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The Effect of Comorbid Illness and Functional Status on the Expected Benefits of Intensive Glucose Control in Older Patients with Type 2 Diabetes: A Decision Analysis

Elbert S. Huang, MD, MPH; Qi Zhang, PhD; Niren Gandra, BA; Marshall H. Chin, MD, MPH; and David O. Meltzer, MD, PhD
[+] Article and Author Information

From the University of Chicago, Chicago, Illinois; Old Dominion University, Norfolk, Virginia; and Boston University School of Medicine, Boston, Massachusetts.


Acknowledgment: The authors thank Priya John, MPH, for her assistance in preparing this manuscript.

Grant Support: By a National Institute on Aging Career Development Award (K23 AG021963 [Dr. Huang]), a National Institute of Diabetes and Digestive and Kidney Diseases Diabetes Research and Training Center (P60 DK20595 [Drs. Huang, Zhang, Chin, and Meltzer]), the Chicago Center of Excellence in Health Promotion Economics (Drs. Huang, Chin, and Meltzer), a National Institute of Child Health and Human Development Small Grant (R03 HD056073 [Dr. Zhang]), and a National Institute of Diabetes and Digestive and Kidney Diseases Midcareer Investigator Award in Patient-Oriented Research (K24 DK071933 [Dr. Chin]).

Potential Financial Conflicts of Interest: None disclosed.

Reproducible Research Statement:Study protocol: Not available. Statistical code: Readers with questions about the simulation model used in this analysis may contact Dr. Huang (ehuang@medicine.bsd.uchicago.edu). The model is not available without establishing written agreements with the authors. Data set: Not available.

Requests for Single Reprints: Elbert S. Huang, MD, MPH, The University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637; e-mail, ehuang@medicine.bsd.uchicago.edu.

Current Author Addresses: Drs. Huang, Chin, and Meltzer: The University of Chicago, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.

Dr. Zhang: 3138 Health Sciences Building, School of Community and Environmental Health, Old Dominion University, Norfolk, VA 23529.

Mr. Gandra: 10 Buick Street, Box 8298, Boston, MA 02215.

Author Contributions: Conception and design: E.S. Huang, Q. Zhang, M.H. Chin, D.O. Meltzer.

Analysis and interpretation of the data: E.S. Huang, Q. Zhang, N. Gandra, D.O. Meltzer.

Drafting of the article: E.S. Huang.

Critical revision of the article for important intellectual content: E.S. Huang, Q. Zhang, M.H. Chin, D.O. Meltzer.

Final approval of the article: E.S. Huang, Q. Zhang, N. Gandra, M.H. Chin, D.O. Meltzer.

Provision of study materials or patients: D.O. Meltzer.

Statistical expertise: E.S. Huang, Q. Zhang.

Obtaining of funding: E.S. Huang.

Administrative, technical, or logistic support: N. Gandra.


Ann Intern Med. 2008;149(1):11-19. doi:10.7326/0003-4819-149-1-200807010-00005
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This decision analysis is an integration of multiple prediction models from the fields of diabetes and geriatrics. We housed all prediction models in the structure of an existing model of diabetes complications, the National Institutes of Health Model (17, 22). This Monte Carlo simulation model is framed by simultaneous progression of disease through individual diabetes-related complications and death (Figure 1). Within a 1-year cycle, patients move from 1 disease state to another or stay in the current disease state until death or age 95 years. The model is run for 10 000 iterations for each specific model setting, such as population characteristics or glucose level, with each iteration representing a patient life. The model was constructed by using Microsoft Excel 2000 (Microsoft, Seattle, Washington) and @Risk 4.0 (Palisades, Newfield, New York).

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Figure 1.
Patient flow through 1 cycle of the model.

Hypothetical patients move through the model from left to right for each cycle length (1 year). On the basis of initial clinical characteristics, patients are subject to the risk for various diabetes-related complications and death. Patients who survive a given year repeat the cycle until death.

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Figure 2.
Expected quality-of-life benefits of intensive glucose control for patients age 60 to 64 years and 75 to 79 years.

Level of comorbid illness or functional impairment is indicated by additional points on the mortality index score (1 to 2 points per illness or impairment). Expected benefits for patients age 65 to 69 years and 70 to 74 years of age are intermediate to those of the subgroups presented here (Appendix Figure 1). A. Patients with new-onset diabetes. B. Patients who have had diabetes for 0 to 5 years. C. Patients who have had diabetes for 5 to 10 years. D. Patients who have had diabetes for 10 to 15 years.

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Appendix Figure 1.
Expected quality-of-life benefits of intensive glucose control for patients age 65 to 69 years and 70 to 74 years.

Level of comorbid illness or functional impairment is indicated by additional points on the mortality index score (1 to 2 points per illness or impairment). A. Patients with new-onset diabetes. B. Patients who have had diabetes for 0 to 5 years. C. Patients who have had diabetes for 5 to 10 years. D. Patients who have had diabetes for 10 to 15 years.

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Figure 3.
Expected differences in lifetime incidence of specific complications for patients age 60 to 64 years and 75 to 79 years.

Level of comorbid illness or functional impairment is indicated by additional points on the mortality index score (1 to 2 points per illness or impairment). The relationships between absolute risk reductions for specific events and the mortality index score are not consistently monotonic because we assessed fairly wide ranges of duration of diabetes (5 years) and the individual complication models vary in their responsiveness to this variable. Expected differences for patients age 65 to 69 years and 70 to 74 years are intermediate to those of the subgroups presented here (Appendix Figure 2). A. Patients 60 to 64 years of age who have new-onset diabetes. B. Patients 60 to 64 years of age who have had diabetes for 10 to 15 years. C. Patients 75 to 79 years of age who have new-onset diabetes. D. Patients 75 to 79 years of age who have had diabetes for 10 to 15 years.

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Appendix Figure 2.
Expected differences in lifetime incidence of specific complications for patients age 65 to 69 years and 70 to 74 years.

Level of comorbid illness or functional impairment is indicated by additional points on the mortality index score (1 to 2 points per illness or impairment). The relationships between absolute risk reductions for specific events and the mortality index score are not consistently monotonic because we assessed fairly wide ranges of duration of diabetes (5 years) and the individual complication models vary in their responsiveness to this variable. A. Patients 65 to 69 years of age who have new-onset diabetes. B. Patients 65 to 69 years of age who have had diabetes for 10 to 15 years. C. Patients 70 to 74 years of age who have new-onset diabetes. D. Patients 70 to 74 years of age who have had diabetes for 10 to 15 years.

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Letter to the Editor
Posted on July 14, 2008
Thomas E. Finucane
Johns Hopkins Bayview Medical Center
Conflict of Interest: None Declared

Huang and colleagues introduce their article on type 2 diabetes in the elderly by stating that "intensive glucose control decreases the risk for multiple complications in patients with diabetes..." They provide 3 references. Two are trials of type 1 diabetes. The third is UKDS 33 which showed a reduction in retinal photocoagulation and little else in benefit from tight control. The authors are correct that goals of glycemic control should be discussed between physician and elderly patients. But these discussions are appropriate for younger patients with type 2 diabetes as well.

Conflict of Interest:

None declared

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