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Paradox of glycemic management: multimorbidity, glycemic control, and high-risk medication use among adults with diabetes
  1. Rozalina G McCoy1,2,3,
  2. Kasia J Lipska4,
  3. Holly K Van Houten2,3,
  4. Nilay D Shah2,3,5
  1. 1Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
  2. 2Division of Health Care Policy & Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
  3. 3Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Rochester, Minnesota, USA
  4. 4Section of Endocrinology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
  5. 5OptumLabs, Cambridge, Massachusetts, USA
  1. Correspondence to Dr Rozalina G McCoy; mccoy.rozalina{at}


Introduction Glycemic targets and glucose-lowering regimens should be individualized based on multiple factors, including the presence of comorbidities. We examined contemporary patterns of glycemic control and use of medications known to cause hypoglycemia among adults with diabetes across age and multimorbidity.

Research design and methods We retrospectively examined glycosylated hemoglobin (HbA1c) levels and rates of insulin/sulfonylurea use as a function of age and multimorbidity using administrative claims and laboratory data for adults with type 2 diabetes included in OptumLabs Data Warehouse, 1 January 2014 to 31 December 2016. Comorbidity burden was assessed by counts of any of 16 comorbidities specified by guidelines as warranting relaxation of HbA1c targets, classified as being diabetes concordant (diabetes complications or risk factors), discordant (unrelated to diabetes), or advanced (life limiting).

Results Among 194 157 patients with type 2 diabetes included in the study, 45.2% had only concordant comorbidities, 30.6% concordant and discordant, 2.7% only discordant, and 13.0% had ≥1 advanced comorbidity. Mean HbA1c was 7.7% among 18–44 year-olds versus 6.9% among ≥75 year-olds, and was higher among patients with comorbidities: 7.3% with concordant only, 7.1% with discordant only, 7.1% with concordant and discordant, and 7.0% with advanced comorbidities compared with 7.4% among patients without comorbidities. The odds of insulin use decreased with age (OR 0.51 (95% CI 0.48 to 0.54) for age ≥75 vs 18–44 years) but increased with accumulation of concordant (OR 5.50 (95% CI 5.22 to 5.79) for ≥3 vs none), discordant (OR 1.72 (95% CI 1.60 to 1.86) for ≥3 vs none), and advanced (OR 1.45 (95% CI 1.25 to 1.68) for ≥2 vs none) comorbidities. Conversely, sulfonylurea use increased with age (OR 1.36 (95% CI 1.29 to 1.44) for age ≥75 vs 18–44 years) but decreased with accumulation of concordant (OR 0.76 (95% CI 0.73 to 0.79) for ≥3 vs none), discordant (OR 0.70 (95% CI 0.64 to 0.76) for ≥3 vs none), but not advanced (OR 0.86 (95% CI 0.74 to 1.01) for ≥2 vs none) comorbidities.

Conclusions The proportion of patients achieving low HbA1c levels was highest among older and multimorbid patients. Older patients and patients with higher comorbidity burden were more likely to be treated with insulin to achieve these HbA1c levels despite potential for hypoglycemia and uncertain long-term benefit.

  • diabetes
  • patient-centered care
  • evidence-based medicine
  • risk treatment paradox
  • overtreatment
  • intensive treatment
  • intensive control
  • insulin
  • sulfonylurea
  • multimorbidity

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  • Contributors RGM designed the study, interpreted the data, and wrote the manuscript. KJL contributed to the discussion and reviewed/edited the manuscript. HKVH analyzed the data and reviewed/edited the manuscript. NDS supervised the study design and data interpretation, contributed to the discussion, and reviewed/edited the manuscript.

  • Funding This work was supported by (RGM): the National Institute of Health-National Institute of Diabetes and Digestive and Kidney Diseases (grant number K23DK114497) and the AARP through the Quality Measure Innovation Grant through a collaboration with OptumLabs and the NQF Measure Incubator; and (NDS): the Agency for Healthcare Research and Quality (grant number 1U19HS024075).

  • Disclaimer Study contents are the sole responsibility of the authors and do not necessarily represent the official views of NIH.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data may be obtained from a third party and are not publicly available. The study was conducted using deidentified claims data from OptumLabs Data Warehouse.

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