Age-Dependent Hemoglobin A1c Therapeutic Targets Reduce Diabetic Medication Changes in the Elderly

OBJECTIVE: To assess whether implementation of age-dependent therapeutic targets for high hemoglobin A1c (HbA1c) changed clinicians’ ordering of diabetes medications for older adults. BACKGROUND: In 2016, Kaiser Permanente Southern California (KPSC) changed the therapeutic targets for alerting clinicians about high HbA1c results in the electronic health record, KP HealthConnect (KPHC). Previously, all HbA1c results ≥7.0 percent were flagged as high in adult patients with diabetes. Starting in 2016, HbA1c therapeutic targets were relaxed to <7.5 percent for patients age 65 to 75, and to <8.0 percent for patients over age 75 to reduce treatment intensity and adverse events. METHODS: This retrospective analysis used logistic regression models to calculate the change in odds of a medication change following an HbA1c result after age-dependent HbA1c flags were introduced. RESULTS: The odds of medication change decreased among patients whose HbA1c targets were relaxed: Odds Ratio (OR) 0.72 (95 percent CI 0.67–0.76) for patients age 65–75 and HbA1c 7.0 percent–7.5 percent; OR 0.72 (95 percent CI 0.65–0.80) for patients over age 75 and HbA1c 7.0 percent–7.5 percent; and OR 0.67 (95 percent CI 0.61–0.75) for patients over age 75 and HbA1c 7.5 percent–8.0 percent. In the age and HbA1c ranges for which the alerts did not change, the odds of medication change generally increased or stayed the same. There was little evidence of medication de-intensification in any group. CONCLUSIONS: These findings suggest that the change in therapeutic targets was associated with a reduction in medication intensification among older adults with diabetes.