A Performance Measure for Overuse? The Loosening Of Tight Control In Diabetes
Performance measures for tighter glycemic control appeared following the DCCT trial (Type 1 diabetes) in 1993 and the UKPDS trial (type 2 diabetes) in 1998., About 7 years ago groups recommended that glycohemoglobin concentrations be less than 7%, even though clear evidence of improved net outcomes was lacking.
Now in an editorial in the online version of Archives of Internal Medicine, Pogach and Aron have nicely summarized details of this journey into overuse of hypoglycemic agents resulting in the problem of harms probably outweighing benefits—at least for some diabetics—in an editorial entitled, The Other Side of Quality Improvement in Diabetes for Seniors: A Proposal for an Overtreatment Glycemic Measure.
The authors review the ACCORD, ADVANCE and VADT trials and remind readers that tight glycemic control did not yield cardiovascular benefits in these trials and that severe hypoglycemia occurred in the intensive treatment groups of all three trials. Of concern was the finding that ACCORD was terminated early because of increased mortality in the intensive glycemic treatment group. These trials appear to have increased concern about the risks of severe hypoglycemia in elderly patients and patients with existing cardiovascular disease, and the National Committee for Quality Assurance Healthcare Effectiveness Data and Information Set (HEDIS) modified its glycohemoglobin goal to less than 7% for persons younger than 65 years without cardiovascular disease or end-stage complications and diabetes and established a new, more relaxed goal of less than 8% for persons 65 to 74 years of age.
Kirsh and Aron took this a step further in 2011 and proposed a glycohemoglobin concentration of less than 7.0% as a threshold measure of potential overtreatment of hyperglycemia in persons older than 65 years who are at high risk for hypoglycemia. They point out that the risk for hypoglycemia could be assessed by utilizing data from the electronic medical record regarding prescriptions for insulin and/or sulfonylurea medications and retrieving information on comorbidities such as chronic kidney disease, cognitive impairment or dementia, neurologic conditions that may interfere with a successful response to a hypoglycemic event.
This commentary is worth reading and thinking about. We agree with them that the time has come to take more actions to prevent the risk of possible overtreatment in diabetes.
 The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Engl J Med. 1993 Sep 30;329(14):977-86. PubMed PMID: 8366922.
 Effect of intensive blood-glucose control with metformin on complications in overweight patients with type 2 diabetes (UKPDS 34). UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998 Sep 12;352(9131):854-65. Erratum in: Lancet 1998 Nov 7;352(9139):1558. PubMed PMID: 9742977.
 Pogach L, Aron DC. Sudden acceleration of diabetes quality measures. JAMA. 2011 Feb 16;305(7):709-10. PubMed PMID: 21325188.
 Published Online: September 10, 2012. doi:10.1001/archinternmed.2012.4392.
 Kirsh SR, Aron DC. Choosing targets for glycaemia, blood pressure and low-density lipoprotein cholesterol in elderly individuals with diabetes mellitus. Drugs Aging. 2011 Dec 1;28(12):945-60. doi: 10.2165/11594750-000000000-00000. PubMed PMID: 22117094.