Patients with diabetes may not receive best treatment to lower heart disease risk

December 18, 2012

ANN ARBOR, Mich. -- For some people with diabetes, there may be such a thing as too much care.

Traditional treatment to reduce risks of heart disease among patients with diabetes has focused on lowering all patients' blood cholesterol to a specific, standard level. But this practice may prompt the over-use of high-dose medications for patients who don't need them, according to new research from the VA Ann Arbor Healthcare System (VAAAHS) and the University of Michigan Health System.

The study encourages a more individualized approach to treatment that adjusts treatment according to the patient in order to improve the quality of care. The findings appear in Circulation: Cardiovascular Quality and Outcomes.

Authors also suggest that blanket goals routinely used to lower heart attack risks may unnecessarily expose some patients to potential adverse side effects of high-dose medications. Researchers also note that when these standard goals are used to assess whether a health provider delivered high quality care, they may encourage overly aggressive treatment.

"We want patients to get the treatment they need to prevent heart attacks and cardiovascular issues but we don't want to expose them to additional treatment risks without strong evidence of the benefits," says senior author Eve Kerr, M.D., director of the Center for Clinical Management Research at the VAAAHS, professor of internal medicine at the U-M Medical School and a member of the U-M Institute for Healthcare Policy and Innovation.

"We need to move away from a one-size-fits-all performance measure that misses the point of providing appropriate treatment."

Managing cholesterol is especially important for people with type 2 diabetes who often have an increased risk for a heart attack. This is especially true for people age 50 and over.

Physicians commonly aim to lower blood cholesterol for all patients with diabetes to below 100 mg/dl. Recent evidence, however, highlights the importance of individualized treatment for each patient that's not focused on bringing cholesterol levels down to a set value.

In the new study, researchers found that 85 percent of veterans age 50-75 with diabetes treated at the VA received appropriate care, most importantly because they were on at least moderate doses of cholesterol treatment medications called statins. But among patients 18 and older who had no known heart disease, nearly 14 percent may have unnecessarily received high-dose statin medications, putting them at risk of harm from overtreatment.

The research stems from new safety data published this year by the U.S. Food and Drug Administration (FDA) on commonly-used cholesterol-lowering medications known as statins. The FDA issued new guidelines for statin drugs warning users that the medications can cause memory loss, elevated blood sugar levels, and type-2 diabetes, in addition to muscle damage and liver disease.

"The study reveals that we may have both underuse and overuse of statins and should invigorate efforts to make sure that each patient has the opportunity to be treated in a personalized way that is best given their risk profile," says Circulation Editor and Director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation Harlan M. Krumholz, M.D.

Authors says modern healthcare electronic record systems that combine blood pressure, prescription and other health data on individual risks such as heart disease make this method of individualized treatment possible.

The study included more than 960,000 active Veterans Affairs primary care patients 18 years of age or older with type 2 diabetes treated from July 2010 to June 2011.
-end-
Additional authors: Ashley J. Beard, Ph.D; Timothy P. Hofer, M.D, MS; John R. Downs, M.D; Michelle Lucatorto, DNP; Mandi L. Klamerus, MPH; Rob Holleman, MPH.

Funding: Veteran Affairs, Veteran Affairs Diabetes Quality Enhancement Research Initiative, Measurement Core of the Michigan Diabetes Research and Training Center (National Institute of Diabetes and Digestive and Kidney Disease of the National Institutes of Health (P60 DK-205721)

Conflict of Interest: NoneReference: "Assessing Appropriateness of Lipid Management Among Patients With Diabetes Mellitus: Moving From Target to Treatment"; doi 10.1161/CIRCOUTCOMES.112.966697.

University of Michigan Health System

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