Variation in treatment preferences and care goals among older patients with diabetes and their physicians

Background: Older persons with diabetes are heterogeneous with respect to life expectancy and frailty, and new guidelines recommend individualizing care. Objectives: (1) To describe variation in the preferences of older patients with diabetes regarding aggressiveness of glycemic control and avoiding diabetic complications. (2) To determine correlates of patient preferences and physician treatment goals. (3) To assess whether physicians' goals were consistent with their patients' preferences. Research Design: Cross-sectional surveys and chart reviews in urban academic clinics. Subjects: Four hundred seventy-three patients with diabetes age 65 or older and 64 physicians. Measures: Patient preferences (utilities on a scale from 0 to 1, 0 death, 1 = perfect health) for diabetic complications and intensity of treatment, and physician target treatment goals and ratings of aggressiveness of approach. Results: Eighty percent of the patients were African American, 63% were women, average age was 73.7 +/- 5.9 years and 26% expected to live 5 years or less. Patient preferences/utilities showed significant variation: blindness 0.39 (SD, 0.32), lower leg amputation 0.45 (0.34), conventional treatment 0.76 (0.27), and intensive insulin treatment 0.64 (0.32). Physicians' hemoglobin Ate goal was <= 7% in 69% of patients. Greater estimated patient life expectancy was consistently associated with higher patient utilities and was associated with physicians' willingness to use aggressive treatments. Physicians' treatment goals and approaches were associated with patients' utilities for treatment. Conclusions: Older patients vary greatly in their preferences regarding diabetic complications and treatments. Acknowledging patient preferences, along with life goals and prognostic data, may improve quality of treatment decisions.