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Full reference and title from the journal:

Intensive Glucose Control in Patients with Type 2 Diabetes — 15-Year Follow-up
Reaven P.D. et al (2019) N Engl J Med 2019;380:2215-24.

This week’s blog is brought to you by: Professor Sir Muir Gray


Authors conclusion:

“In conclusion, in this group of participants with type 2 diabetes who were at high risk for cardiovascular disease, 5.6 years of intensive glucose lowering to a glycated hemoglobin level of 6.9% did not reduce the incidence of major cardiovascular events over a follow-up of 13.6 years or reduce total mortality or improve quality of

life over a total follow-up of 15 years. Although there was a significantly lower risk of major cardiovascular events during the 7.1 years of separation of the glycated hemoglobin curves (during the trial and observation periods), there was no evidence of a beneficial legacy effect after this period of improved glucose control.”

3V bottom line:

Doing more for people with a long-term condition seems like a good idea butas Avedis Donabedian argued in 1980, more is not always better and this seems to be the case with Type 2 diabetes. The authors also report there was no improvement in quality of life. Closer examination might have revealed that for some people there was harm resulting from more intensive treatment as well as extra costs in terms of money and, perhaps more important, the time of the people with Type 2 diabetes.

3VH – Implications for value

This has been shown before:

“In this US cohort of adults with stable and controlled type 2 diabetes, more than 60% received too many HbA1c tests, a practice associated with potential overtreatment with hypoglycemic drugs. Excessive testing contributes to the growing problem of waste in healthcare and increased patient burden in diabetes management.”

HbA1c overtesting and overtreatment among US adults with controlled type 2 diabetes, 2001-13: observational population based study Rozalina G McCoy R.G. et al (2015) BMJ 2015;351:h6138 doi: 10.1136/bmj.h6138

This problem of well-intentioned over treatment cannot be tackled through the structure of payers and providers. It has to be tackled by the network of clinicians, people from finance and patient representatives responsible for the population. They have to be given responsibility for all the resources for people with Type 1 and Type 2 and asked to identify sub groups of the population who need more high value intervention, and often this would be people from deprived parts of the population because inequity is very common in long term conditions. Then they should be asked to review the value frameworks for the systems of care for people with Type 1 and type 2 with the aim of shifting resources from lower value activity, for example intensive treatment for people with Type 2 diabetes, to, for example the podiatry service.