New QOF glycaemia targets are achievable and evidence basedBMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1915 (Published 12 May 2009) Cite this as: BMJ 2009;338:b1915
- 1MRC Epidemiology Unit, Box 285, Addenbrooke’s Hospital, Cambridge CB2 0QQ
- 2General Practice and Primary Care Research Unit, University of Cambridge, Cambridge
Lehman and Krumholz suggest that the revised targets for glycated haemoglobin in the quality and outcomes framework (QOF) pose a risk to people with diabetes, many of whom will need insulin if 50% are to achieve values of 7.0% or less.1 Fortunately, glycaemic control is rather better than they realise: in the 2005-6 national diabetes audit 45% of patients had values of 7.0% or less.2
They present an unbalanced view of recent data: tight glycaemic control was associated with fewer non-trivial microvascular complications,3 4 reduced cardiovascular risk,4 5 albeit only the trial with sufficiently long follow-up reporting significant results,3 and reduced mortality.3
They also completely overlook the incontrovertible evidence supporting tight control in type 1 diabetes. Observational studies show a continuous relation between glycaemia and risk of mortality and cardiovascular events. The reasons for the excess mortality in ACCORD remain unclear.5 However, participants had poor baseline glycaemic control and glycated haemoglobin was reduced rapidly (by 1.4% over four months) towards a target of 6.0%, often using rosiglitazone. ACCORD data may not be relevant to the QOF target of 7% for 50% of all diabetic patients.
People with diabetes and their professional advisers should negotiate individually tailored targets but avoid rapid reductions in glycated haemoglobin to below 6.5%. They can have confidence that the modest changes encouraged by the QOF are safe and will lead to further reductions in risk over time.
Cite this as: BMJ 2009;338:b1915
Competing interests: SG and JG were members of the expert reference group providing advice on the QOF diabetes targets.