Diabetes is a condition characterised by higher-than-normal levels of sugar (glucose) in the bloodstream. One problem here is that there is more tendency for glucose to react with proteins and fats in the body (through a process known as glycation) that can damage tissues. The complications of diabetes, including nerve, vessel, eye and kidney damage, generally have their roots in glycation.
So, it makes sense then keeping blood sugar levels in check should help to prevent the complications of diabetes. So important is this deemed to be, that the UK government gives general practitioners (GPs) money to ‘incentivise’ them to assist their patients in achieving relatively tight control over their blood sugar levels. From April of this year, if GPs can get half of their type 2 diabetic patients to have a HbA1c level (this is a measure of blood sugar control over the preceding 3 months or so) of less than 7 per cent, then the practice gets an additional payment of £3000 ($4250). Prior to this, the target set by the government was 7.5 per cent. Clearly, the government feels that when it comes to HbA1c levels, lower is better.
I imagine that not everyone will be comfortable with the notion of doctors being financially incentivised to treat patients in a way deemed appropriate by their government. But, these individuals at least can take comfort in the fact that the government’s strategy is ‘evidence-based’. However, as a recent piece in the British Medical Journal [1] points out, this is far from assured.
In this piece, the authors (one a UK GP and the other a professor of medicine, epidemiology and public health in the USA) detail the results of three recent studies which suggest that tighter control of blood sugar by pharmacological means may not be such a good idea. One of these trials [2] I reported on here. It showed a higher mortality rate in individuals who were more intensively treated. The other two studies cited [3,4] showed little or no differences in outcomes.
All of the studies found intensive treatment to be associated with an increased risk of hypoglycaemia (low blood sugar). The authors summarise the findings of these three studies thus: Taken together, the three trials show that no reduction of clinically meaningful adverse outcomes occurred in patients with long standing type 2 diabetes treated to a glycated haemoglobin below 7.0% in the time periods studied. Moreover, intensive treatment is accompanied by substantial costs and an increased risk of hypoglycaemia and perhaps mortality.
The authors point out that these studies were done in older individuals (mean age 60+) with quite long-standing illness. There is some evidence that more intensive therapy in younger individuals (mean age 54) with newly diagnosed diabetes [5]. Nevertheless, the authors argue, the current state of the evidence gives us enough reason to reconsider the conventional wisdom regarding blood sugar control in type 2 diabetes.
They bring up another interesting point too, when they question whether all strategies that reduce HbA1c levels have the same effect. Even for a given level of blood sugar lowering effect, different drugs or combinations of drugs may have very different effects on the outcomes that matter (like risk of disease and death). As they point out, our knowledge in this area is quite unsatisfactory.
It seems that not only is the UK government’s recent move to lower the HbA1c targets for GPs not particularly evidence-based, there is a risk it might actually do more harm than good. The authors of the BMJ piece use some good old-fashioned plain-speak to conclude their piece by stating: The change of target from 7.5% to 7% should be withdrawn before it wastes resources and possibly harms patients.
References:
1. Lehman R, Krumholz HM. Tight control of blood glucose in long standing type 2 diabetes. BMJ 2009;338:b800
2. Action to Control Cardiovascular Risk in Diabetes Study Group. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med 2008;358:2545-59.
3. ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 2008;358:2560-72.
4. Duckworth W, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 2008;360:129-39.
5. Holman R, Paul S, Bethel MA, Matthews D, Neil A. 10-year follow up of intensive glucose control in type 2 diabetes. N Engl J Med 2008;359:1577-89.
Being T2db my own personal experience suggests to me that HbA1c values can be regulated significantly by diet and further improved by factoring in some regular exercise. I concede this would not be wholly true for all and would depend upon the degree of advancement of the patients condition. Without doubt factors other than diet and lifestyle play a part, but diet and lifestyle are the leading members of the cast.
Target setting and incentivising in simplistic models have no place in the management of the complex arena of patient and nations’ health. If patients fully understood what lies at the root of the global epidemic surely they could be motivated to adopt better diet and lifestyle choices. I am not suggesting it would be easy; what is needed is a sea change in our outlook, and in the outlook of those elected to govern us and those appointed supposedly to look after our interests.
Targets and incentives insult the professionalism of GPs.
Of course pharmacological intervention has a part to play in the treatment of many conditions. On the other hand, when the health service and patients put too much trust in the pharmaceutical industry we play into the hands of that industry. We put our trust in people whose intentions are for profit and not necessarily for our well-being. I wonder what were the origins of the bulk of ‘evidence’ upon which the government and its’ advisers based the decision?
Now patients have to put their trust in GPs whose actions may be influenced by financial incentives and guided by unreliable or unbalanced evidence.
Good blog post and raises some good points. Yet again it is pouring the money into the wrong places. As a type 1 diabetic I have learnt to control my blood sugar levels through nutritonal support and an excellent nutritional consultant to help me. Most diabetics both type 1 and 2 are desperate for one to one help, advice and support with their diets as individuals. We are all on different medication which reacts in differnet ways that requires a good dietician or if you can afford it a clinical nutritional consultant.
