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Wednesday, October 22, 2008: 8:00 AM
Grand Ballroom AB (Hyatt Regency Penns Landing)
Purpose: Diabetes care guidelines now recommend that cardiovascular prevention should be prioritized over glucose control among sicker, elderly patients with limited life expectancy (LE) (<5 years). Using decision analysis, we assess the impact of varying baseline comorbid illnesses, functional status and associated life expectancy on the comparative benefits of intensive blood pressure and glucose control.
Method: We used an integrated model of diabetes complications that includes individual prediction models from the United Kingdom Prospective Diabetes Study and a 4-year mortality prognostic index that accounts for age, functional status, and comorbid illness. We considered care for hypothetical patients 60-80 years of age with new onset diabetes and varying prognostic index scores. Main outcomes were the lifetime differences in average quality-adjusted days (QADs), calculated with literature-based health state utilities, and incidence of complications comparing intensive and conventional blood pressure (SBP ~120 mm Hg vs. ~140 mm Hg) and glucose control (HbA1C ~ 7% vs. ~ 7.9%).
Results: Healthy older patients consistently had larger expected benefits from intensive blood pressure control (150-196 QADs) than intensive glucose control ranging from (70-107 QADs). Expected benefits were slightly lower among the oldest age group compared to the youngest age group for blood pressure lowering (75-79 years, 150 QADs vs. 60-64 years 196 QADs) and glucose lowering (75-79 years, 70 QADs vs. 60-64 years, 106 QADs). Within each age group, the expected benefits of both therapies steadily declined as the level of comorbid illness and functional impairment increased. For patients 60-64 years of age, the benefits of intensive blood pressure control declined from 196 QADs at baseline good health (LE 15.4 years), to 77 QADs with 3 additional prognostic index points (LE 9.5 years), and to 14 QADs with 7 additional index points (LE 4.2 years). A similar and slightly steeper decline in expected benefits occurred among patients with intensive glucose control over the same intervals of baseline health status.
Conclusions: Intensive blood pressure control confers larger expected benefits than intensive glucose lowering among healthy, older diabetes patients. However, the expected benefits of both treatments are dramatically reduced among older patients with significant baseline illness. Prioritization of preventive therapies among the very sick may be better guided by expected harms of therapies than expected benefits.
Method: We used an integrated model of diabetes complications that includes individual prediction models from the United Kingdom Prospective Diabetes Study and a 4-year mortality prognostic index that accounts for age, functional status, and comorbid illness. We considered care for hypothetical patients 60-80 years of age with new onset diabetes and varying prognostic index scores. Main outcomes were the lifetime differences in average quality-adjusted days (QADs), calculated with literature-based health state utilities, and incidence of complications comparing intensive and conventional blood pressure (SBP ~120 mm Hg vs. ~140 mm Hg) and glucose control (HbA1C ~ 7% vs. ~ 7.9%).
Results: Healthy older patients consistently had larger expected benefits from intensive blood pressure control (150-196 QADs) than intensive glucose control ranging from (70-107 QADs). Expected benefits were slightly lower among the oldest age group compared to the youngest age group for blood pressure lowering (75-79 years, 150 QADs vs. 60-64 years 196 QADs) and glucose lowering (75-79 years, 70 QADs vs. 60-64 years, 106 QADs). Within each age group, the expected benefits of both therapies steadily declined as the level of comorbid illness and functional impairment increased. For patients 60-64 years of age, the benefits of intensive blood pressure control declined from 196 QADs at baseline good health (LE 15.4 years), to 77 QADs with 3 additional prognostic index points (LE 9.5 years), and to 14 QADs with 7 additional index points (LE 4.2 years). A similar and slightly steeper decline in expected benefits occurred among patients with intensive glucose control over the same intervals of baseline health status.
Conclusions: Intensive blood pressure control confers larger expected benefits than intensive glucose lowering among healthy, older diabetes patients. However, the expected benefits of both treatments are dramatically reduced among older patients with significant baseline illness. Prioritization of preventive therapies among the very sick may be better guided by expected harms of therapies than expected benefits.