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Beyond Compliance, Adherence, & Concordance - Supporting The Patient’s Implementation Of Optimal Treatment

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Diabetics Weigh Cost Of Compliance Vs Longer Life

September 28th, 2007 at 11:46 am · Allan Showalter, MD · Clinical Info · No Comments



The Diabetics’ Quality Of Life Study

Patient Perceptions of Quality of Life With Diabetes-Related Complications and Treatments
Elbert S. Huang, MD, MPH1, Sydney E.S. Brown, AB1, Bernard G. Ewigman, MD, MSPH2, Edward C. Foley, MD, MPH2 and David O. Meltzer, MD, PHD1 Diabetes Care 30:2478-2483, 2007



This study quantified how 701 adult patients with diabetes weigh the quality of life associated with complications of their disease and treatments for that disorderby “elicit[ing] utilities (ratings on a 0–1 scale, where 0 represents death and 1 represents perfect health) for hypothetical health states by using time-tradeoff questions. [The researchers] evaluated 9 complication states (e.g., diabetic retinopathy and blindness) and 10 treatment states (e.g., intensive glucose control vs. conventional glucose control and comprehensive diabetes care [i.e., intensive control of multiple risk factors]).”

In other words, patients had to select their preferences from a series of either-or options such as “Would you prefer five years of perfect health or 8 years life with blindness?” and “Would you prefer four years of life without taking insulin or six years of life taking insulin?”1

Results and Conclusions, excerpted from the abstract, follow:

End-stage complications had lower mean utilities than intermediate complications (e.g., blindness 0.38 [SD 0.35] vs. retinopathy 0.53 [0.36], P less than 0.01), and end-stage complications had the lowest ratings among all health states. Intensive treatments had lower mean utilities than conventional treatments (e.g., intensive glucose control 0.67 [0.34] vs. conventional glucose control 0.76 [0.31], P less than 0.01), and the lowest rated treatment state was comprehensive diabetes care (0.64 [0.34]). Patients rated comprehensive treatment states similarly to intermediate complication states.
End-stage complications have the greatest perceived burden on quality of life; however, comprehensive diabetes treatments also have significant negative quality-of-life effects. Acknowledging these effects of diabetes care will be important for future economic evaluations of novel drug combination therapies and innovations in drug delivery.

Commentary

1. This may be the rare case when the clinician reading the published scientific report may benefit by also perusing a secondary article about the same research carried in the lay press.

The findings are appropriately, if dryly, reported in the Diabetes Care article but take on additional impact when a specific case is described. The Chicago Tribune article about the study, Some diabetics sick of treatment ,2 for example, begins with the story of William Haynes:

William Haynes refuses to go on insulin. The retired Chicago UPS driver was diagnosed with Type II diabetes 15 years ago and was supposed to start giving himself insulin injections two years ago. But he says swallowing daily pills for his diabetes, high blood pressure and high cholesterol is enough of a chore. As a boy, he helped his mother and grandmother with their insulin shots. Now 59, he has decided: “I don’t want to be hooked up on insulin for the rest of my life.”
Chronic illnesses account for 70 percent of all deaths in the United States, according to the federal Centers for Disease Control and Prevention. But many of those living with the diseases are turning their backs on treatments they consider too confusing, too time-consuming or too physically uncomfortable.

2. I suspect that no clinician who treats patients with chronic disorders will be surprised by the findings (although seeing these outcomes expressed in such stark terms as “I’d give up 5 years of life to quit taking the pills” is likely to take one aback regardless). Given that, the fact that this is the first such study to quantify patient perceptions of quality of life on diabetes treatments and living with diabetes-related complications is amazing and not a little embarrassing for the profession.

3. Most poignant of all may be Dr Huang’s summary,

There is wide variation in how people view life with drugs. The majority, about 80 percent, can manage. But there is a vocal subgroup of patients who are willing to give up a lot to avoid medication.

That 10 percent to 18 percent of the total (and perhaps more, given that the study included only patients currently opting for treatment) felt their treatments were sufficiently burdensome that they would be willing to die earlier (up to 10 years earlier) if that were the tradeoff for stopping their medications renders adherence reinforcement efforts exponentially more complex both ethically and clinically.

Viewed from another angle, however, that quandary also speaks to the insufficiency of current definitions of compliance and adherence and the need to reorganize those principles into a more useful form. I’ve made this argument many times in the past and today will settle for providing links to one such essay captured in this set of two pontification-posts: The New, Improved Patient Compliance and Running Patient Compliance Up The Flagpole



Footnotes

__________
  1. These specific questions were not taken from the study but are offered only as examples of the forced choice format↩
  2. Some diabetics sick of treatment By Deborah L. Shelton. Chicago Tribune. September 27, 2007↩

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