05 July 2013

Physicians Want Cut-and-Dried Answers

Forget individualizing HbA1c goals, physicians want cut-and-dried answers to the question of what level of HbA1c lowing yields the most benefit and the least risk. More and more studies are being commissioned to attempt to find this answer, but to date, they have been unsuccessful.

To me this means the physicians are putting numbers on our backs and treating us as numbers rather than as people that are patients. As long as they continue to do this, a satisfactory treatment will continue to be elusive and we as patients will continue to be harmed. We know that the young (below 19) and the elderly (above 64) are discriminated against now, but to put numbers on us is even more discriminatory and an insult to us as patients.

Everyone forgets that we are unique and what works for one patient may not work for another patient. Some of us may do well by lowing our A1c's more than the next person, yet doctors are looking for a one-size-fits-all solution. Until doctors and researchers realize that there is more than one type 2 diabetes, that there are several subclasses, and that each needs different treatment, researchers will continue to have problems finding a one-size-fits-all answer.

Dr Gregory Nichols (Kaiser Permanente Center for Health Research, Portland, OR) understands that glycemic burden is intuitively appealing, but it is not straightforward to calculate, and . . . was not a substantially better predictor of CVD risk than mean A1c. Dr. Nichols also believes other covariates such as age, systolic BP, cholesterol, presence of CAD or heart failure, well-established risk factors, were much better predictors of a CVD hospitalization than all of the different HbA1c measures. One exception, he noted is if an HbA1c "ever rising above 7%" was found to be a powerful predictor of CVD and that increased their risk of a CVD hospitalization by 39% when compared to those who never went above 7%.

Other studies have indicated studying different subgroups may yield better analysis for each subgroup. This is important and indicates that some researchers are seeing value in moving away from a one-size-fits-all solution. The resistance is coming from doctors that still believe in the one solution for everyone.

1 comment:

  1. Great post, Bob. You are so right about everyone being different. This also applies very well to type 1 diabetes, and I'd imagine gestational and any other sorts as well.