See links to video and audio resources at the bottom of this post.
In an article published April 21, 2009 in Annals of Internal Medicine, Mayo Clinic endocrinologist Victor Montori, M.D., and co-author Mercè Fernández-Balsells, M.D, review evidence from several large randomized trials involving patients with type 2 diabetes and conclude that current diabetes treatment guidelines place inordinate emphasis on tight glucose control and should be replaced with broader, more flexible standards that incorporate strategies proven to reduce mortality and improve quality of life for patients.
Dr. Montori will discuss the findings during a special one-hour Twitter chat scheduled for Monday, April 27 at 5 p.m. CDT. Follow the Twitter hashtag #a1cflex to participate in the discussion.
Some diabetes guidelines set low glycemic control goals for patients with type 2 diabetes mellitus (such as a hemoglobin A1c level as low as 6.5% to 7.0%) to avoid or delay complications. Our review and critique of recent large randomized trials in patients with type 2 diabetes suggest that tight glycemic control burdens patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return. We believe clinicians should prioritize supporting well-being and healthy lifestyles, preventive care, and cardiovascular risk reduction in these patients. Glycemic control efforts should individualize hemoglobin A1c targets so that those targets and the actions necessary to achieve them reflect patients’ personal and clinical context and their informed values and preferences.
Dr. Montori says current diabetes treatment guidelines and pay-for-performance measures make it “impossible” for physicians to have discussions with patients about broader treatment strategies that have demonstrated benefits in patient outcomes. As he concludes in the video and audio segments linked below:
The fundamental reason it’s not possible is that clinicians are committed, either by their understanding of the data or more likely by these policies of achieving A1c of less than 7 percent as a measure of the quality of their work, that they cannot afford to have a conversation with their patients in which they say, “You know, the sugar control is not the key issue. The key issue is your overall health, and the things that impact your overall health are paying attention to your wellness, your lifestyle and your cardiovascular risk reduction. The sugar thing, unless it’s giving you symptoms, can wait.” We cannot have that conversation because clinicians are being held accountable to a single measure – of sugar – to describe all that care for a patient with diabetes. And that measure of sugar is so strict that it does not give any leeway to individualized care. Our results would suggest that there is no – or very limited – benefit from that approach, and in fact an approach that focuses on the patient, rather than on the numbers, would be potentially more beneficial.
Media Files (right-click and “Save as…” to download)
Video file (.mov – 416 MB)
Audio file (.wav – 48.4 MB )