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GPs set to struggle with new NICE diabetes targets

By Lilian Anekwe

GPs will struggle to meet proposed NICE diabetes targets for most of their patients according to research to be presented at next month's Diabetes UK Annual Professional Conference.

The new NICE targets - due to be published in April - differ substantially from the current QOF, including targets of 6.5% for HbA1c and 140/80mmHg for blood pressure or 130/80mmHg for those with diabetes and renal disease.

But the new study of more than 12,000 patients with diabetes on a regional diabetes register in Dundee found that GPs would have reached the new NICE targets for blood sugar, blood pressure and cholesterol in only 9.2% of patients, compared with 33.9% under QOF targets, a difference of 73%.

Only 6.5% of patients fail to meet any treatment targets under QOF, compared with nearly one in five (19.2%) under the more stringent targets proposed by NICE. HbA1c targets were hardest of all to meet.

Study author Dr Alistair Emslie-Smith, a GP in Dundee, said: ‘Despite high levels of monitoring, diabetes control targets are hard to achieve, and only a small proportion of subjects achieve QOF targets across all indices.'

Dr Roger Gadsby, a GP in Nuneaton, Warwickshire, who is a member of the NICE type 2 diabetes guideline development group, admitted: ‘There are huge difficulties in getting patients from 7.5% to 6.5%.'

But he added: ‘It's right that there's a difference between NICE and QOF as the two are doing very different jobs. NICE is a goal of perfection.'

The debate over ever-lowering diabetes targets took an unexpected turn last week with the announcement that an intensive blood-glucose lowering arm of a major trial was stopped due to an increase in patient deaths (see box).

A second study to be presented at the Diabetes UK conference claims that achieving real and consistent lipid targets in patients with diabetes is difficult due to huge variability in successive readings.

The study of 26 patients given either simvastatin 40mg or atorvastatin 10mg suggests that in order to sustain a target cholesterol level below 5 and 3, patients will actually need to maintain a mean total cholesterol of 4.2-4.3mmol/l or LDL of 2.3-2.4mmol/l.

Lead author Dr Thozhukat Sathyapalan, a clinical research fellow in diabetes and endocrinology at the University of Hull, said cholesterol levels ‘needed to consistently remain below target are much lower than the target itself. This means that targets… may overestimate the lipid reductions required.'

How low is dangerously low? How low is dangerously low?

The debate over how aggressively to treat patients with type 2 diabetes heated up last week, when the US National Heart Lung and Blood Institute stopped the intensive blood-glucose lowering arm of the ACCORD trial 18 months early, because of an unacceptable increase in the risk of death.
After four years of follow-up, patients who had had their HbA1c levels lowered to <6.0% had="" a="" 27%="" higher="" relative="" risk="" of="" dying="" than="" whose="" hba1c="" target="" was="">
Researchers said the increased risk equated to 3 extra deaths per 1,000 participants per year, a risk that ‘outweighed the potential benefits of the intensive treatment strategy'.
The division between the two has been controversial. Many GPs and academics felt that the draft NICE type 2 diabetes guidance – published in October – missed an opportunity to try for the greatest gains in people with diabetes.

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