The lower our blood sugar levels have to be which has changed for both type 1 and 2 we are at greater risks from ‘hypos’, increasing the risk of ending up with compications with large fluctuations in blood sugar levels. A slightly higher reading (their old targets) would be better for type 2’s especially.
My advice is for too long we have been told to eat lots of carbohydrates. That in itself brings detrimental effects on health.
I was diagnosed with type 2 diabetes after a stroke 10 months ago, I have eaten a low carb diet since and my blood sugars are perfect. I can even have the odd piece of 70% dark chocolate now without raising my blood sugar…….The diet the so-called diabetes “experts” recommend is total rubbish, the diabetic nurse I saw told me I was her only diabetic she didn’t worry about, I told her what I was eating and she even tried the diet herself and lost a stone, but, couldn’t recommend it to her patients as it wasn’t government guidelines. Criminal!
Good grief ! I’m a type 2 diabetic and I’ve got my HbA1c down to 5.4% by keeping to a very low carbohydrate diet à la Dr Bernstein. It’s hardly surprising that type 2’s prescribed hypoglycaemic medications will suffer adverse effects and that lowering their HbA1c’s will come at a price, but if GPs advised dietary change then their patients could lower their HbA1c much more safely. The advice given to me by the dietician at my GP’s practice, though, would have raised my HbA1c to heaven knows what and I’d have needed to take the Prandin I am prescribed. When will GPs and dieticians learn that it is the carbohydrates that diabetics are told to eat which causes high blood sugars and high HbA1c’s ?
Btw, if GP’s are given extra money to lower their patient’s HbA1c’s they should pass it on to those patients like me who do the hard work !
Anne
I do not think that financial incentives for GP’s should be linked to medical targets for managing all sorts of conditions as we know fashions in medical science and the findings of research can change, the effects of certain drugs, such as statins may be conterproductive etc. HRT is no longer assumed to be the greatest thing for all women… Financial incentives are responsible for people on thyroxine having to get a repeat prescription every month ( instead of 3 months supply) because the GP loses money if they don’t comply with the PCT rules on repeat prescriptions whatever the condition. I find it demeaning. Most people who take this are older, and its ageist having to ask for a packet a month as if we’re gaga. You can go on a 6 month collect @ pharmacy schemes which actually costs the NHS more. At the age of 60 I was offered a age health check. My blood pressure was borderline high, my cholesterol was high & I was told on the phone by the GP they could put me on a ‘pill’ to lower it. I was sent off to the hospital for a cardiogram – (financial incentive) which turned out fine, but it was depressing and made me feel I was being medicalised and old and about to be a ‘patient’ at a time when you have to make adjustments to your way of life, re. retirement. I looked into the question of taking statins and was not happy about that. It has left me feeling distrustful of my GP’s and very wary of being stuck on drugs that for all I know interfere with my quality of life and have serious side effects. So I’m trying to deal with these health issues myself… losing weight, giving up regular alcohol blah blah
Horrific Story: Acquaintance diagnosed as diabetic. Age 49, very overweight. Nurse gave him a strict diet, but doctor just sad. ‘Eat what you like’. Person knows nothing about diet and I would not interfere, but horrified and worried! Hilda Glickman Nutritionist.
Hilda, Why would you not offer some advice as you are a qualified nutritionist?
Susan
Seems some other people feel strongly about the recommended one-month repeat prescription of thyroid medication: see here http://news.bbc.co.uk/1/hi/health/7941889.stm
To Sue,
I would like to he has not come to me for advice and he would have to be a proper client etc but also Iit would be irresponsible for me to go against the advice of the GP who is treating him-might also be illegal. Hilda
Do you not mean “mistreating” him? Surely it wouldn’t be irresponsible, in the classic sense, to offer better advice.
Hilda,
Yes, you’ve got to be careful. With naturopaths in Australia you’ve got to be careful not to actually diagnose a condition because you are not a doctor. We study anatomy and physiology, biochemistry, microbiology and talk about all the relevant symptoms for most conditions etc – so would be able to diagnose. You always have to cover yourself and suggest they see their GP for major issues.
John,
You might be interested to know that this has been the point of some considerable discussion among diabetics. The consensus is that in most cases taking better care of yourself is largely down to nutrition (not least ignoring the ‘experts’), exercise, increased self-testing etc — nearly all of which is down to individual people taking more responsibility for their own health.
Why on earth should my doctor, who frankly knows jack about my diabetes anyway, be financially rewarded for MY efforts to take better care of myself?
Are the financial incentives given to UK doctors regarding diabetes doing more harm than good?
.. topic gets a mention at NEW SCIENTIST
http://www.newscientist.com/article/mg20227063.600-payments-to-doctors-should-be-posted-online.html