Spotlight on the value of care

Two recent European studies looked at situations in which current screening and treatment might be excessive for patients with type 2 diabetes.

The first study, published by Diabetes, Obesity and Metabolism on Jan. 24, included 1,002 Dutch patients with type 2 diabetes. Among the 319 patients who were age 70 years or older, the median HbA1c level was 7.0%; 30.1% had macrovascular complications, and 50.8% had microvascular complications. Using an algorithm from Dutch guidelines, these patients were classified into three subgroups by HbA1c target. Focusing specifically on the patients age 70 years and older who had an HbA1c target greater than 7%, the study found that 38.8% were overtreated (that is, they had a HbA1c level below their target). Hypoglycemia occurred in 20.3% of these patients, and almost 30% had reported falls. The study authors concluded that a substantial number of older patients with type 2 diabetes may be overtreated, even after they have reported hypoglycemia and falls to clinicians. “Care professionals should abandon the ‘one size fits all’ approach and realize the possible benefits of de-intensifying blood glucose-lowering treatment. To prevent overtreatment, a lower HbA1c limit in the guidelines might be helpful. Diabetes quality indicators should not be based on population-based mean values, because means will overlook under- and overtreatment completely,” the authors said.

The second study, published by Diabetic Medicine on Jan. 10, examined the potential impact of recently proposed recommendations on diagnosis of non-alcoholic fatty liver disease from the European Association for the Study of the Liver, European Association for the Study of Diabetes, and European Association for the Study of Obesity. Researchers assessed 179 patients with type 2 diabetes, finding that 68.7% had steatosis according to proton magnetic resonance spectroscopy. Applying the guidelines and various combinations of scores, including the fatty liver index, non-alcoholic fatty liver disease fibrosis score, Steatotest score, and FibroTest score, they calculated that 33.5% to 84.9% of the patients would be referred to a liver clinic. “It would not be possible to refer such a high proportion of people with Type 2 diabetes to a liver clinic,” the study authors wrote. “We suggest that new clinical and/or biological biomarkers of steatosis and fibrosis be specifically validated in people with Type 2 diabetes.”