Minimizing harms of tight glycemic control in older people with type 2 diabetes

Minimizing harms of tight glycemic control in older people with type 2 diabetes

The Therapeutics Initiative produced individual prescribing Portraits on the topic of prescribing diabetes medications to older adults with type 2 diabetes (2022). The Portraits were released online to clinicians in BC who are registered for the Portrait program. Eligible clinicians (primary care physicians and nurse practitioners) were randomized to have access to the Portrait in two groups, an early group of clinicians were granted online access to Portrait in January 2024 and a delayed group will be granted access at least 6 to 9 months later. This Portrait was accompanied by the Therapeutics Letter: Minimizing harms of tight glycemic control in older people with type 2 diabetes.1


Abbreviations used

A1c: A measure of average blood sugar (glucose) level over the past 3 months
ATC: Anatomical Therapeutic Chemical code assigned to medicine
BCN&M:  British Columbia College of Nurses & Midwives
CPSBC: College of Physicians and Surgeons of British Columbia
FP: Family practitioner
FNHA: First Nations Health Authority
GP: General practice
ICD: International Classification of Diseases
MSP: Medical Services Plan
NP: Nurse practitioner
PSP: Practice Support Program
RCT: Randomized controlled trials
SU: Sulfonylureas
T2DM: Type 2 diabetes


Data definitions

Who received this Portrait?

Clinicians who have registered online for a Portrait account and who meet all of the following criteria have access to an individual prescribing Portrait:

  • General practice (GP) physicians or nurse practitioners (NP) registered to practise in British Columbia;
  • Family practitioners (FP) registered by the BC Medical Services Plan and the College of Physicians and Surgeons of BC with an active practice, or physicians registered primarily as GP-emergency medicine and FP-emergency medicine physicians;
  • NPs registered by the BC Medical Services Plan and the BC College of Nurses & Midwives with an active practice; and
  • had ≥100 patients with prescriptions filled at a community pharmacy in 2022, according to PharmaNet claims data; and
  • have not opted out of the Portrait program.

How were patients assigned to this Portrait?

Patients were included in a clinician Portrait if they met all of the following criteria:

  • filled a prescription for insulin and/or SU in a community pharmacy during the Portrait period;
  • were considered to be taking the medication in the month preceding an A1c test ≤7% based on the days’ supply from PharmaNet dispensing data;
  • were age 65 years or older on January 1, 2022, and
  • were BC residents based on continuous BC MSP enrollment.

Data for patients who are federally insured (e.g., Veterans, RCMP, Armed Forces and beneficiaries of Non-Insured Health Benefits) or First Nations Health Benefits (PharmaCare Plan W) were not available.

A1c is a continuous variable, and individual test results reflect inherent biological variability, test-to-test variability, and lab error.

Clinicians may have received a Portrait with masked or missing elements (i.e., no blue red bars shown) because they met the above requirements but prescribed between 1 and 5 prescriptions for that section element of the Portrait. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the total number of patients may be presented as a range (e.g., 1-20 patients), and percentages were rounded to the nearest 5%. Clinicians with no prescriptions (“0 prescriptions”) will have this element displayed.

What prescriptions were included in this Portrait?

Dispensing events of insulin/SU medication prescriptions were extracted from PharmaNet claims data and included all prescriptions dispensed at a community pharmacy in BC with a clinician’s prescribing number, regardless of the provider who referred patients for A1c tests. Reversed prescription claims, out-of-province prescriptions, or drugs dispensed in hospital were not included.

Prescriptions included were insulin (ATC A10A) and/or sulfonylureas (ATC A10BB)

How was “Optimal” determined?

Based on the best available evidence, no patients ≥65 with type 2 diabetes who have an A1c of 7.0% or lower should receive sulfonylureas or insulin. This is why we set the optimal target as zero (0). Please refer to Therapeutics Letter: Minimizing harms of tight glycemic control in older people with type 2 diabetes1 for a more detailed assessment of the evidence.


