Paper of the week: 03.08.18

Muir Gray’s paper of the week: For Patients With Type 2 Diabetes, What’s the Best Target Hemoglobin A1C?

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Reference: Abbasi J. For Patients With Type 2 Diabetes, What’s the Best Target Hemoglobin A1C?. JAMA. 2018;319(23):2367–2369. doi:10.1001/jama.2018.5420

Bottom line, chosen by Muir from the paper

Medical organizations are at odds over new guidance that recommends easing hemoglobin A1C (HbA1c) targets for patients with type 2 diabetes. The updated guidance statement

from the American College of Physicians (ACP), which focuses on glycemic control with medications, says clinicians should personalize goals and aim to achieve an HbA1c level of between 7% and 8% for most patients with type 2 diabetes.

The ACP set its target higher than recommended by other prominent health groups. The American Diabetes Association (ADA) generally recommends anHbA1C goal of less than 7%, while the American Association of Clinical Endocrinologists (AACE) advises even tighter control of 6.5% or lower if it can be achieved safely.

…… These efforts to reach an HbA1c of less than 7% can also result in overburdened patients

with a poor quality of life, Lipska said. This can be especially true for patients who are managing multiple chronic conditions and medications, sometimes with limited social and financial support. “We have to be very mindful about the trade-offs in the benefits versus the harms on quality of life,” Lipska said….. Personalization Is Key.

Implications for value improvement

The classic Donabedian image below of 1980 shows the changing relationship between benefit and harm as the intensity of treatment increases.

What is the right level? Well that is a matter of judgement for the population because the lower the target, the higher the level of investment required and less favourable the benefit to harm ratio. Furthermore, the target needs to take into account the values the person we call the patient places on the benefits and the harms, as the article rightly emphasises.