QOF for diabetes: action overdue
Almost one year ago, we wrote an editorial pointing out the lack of
evidence from interventional trials to support a lowering of the glycaemic
target in type 2 diabetes to below 7% glycated haemoglobin (gHb)(ref 1).
Based on this lack of evidence for benefit, and some evidence of harm in
patients treated vigorously to achieve the a target below 7% (ref 2), we
called for an abandonment of this target in the Quality and Outcomes
Framework (QOF) which came into force in April 2009. At this point, the
measure still stands.
A large observational study has just been published which examines the
effect of additional glucose lowering medication given to nearly 29,000
patients with type 2 diabetes in the UK (ref 3). The level of gHb
associated with the lowest mortality in these primary care patients is
7.5%. Levels below 7% are associated with a higher mortality which is only
matched at the other end of the scale by levels above 9%, whether the
additional treatment was another oral drug or insulin. Although these
findings are not definitive, they are consistent with some of the trial
evidence and reflect what is occurring in clinical practice. The
accumulating evidence is suggesting the potential for an important safety
problem with a strategy to achieve a gHb below 7%. If these data had been
published for a particular drug, a moratorium on its use would in all
likelihood be declared until more reassuring information became available.
At this point the burden of proof is on proponents of the intensive
strategy to generate data that such a course is safe and effective for
older patients with established type II diabetes. And the effectiveness
should refer to patient outcomes.
Accordingly, we would like to recommend that the UK follow the lead of the
National Committee on Quality Assurance in the United States and suspend
this measure. We cannot risk harm by quality measures that encourage
practice patterns that the evidence cannot support and that may even
compromise patient safety. The QOF targets which encourage this should be
abandoned before they come into force for a further year.
Harlan M Krumholz
1. 1 Lehman R, Krumholz HM. Tight control of blood glucose in long
standing type 2 diabetes. BMJ 2009;338:b800.
2. Action to Control Cardiovascular Risk in Diabetes Study Group. Effects
of intensive glucose lowering in type 2 diabetes. N Engl J Med
3. Currie CJ, Peters JR, Tynan A et al Survival as a function of HbA1c in
people with type 2 diabetes: a retrospective cohort study. Lancet
Competing interests: No competing interests