1. Individualization Strategies for Older Patients with Diabetes Elbert S. Huang, MD MPH FACP University of Chicago

2. Framework for Studying Individualization of Medical Decisions

3. General Framework for Glycemic Control Decision A1C < 8% A1C <7% Course of Diabetes with A1C < 8% Course of Diabetes with A1C < 7% Health Outcomes

4. Individualization of Medical Decisions A1C < 8% A1C <7% Course of Diabetes with A1C < 8% Course of Diabetes with A1C < 7% Health Outcomes A1C < 8% A1C <7% Course of Diabetes with A1C < 8% Course of Diabetes with A1C < 7% Health Outcomes Subgroup 1 Subgroup 2

5. Evidence Regarding the Presence of Key Subgroups

6. Trial in New Onset Diabetes (UKPDS) Intervention Trial Median follow-up 10.0 years Intervention Trial + Post-trial monitoring Median follow-up 16.8 years RR=0.88 (0.79-0.99) P=0.029 Conventional Sulfonylurea/ Insulin Conventional Sulfonylurea/ Insulin Lancet 1998;352(9131):837-53; NEJM 2008; 359:1577-1589

7. Trials in Long-Duration of Diabetes ACCORDADVANCEVADT Age, mean62.26660.4 Duration of DM10 yrs (median)8 yrs (mean)11.5 yrs (mean) A1C comparison7.5% vs. 6.4%7.3% vs. 6.5%8.4% vs. 6.9% Follow-up time3.5 years5 years Selected Mortality Results 257deaths/5128 (intensive) 203 deaths/5123 No excessive deaths More sudden deaths in intensive arm (11/4) but not significant N Engl J Med. 2008;358(24):2545-59. N Engl J Med. 2008;358(24):2560-72. N Engl J Med. 2009;360(2):129-39.

8. Impact of intensive glucose-lowering therapy by coronary calcification (VADT) Reaven P, et al. Diabetes. 2009 Nov;58(11):2642-8.

9. Implications of Being Sicker – Expected Benefits of Glucose Control Decline Huang ES, et al. Ann Intern Med. 2008; 149(1): 11-19.

10. Reduction in Cardiovascular Risk Associated with A1C≤6.5% by TIBI Subgroup TIBI ScoreUnadjusted Hazard Ratio (95% CI) Adjusted Hazard Ratio (95% CI) P for interaction <120.58 (0.41, 0.82) 0.60 (0.42, 0.85) 0.036 ≥120.93 (0.68, 1.26) 0.92 (0.68, 1.25) TIBI = Total Illness Burden Index Models adjusted for age and sex Greenfield S, et al. Ann Intern Med. December 2009;151(12):854-860

11. Classifying Older Adults with Diabetes by Comorbid Conditions (NSHAP) Laiteerapong N, Iveniuk J, John P, Das A, Laumann EO, Huang ES. Prev Chronic Dis. 2012 May;9:E100.

12. Clinical Complexity Groups (HRS) Health Status GroupsDescription A Relatively Healthy GroupNo comorbidities, or comorbidities constrained to osteoarthritis and hypertension, and with no impairments. Difficulties with Diabetes Self- Management Multiple comorbidities and/or any one of the following: mild cognitive impairment, poor vision, and 2 or more IADL impairments. A Limited Benefit GroupPoorest health status, with one or more of the following: moderate to severe cognitive impairment, 2 or more ADL dependencies, and/or residence in a long-term nursing facility. Blaum CS, et al. Med Care. 2010 April; 48(4): 327-334.

13. Care Guidelines for Older Patients

14. California Healthcare Foundation/AGS - 2003 Preventive careTarget goals Non-FrailFrail GlucoseA1C<7% A1C  8% Blood pressureSBP<130 mm HgSBP<140 mm Hg CholesterolGoals unchanged Aspirin prophylaxisGoal unchanged Brown AF, et al. J Am Geriatr Soc 2003;51(Suppl. Guidelines): S265–S280

15. Kirkman et al, Diabetes Care and JAGS Dec 2012

16. Tools for Individualizing Diabetes Care in Clinical Practice

17. Variables/Tools for Guiding Individualization Individual variables – Age – Duration of diabetes – Cardiovascular disease Mortality prediction models – Comorbidity alone (TIBI, NSHAP) – Comorbidity and functional status (HRS) Diabetes simulation models Decision support tools for clinical practice

18. Comorbidity and Functional Status Index (JAMA 2006;295(7):801-808) 4-year Mortality Index in Older Adults Risk FactorAssigned Score Risk FactorAssigned score AgeComorbidities (continued) 60-641Heart failure2 65-692BMI<251 70-743Current smoker2 75-794Functional measures Male sex2Bathing2 ComorbiditiesManaging finances2 Diabetes mellitus1Walking several blocks2 Cancer2Pushing/pulling heavy objects1 Lung disease2 JAMA. 2006;295(7):801-808

19. Probability of death in 4-years

20. Traditional Model of Diabetes Complications Assign initial patient characteristics Simulate natural history of diabetes progression according to patient characteristics Retinopathy Module Neuropathy Module Nephropathy Module Coronary Heart Disease Module Stroke Module Mortality Module Alive Dead Advance in disease progression one year Select next patient

21. B Clinical Decisions: Treatment Selection A C D Conceptual Framework for Personalized Decision Support Wilkinson, Nathan, Huang. Curr Diab Rep. 2013 Apr;13(2):205-12

22. Future Directions Individualization of diabetes care is frequently cited but what it means varies What is the best way to individualize care? – No clear consensus on categorization of older patients – Numerous variables to consider (life expectancy, duration of diabetes, pre- existing cardiovascular disease) Need trials of competing algorithms and decision support tools

23. Thank You ehuang@medicine.bsd.uchicago.edu