Diabetes care: Whose goals are they?

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John Hickner, MD, MSc

Words are important, and the language of medicine is changing. Two words that have taken on great importance in health care are “goals” and “targets.” A portion of primary care physicians’ compensation for caring for patients with diabetes, hypertension, and hyperlipidemia depends on our patients achieving certain goals and targets for blood sugar, blood pressure (BP), and lipids, as summarized for type 2 diabetes in “Is your patient on target? Optimizing diabetes management” by Harmes and Cigolle. Based on randomized trials published during the past several years, the “official” US goal for glucose control should be customized to fit patients’ individual risk profiles, although 7% is still recommended for younger and healthier patients with diabetes. Based on randomized trial data, the BP target is less stringent than in the past—now 140/90 mm Hg for all patients with hypertension, including those with diabetes, although not all experts agree with this newer recommendation.

I like the idea of sharing a simple “report card” with patients at each visit that lists the A (A1c), B (BP), and C (cholesterol) targets and the patient’s most recent values. We have entered a confusing time regarding lipid control because of the new and controversial guidelines to treat patients based on risk of cardiovascular disease rather than treating to a specific low-density lipoprotein cholesterol target.

Whose goals and targets are these? We know they are goals for insurance companies and health plans because they send us reports and pay us incentives when enough of our patients hit the targets (or penalize us if they don’t).

They are our goals, too, because we know that, to some extent, our patient’s likelihood of bad things happening to them is linked to their blood sugar, BP, and lipid control.

Ultimately, these have to be our patients’ goals, because they are the ones who have to buy into taking medications, which have costs, risks, and side effects, and altering their lifestyles, which is difficult for most.

Goal setting is an effective method for helping people increase physical activity and improve their diets.1 This requires negotiating with patients about what they believe is achievable. In addition, these goals need not be the same as the targets proposed by the experts. Even the American Diabetes Association has come around to the idea that patients should have some flexibility and that one hemoglobin A1c target does not fit all. I like the idea of sharing a simple “report card” with patients at each visit that lists the A (A1c), B (BP), and C (cholesterol) targets and the patient’s most recent values. Point-of-care testing allows for immediate feedback and medication adjustment.

What tools do you use to help your patients achieve their diabetes goals?

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