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Using an Electronic Health Record and Deficit Accumulation to Pragmatically Identify Candidates for Optimal Prescribing in Patients With Type 2 Diabetes

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posted on 21.03.2022, 19:58 by Kathryn E. Callahan, Kristin M. Lenoir, Chinenye O. Usoh, Jeff D. Williamson, LaShanda Y. Brown, Adam W. Moses, Molly Hinely, Zeev Neuwirth, Nicholas M. Pajewski
Objective. Despite guidelines recommending less stringent glycemic goals for older adults with type 2 diabetes, overtreatment is prevalent. Pragmatic approaches for prioritizing patients for optimal prescribing are lacking. We describe glycemic control and medication patterns for older adults with type 2 diabetes in a contemporary cohort, exploring variability by frailty status.

Research Design and Methods. This was a cross-sectional observational study based on electronic health record (EHR) data, within an accountable care organization (ACO) affiliated with an academic medical center/health system. Participants were ACO-enrolled adults with type 2 diabetes who were ≥65 years of age as of 1 November 2020. Frailty status was determined by an automated EHR-based frailty index (eFI). Diabetes management was described by the most recent A1C in the past 2 years and use of higher-risk medications (insulin and/or sulfonylurea).

Results. Among 16,973 older adults with type 2 diabetes (mean age 75.2 years, 9,154 women [53.9%], 77.8% White), 9,134 (53.8%) and 6,218 (36.6%) were classified as pre-frail (0.10 < eFI ≤ 0.21) or frail (eFI >0.21), respectively. The median A1C level was 6.7% (50 mmol/mol) with an interquartile range of 6.2–7.5%, and 74.1 and 38.3% of patients had an A1C <7.5% (58mmol/mol) and <6.5% (48mmol/mol), respectively. Frailty status was not associated with level of glycemic control (P = 0.08). A majority of frail patients had an A1C <7.5% (58mmol/mol) (n = 4,544, 73.1%), and among these patients, 1,755 (38.6%) were taking insulin and/or a sulfonylurea.

Conclusion. Treatment with insulin and/or a sulfonylurea to an A1C levels <7.5% is common in frail older adults. Tools such as the eFI may offer a scalable approach to targeting optimal prescribing interventions.


National Center for Advancing Translational Sciences (NCATS) x UL1TR001420

U.S. Department of Health and Human Services > National Institutes of Health > National Institute on Aging K76-AG059986 P30AG021332

U.S. Department of Health and Human Services > National Institutes of Health