Sometimes less is better
Sometimes less is better – so why don’t doctors ‘deintensify’ medical treatment?
Doctors know a lot about when to start medications to treat disease. But sometimes our focus on starting medicines means we can confuse providing more care with providing better care. And better care sometimes means fewer medicines, not more.
For instance, patients with high blood pressure who have lost weight or are exercising more may find that they may no longer need blood pressure pills. Patients with heartburn who take proton-pump inhibitors (such as Nexium) may do just as well with a lower dose or occasional therapy. Patients who take medications for osteoporosis may be candidates for “drug holidays.”
And as we age, our bodies process medications differently and we become susceptible to different side effects. What may have been the right treatment for a patient when she was 50 can turn out to be dangerous at 80.
That may mean many patients can have their treatment deintensified – changing or stopping medicines when they are no longer needed. But it turns out, doctors often don’t do this, even though it means patients risk fewer side effects and can avoid extra health costs. So why, and when, should a person’s drugs be deintensified?
Who benefits from having treatment deintensified?
Diabetes makes a great case study for deintensification, because patients often need treatment over the course of a lifetime. For decades, doctors have focused on treating diabetes intensively to lower their patients’ risks of developing kidney disease and other complications. But we now know that intensive treatment for diabetes, like nearly all medical treatments, can have also cause serious harm, such as low blood sugar levels, which can lead to falls and memory problems, and even death.
Many patients with diabetes may benefit from deintensification. Older patients, in particular, are more likely to experience drug side effects, and patients taking more than one medicine run a risk of harmful drug interactions. Older patients also have less to gain from intensive treatment of their diabetes because they have fewer years to develop the long-term effects of diabetes on their bodies. And as a person’s health status changes, they may need fewer – not more – medicines to manage their diabetes.
That doesn’t mean intensive treatment is bad – it just means that not every patient needs it, and some patients may need it for only a certain amount of time. For example, intensive treatment to lower blood sugar in younger people lowers their risk of developing kidney and eye disease, and other harmful long-term effects of diabetes.
So drug choices need to be individualized based on what a person stands to gain from intensive treatment, balanced against their risk of treatment side effects. Deintensifying treatment means finding the sweet spot between too much and too little medicine.
Even though many clinical practice guidelines already recognize that goals for diabetes control and other chronic conditions should be based on a patient’s individual risk and benefits of treatment, this message hasn’t gotten through to all doctors and patients. And none of these guidelines specify who should have treatment deintensification and when that should happen.
Older diabetes patients are often overtreated
Several studies have found that older patients with diabetes are often overtreated – meaning that they are taking more medications, or medications at too high doses, than they need to achieve a safe level of sugar control.
Recently, we reported that doctors deintensified medications for only a quarter of nearly 25,000 older patients with diabetes who were treated to potentially dangerously low levels of sugar control. Deintensification rates barely budged even if the patient has had low blood sugar multiple times or had severely limited life expectancy.
In patients with low blood sugar who did not have their treatment intensified, 40% did not even have their diabetes control values rechecked within six months. This means that the majority of overtreated patients continued to take medications that they did not need or at doses that were too high.
Why don’t clinicians deintensify treatment?
Doctors usually focus on intensifying therapy to control blood sugar, which means that deintensifying treatment can take a completely new mindset.
In another study, we asked primary care providers what they thought would be appropriate treatment for a hypothetical patient in his late 70’s who has had diabetes for 20 years and also has kidney disease. The patient takes two pills every day to manage his diabetes, but could be fine just taking one of them. We found that 39% of almost 600 respondents felt that this patient would continue to benefit from stringent diabetes control – despite current expert recommendations to the contrary.
When we looked at reasons why, 42% of providers worried that not treating him intensively could harm the scores on their clinical report cards, which track the quality of care the doctors’ provide to their patients. Nearly one-quarter worried about legal liability resulting from decreasing medications.
Just as troubling, 30% wouldn’t deintensify the diabetes medications because they worried they wouldn’t have enough time to discuss these changes with the patient.
Finding the treatment sweet spot
This isn’t just an issue for people with diabetes – it’s an issue for anyone living with a chronic condition.
So how do we encourage appropriate deintensification in order to get to the sweet spot for treatment? There are many changes that could help.
First, health care systems should institute programs that systematically engage providers and patients to consider stopping medications that are no longer necessary.
For example, the VA has instituted a national “Hypoglycemia Safety Initiative” to encourage appropriate deintensification of diabetes medications in order to decrease the harm of intensive treatment among those at risk for hypoglycemia (low blood sugar).
Second, patients should ask their providers if their medications are still necessary. Some could possibly be stopped or the dose decreased. Providers should regularly reexamine their patients’ medication lists and discuss the options.
Third, while existing clinical practice guidelines already say that treatment should be based on risk and benefits for an individual patient, these guidelines should go a step further and include explicit recommendations for deintensification to help providers and patients decide when stopping a medication might be wise.
Fourth, the way we assess whether doctors are providing high-quality care should look not just at whether high-intensity treatment is provided for a patient, but also if doctors are deintensifying treatment when possible and beneficial.
Finally, we must get out the message that more is not always better. Campaigns such as Choosing Wisely, in conjunction with Consumer Reports, educate the public about care that might not be needed, but only 21% of US doctors surveyed were aware of the campaign.
Changing the “more is better” mindset among both patients and providers will not be easy, but it will be essential if we want to ensure that patients get the treatments they need but not those that are unnecessary and potentially harmful.