If you can’t score a goal, move the goal posts !

Regular readers here know we never tire of publishing the NHS annual audits regarding diabetes in the UK. Year in and year out the abysmal lack of progress is presented. Of course the situation regarding numbers of confirmed diabetics goes forever up, the epidemic of type two diabetes continues unabated. The stats on HbA1c which give an illustration of how well controlled a diabetic is, are woeful in the extreme. So, what do you do if you want to give the impression you are making some headway, what do you do if you can‘t score a goal ? Improve treatment and reduce the grim numbers, not in the UK. In the UK they move the goal posts.

Results for England. The National Diabetes Audit 2010-2011
Percentage of registered Type 1patients in England
HbA1c >= 6.5% (48 mmol/mol) = 92.6%
HbA1c >   7.5% (58 mmol/mol) = 71.3%
HbA1c > 10.0% (86 mmol/mol) = 18.1%

Percentage of registered Type 2 patients in England
HbA1c >= 6.5% (48 mmol/mol = 72.5%
HbA1c > 7.5% (58 mmol/mol) = 32.6%
HbA1c >10.0% (86 mmol/mol) = 6.8%

These results are very similar to those obtained in previous NHS audits over the past 5 - 6 years.

"An NHS prescribing advisory body has called for a change in diabetes guidance to include a minimum HbA1c target level, reflecting the weight of trial data suggesting lowering blood sugar below a certain level may harm patients.

In the light of mounting evidence that driving levels down to below the 7.5% recommended in the QOF increases the risk of cardiovascular events.

The latest MeReC Extra includes an analysis of the UK primary care trial published in The Lancet in February, and follows an editorial in the BMJ which also questioned the clinical value of an HbA1c value of less than 7.0%.

The Lancet paper, a retrospective study using data from the UK General Practice Research Database, identified that a median HbA1c level of about 7.5% was associated with the lowest risk of all-cause mortality and macrovascular disease events.

But it also showed there was a U-shaped association between increased all-cause mortality above and below an HbA1c of 7.5%. Changes above or below an HbA1c of 7.5% was associated with a greater risk, regardless of whether treatment was intensified with oral hypoglycaemic agents or insulin injections.

Compared with the reference group who had a median HbA1c of 7.5%, all-cause mortality in the 6.4% HbA1c decile was 52% higher and 79% higher in the 10.6% HbA1c decile.

The May MeRec Extra suggested GPs ‘may wish to consider the implication of the study in their discussion with patients about risks and benefits of intensifying drug treatment and setting of individual HbA1c targets.'

It concluded: ‘If this ‘U-shaped' relationship between HbA1c levels and mortality in patients with type 2 diabetes receiving combination blood glucose lowering treatment is confirmed, this would add weight to the view that diabetes guidelines might need revision to include a minimum HbA1c value.'

The NPC review said that this evidence, in addition to similar findings from the ACCORD, ADVANCE and Veterans Affairs diabetes trials, which also failed to find a consistent significant benefit of intensive glycaemic control on cardiovascular outcomes and mortality, ‘added weight' to the possibility of a minimum HbA1c target."

As you can see the deeply flawed ACCORD trial is being trotted out again.

Eddie

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