By Richard Staines
Exclusive: NICE is to review the QOF diabetes targets after a major new study found taking HbA1c to below 7.5% could drive up mortality.
The research, based on 50,000 patients in UK general practice and published in The Lancet last week, found treating blood glucose to strict targets was almost as dangerous as not controlling it at all.
The study authors warned their results ‘cast doubt’ on tight blood glucose control, while one leading GP cardiovascular expert went further, insisting the QOF DM23 indicator was ‘dangerous’ and should be scrapped immediately.
Researchers stratified patients with type 2 diabetes on the UK general practice research database by their HbA1c levels and found the lowest mortality risk was among patients whose readings were around 7.5%.
In comparison, mortality was 52% higher in the lowest tenth of HbA1c levels recorded (around 6.4%), while in the highest tenth (10.6%), mortality risk was 79% higher.
Last year, NICE lowered the tightest HbA1c target in the QOF from 7.5% to 7% as part of its continuous review of QOF targets – and the blood glucose target in the institute’s own guidance is 6.5% for most patients (see box, right).
Study leader Dr Craig Currie, reader in diabetes from Cardiff University School of Medicine, said the study questioned the trend towards incentivising stricter glucose control regimes in the QOF.
Dr Currie told Pulse: ‘It certainly raises doubts about the value of putting all patients on extremely tight glucose control.’
He added that the research suggested that HbA1c targets should be individualised, based on factors such as age of diagnosis.
Dr George Kassianos, research fellow at the European Society of Cardiology and a GP in Bracknell, Berkshire, said the evidence, combined with the earlier ACCORD study, meant the current QOF target was dangerous and should be raised to 7.5%.
He said: ‘[The 7% target] can be seen as dangerous practice in view of the repeat findings that very low HbA1c kills. There should, therefore, be one change in the QOF, not only for next year but also for the current year, and that is the immediate abolition of QOF DM23. We cannot continue aiming for an HbA1c of less than 7%, knowing clear evidence that harm exists.’
But Professor Kamlesh Khunti, professor of general practice at the University of Leicester and a GP in the city, disagreed, insisting ‘the evidence base seems to be strong for 7%’.
Dr Colin Hunter, chair of the QOF independent advisory committee, set up by NICE to oversee the framework, told Pulse: ‘I am sure, as with all new evidence, that the QOF advisory committee will review the diabetes indicator.’
GPC deputy chair Dr Richard Vautrey said: ‘The reality is that any indicator for the QOF is based on the available evidence. If that evidence is substantial it could change – but it depends on taking all evidence together.’
How the new study could change practice
What NICE guidance says:
• Involve patient in decisions about HbA1c target, which may be above that of 6.5% set for people with type 2 diabetes in general
• Encourage patients to maintain their target unless the resulting side-effects or their efforts to achieve this impair quality of life
• Inform a person with a higher HbA1c that any reduction towards the target is advantageous
• Avoid pursuing highly intensive management to levels of less than 6.5 %
What the study says:
• The lowest mortality risk was in patients with HbA1c around 7.5%
• Mortality risk 52% higher in patients with HbA1c around 6.4%
• Mortality risk 79% higher in patients with HbA1c around 10.6%
Sources: NICE guidance CG66; Lancet 2010, online 27 JanuaryResearchers suggested individual HBA1c targets rather than intensive control for everybody Researchers suggested individual HBA1c targets rather than intensive control for everybody