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Will new diabetes targets neglect high-risk patients?

The new diabetes targets may not be achievable, will be too aggressive and won't target those at highest risk, warns Dr Martin Hadley-Brown. But Dr Jonathan Graffy argues that by setting targets across a range of blood sugars, the indicators will extend benefits to more patients and drive improvement

The new diabetes targets may not be achievable, will be too aggressive and won't target those at highest risk, warns Dr Martin Hadley-Brown. But Dr Jonathan Graffy argues that by setting targets across a range of blood sugars, the indicators will extend benefits to more patients and drive improvement

Changes in the QOF indicators for glycaemic control in diabetes have been agreed by the BMA and Department of Health for 2009/10. But the negotiating teams have ignored the suggestion that progressive improvements in HbA1c – for example a 1% reduction over 12 months – would be the best way to direct efforts towards patients at highest risk.

The previous payment triggers were at an HbA1c of 10% (11 points) and 7.5% (17 points), but these are being replaced by three new indicators. Seven points have been added, reallocated from other QOF areas, and the revised indicators stand at HbA1c levels of 7% (17 points, thresholds 40-50%), 8% (8 points, thresholds 40-70%) and 9% (10 points, thresholds 40-90%).

Most practices will lose points under this formula. Experience shows, however, that practices will expend great efforts to achieve the targets. How, you might ask, can this not be good for patients? Surely there is an overwhelming argument that reducing hyperglycaemia will reduce the complications of diabetes? Surely an HbA1c target no higher than 6.5% should be the aim for most patients and QOF thresholds should be tightened to reflect this?

Would that life were so straightforward. The QOF thresholds were supposed to be evidence-based, achievable by most good practices and beneficial to patients. The 7% target is unlikely to be generally achievable, as shown by the fact that few diabetes trials achieve 50% of patients below that threshold except in carefully selected populations. Trials that do attain anywhere near that level exclude many of those who make up our practice populations, on the grounds of age, initial hyperglycaemia or other morbidity. The trial population is treated far more intensively than in normal practice and dropout rates are often high. Even more worryingly, some trials of intensive glucose lowering have found increased mortality, possibly as a result of actual or relative hypoglycaemia. The precise significance of these findings, most evident in the ADVANCE study, is still debated but it is likely to represent a real danger.

So the evidence that intensive blood glucose control is generally achievable is lacking, and there are even doubts over the safety of nonspecialist practices attempting to impose such tight levels of glycaemic control on a real-world population. The incidence of hypoglycaemic events in people with type 2 diabetes is unclear. Figures from East Anglian Ambulance NHS Trust show the majority of hypoglycaemic callouts are not reported back to GPs. Hypoglycaemia may not only be unpleasant but also potentially dangerous, particularly in elderly patients liable to falls or fractures or living alone, so it is essential we take this into account. Although some modern oral antidiabetic drugs minimise the risk compared with sulphonylureas, it is sulphonylureas which remain the standard agents for use after metformin and the temptation will be to use higher doses in more patients to achieve the new targets.

Make no mistake – I desire the best possible glycaemic control for all patients with diabetes, together with all other best care. The QOF has been a significant driver of better performance from primary care. But I do not believe this tightening of QOF targets has been sufficiently considered, or that its potential implications for whole practice populations have been taken into account. The wider use of exception reporting is one answer but its implications for practice prevalence, and the likely reactions of PCTs, will make it an impractical one. I simply have to trust that my practice colleagues will continue to treat each person with diabetes as an individual, setting personal HbA1c targets, and allowing their QOF income to be pared back by the Government as a result. Hardly a constructive partnership.

Dr Martin Hadley-Brown is chair of the Primary Care Diabetes Society and a GP in Thetford, Norfolk

There have been real improvements in diabetes care since the QOF was introduced in 2004. More patients are diagnosed, and risk factors such as raised blood pressure, hyperglycaemia and raised cholesterol are managed more effectively. The QOF has provided a means to reward systematic care and GPs and practice nurses have responded with results that have impressed policy-makers across the world.

In 2006, QMAS data revealed 62% of patients had an HbA1c below 7.5%, although practices only needed 50% of patients to be below this to achieve full points. And 92% of patients had an HbA1c below 10%, also above the top payment threshold of 90%. So should we sit back, rest on our laurels and assume we can do no more?

In May last year, NICE published revised guidance on type 2 diabetes emphasising the need to set individual targets. The institute saw 6.5% as ideal, but cautioned against intensive efforts to get below this.

It recognised that for many people, higher targets were more appropriate. But as a result of this new guidance, the QOF targets looked increasingly out of line.

QOF targets for a measure like HbA1c aren't meant to dictate individual treatment decisions; instead they provide a means to audit performance across the range of people with the condition. This is important because the current targets (7.5% and 10%) only measure performance at two points on the distribution curve.

The new targets will assess how many patients have readings below 7%, 8% and 9%. Statistics from the National Diabetes Audit show how many people were below each target in 2006. In that year, 45% had HbA1c readings below 7%, 72% under 8% and 85% under 9%. This suggests practices will need to do more to pick up the extra points available for these new targets. But it also suggests the targets are achievable. Even if GPs don't quite get enough people below a target level, there are still payments based on the threshold scale.

Some have suggested GPs might neglect people with HbA1c levels greater than 10%, but these changes should have the opposite effect. They will encourage us to do more for people with poor control. If we can get their readings down to 9%, they should face fewer complications in the long term.

There are many reasons for poor control. People with type 1 diabetes may be more concerned about avoiding hypoglycaemic events than reducing HbA1c. People with type 2 diabetes may be reluctant to switch to insulin, although as ß-cell function declines over time their tablets may not be enough. Many don't follow healthy diets or lead active lives. Some baulk at taking multiple medications. Alcohol, depression and family stress all play a part. Despite efforts to provide education, some are still ill-informed about how to manage their condition. It's our job to help them. The idea we will give up on them because the target level is harder to achieve is ludicrous.

If the QOF is allowed to stagnate, politicians will question whether they are seeing the improvements they want. If GPs are complacent, there's a risk the money it brings will leach away. We should take this opportunity to make the targets relevant to more people with diabetes, across the whole range of HbA1c values. But controlling HbA1c is only part of the story. Managing blood pressure, weight and lipid levels are also important, as is the early detection of complications. The debate about HbA1c targets should prompt a wider discussion on how the QOF might better reward best practice for these other aspects of care.

Dr Jonathan Graffy co-authored the evidence report for the diabetes QOF indicators. He is a senior clinical research associate at the University of Cambridge and a GP in Waterbeach, Cambridgeshire

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