Variation in Treatment Patterns of Type 2 Diabetes in Older Patients

To estimate the proportion of older patients with type 2 diabetes (T2D) and HbA1c above or below goal at provider level and explore factors associated with patients being above or below goal.

We used 2023 Cleveland Clinic electronic health records, including patients ≥ 65 years old with T2D, ≥ 1 diabetes medication and ≥ 1 HbA1c measurement. Patients were assigned to their listed primary care provider or the one they saw most frequently and stratified into good, intermediate, or poor health. Outcomes were patients being above, at, and below goal, defined as HbA1c greater than, 0%-1.5% lower than, and ≥ 1.5% lower than goal, respectively. HbA1c goals were < 7.5% for patients with good, < 8% intermediate and < 9% poor health.

We included 406 providers and 15 865 patients. Across providers, 52.1% (range: 10%-87.9%) of patients were below goal (13.4% in those with good, 42.0% intermediate, 76.0% poor health); 11.3% (range: 0.0%-36.4%) were above goal (25.1% in those with good, 13.7% intermediate, 6.7% poor health). There was significant variation across providers (p < 0.001). In a multivariable model, having endocrinology providers (vs. internal medicine) decreased the adjusted relative risk ratio (aRRR) of being below goal (aRRR = 0.69; 95% CI: 0.57-0.82) and increased the probability of being above goal (aRRR = 1.65; 95% CI: 1.33-2.05).

Substantial provider-level variation suggests that individualised glycemic management for older adults remains difficult to operationalise in routine care. Clinical decision support tools that automate assessment of health status and recommend glycemic goals may help clinicians better align glycemic management with patient needs.