Reference and additional information

  1. Therapeutics Initiative. Minimizing harms of tight glycemic control in older people with type 2 diabetes. Therapeutics Letter. 2024. Limited early release (January):1-2.

We recommend developing therapeutic plans in discussion with patients. Decide whether to stop medications, gradually taper to the minimum available dose before stopping, or reduce the dose. There is no evidence for one best approach. The most appropriate choice for any individual depends on the actual drug dose, patient context (e.g., baseline glycemic control, risk of harm), and patient goals and preferences. See Reference 1 for more information about developing and implementing deprescribing plans.


Research component

The research objective is to determine the impact of the Portrait on clinician prescribing. This impact will be evaluated at an aggregated level over the coming year by comparing pooled prescribing data from clinicians in the early mailing group to pooled prescribing data from clinicians in the delayed group. All prescribing data analyzed for this evaluation will not contain names, only encrypted patient and clinician numbers. No clinician or patient will be identified in any reports or publications. Portrait’s data access agreement requires the masking of data elements when <6 individuals (patients or clinicians) are included. Ethics approval for this evaluation will be obtained from the University of British Columbia Clinical Ethics Review Board. This evaluation is being led by Drs. Wade Thompson and Colin Dormuth, University of British Columbia, Faculty of Medicine, Department of Anesthesiology, Pharmacology, & Therapeutics.

If you have any questions or would like further information with respect to this evaluation, you may contact the Portrait team at (604) 822-4887 or email Portrait@ti.ubc.ca


FAQ

Can I request the names of my patients included in this Portrait?

No. Portrait’s data access agreement only permits access to encrypted patient identifiers. There is no way for us to identify individual patients in the data or to provide you with a list. However, other resources may be available for you. Contact your Practice Support Program (PSP) regional team to discuss how they might help you use your EMR to identify these patients.

I have a unique/specialized practice and do not believe that my data should be compared to GPs. Shouldn’t my comparison cohort be other clinicians with practices similar to mine?

Our ability to accurately include clinicians depends on how each clinician is listed in the BC MSP data. For example, to be included in the program, a clinician must be defined as a Nurse Practitioner or a General Practitioner with a licence status of Private Practice in the MSP data; beyond that, it is difficult to accurately identify any individual’s specific work environment, as many clinicians work in multiple locations. We try to keep Portraits relevant to recipients by having a minimum prescribing criterion for each Portrait topic. Clinicians who prescribe no or very little of the drug in question typically will not receive a Portrait.

Creating accurate comparison cohorts is difficult for the same reasons. We often include the BC median as a points of interest when it is feasible, but we know that many clinicians have unique or specialized practices and this comparator is not ideal. Hopefully, as we continue to build and refine the Portrait program, we will be able to provide comparisons that are more relevant to a variety of practices.

Portraits are really intended to be a tool for you to reflect upon and consider your own prescribing. Rest assured that we are not directly comparing your prescribing to any particular cohort. You are the only one who ever sees your own Portrait data, and you can decide for yourself whether you think your prescribing is in line with the evidence given your unique clinical setting. You will only receive future Portraits for which you have prescribed more than the minimum inclusion criteria, so you shouldn’t receive anything that is irrelevant to your practice.

Why does my Portrait show ranges of patients that I treated (1-20, 20-30, etc.), and not exact numbers?

Clinicians may have received a Portrait with masked or missing elements (i.e., no blue red bars shown) because they met the above requirements but prescribed between 1 and 5 prescriptions for that section element of the Portrait. Portrait’s data access agreement requires the suppression of data elements that contain <6 individuals. To comply with the agreement, the total number of patients may be presented as a range (e.g., 1-5 patients), and percentages were rounded to the nearest 5%. Clinicians with no prescriptions (“0 prescriptions”) will have this element displayed.

I don’t see my question here. Where can I find more information?

Please check out our program FAQ section. We also welcome your feedback. Questions can be directed to our Portrait team by phone (604) 822-4887 or email Portrait@ti.ubc.ca.

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