haven, Connecticut, USA.
J Am Geriatr Soc. 2025 Apr;73(4):1155-1167. doi: 10.1111/jgs.19352. Epub 2025 Jan 9.
Little is known about how patients' preferences, expectations, and beliefs (jointly referred to as perspectives) influence deprescribing. We evaluated the association of patients' self-reported perspectives with subsequent deprescribing of diabetes medications in older adults with type 2 diabetes.
Longitudinal cohort study of 1629 pharmacologically treated adults ages 65-100 years with type 2 diabetes who received care at Kaiser Permanente of Northern California (KPNC) and participated in the Diabetes Preferences and Self-Care survey (2019). The survey asked questions about perspectives regarding the use of diabetes medications. Deprescribing was identified during the 24 months following the survey and defined as any of the following: discontinuation of one or more therapeutic classes, reduction in frequency of daily dosing, reduction in total daily pill count, or reduction in total daily dose for oral hypoglycemic agents. Rates of deprescribing and measures of relative risk were calculated for patients' perspectives and select clinical factors. Models predicting deprescribing were adjusted for age, sex, race/ethnicity, health literacy, baseline number of diabetes medications, duration of diabetes, overtreatment per Endocrine Society guidelines, and KPNC eligibility for targeted deprescribing and weighted to account for the age-stratified complex sampling design and survey response.
Six hundred seventy-three (38%) patients experienced deprescribing over a mean follow-up of 23 months. Deprescribing was significantly associated with the following patient perspectives: not expecting to need diabetes medication for life (RR = 1.48, 95% CI: 1.07-2.03) and not recognizing that taking fewer medications could lead to higher blood sugar levels (RR = 1.31, 95% CI: 1.09-1.58).
Patients' perspectives may enable or hinder deprescribing, emphasizing the importance of soliciting these perspectives during shared decision-making. Effective deprescribing will benefit from understanding patients' perspectives and fostering patient-provider communication about medication changes throughout the disease course.
关于患者的偏好、期望和信念（统称为观点）如何影响减药，目前所知甚少。我们评估了老年2型糖尿病患者自我报告的观点与随后糖尿病药物减药之间的关联。
对1629名年龄在65 - 100岁、接受药物治疗的2型糖尿病成年人进行纵向队列研究，这些患者在北加利福尼亚凯撒医疗集团（KPNC）接受治疗，并参与了糖尿病偏好与自我护理调查（2019年）。该调查询问了有关糖尿病药物使用观点的问题。在调查后的24个月内确定减药情况，减药定义为以下任何一种情况：停用一种或多种治疗类别、减少每日给药频率、减少每日总药片数或减少口服降糖药的每日总剂量。计算患者观点和选定临床因素的减药率及相对风险度量。预测减药的模型针对年龄、性别、种族/族裔、健康素养、糖尿病药物的基线数量、糖尿病病程、根据内分泌学会指南的过度治疗情况以及KPNC进行靶向减药的资格进行了调整，并进行加权以考虑年龄分层的复杂抽样设计和调查回复情况。
在平均23个月的随访中，673名（38%）患者经历了减药。减药与以下患者观点显著相关：不期望终身需要糖尿病药物（风险比[RR]=1.48，95%置信区间[CI]：1.07 - 2.03）以及未认识到服用更少药物可能导致血糖水平升高（RR = 1.31，95% CI：1.09 - 1.58）。
患者的观点可能促进或阻碍减药，这强调了在共同决策过程中征求这些观点的重要性。有效的减药将受益于了解患者的观点，并在整个疾病过程中促进患者与提供者之间关于药物变化的沟通。
