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April 15, 2019

Measuring What Matters in Diabetes

Author Affiliations
  • 1Knowledge and Evaluation Research Unit in Endocrinology, Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic, Rochester, Minnesota
  • 2Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, Knowledge and Evaluation Research Unit México, Dr Jose E. Gonzalez University Hospital, Monterrey, Mexico
  • 3Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
  • 4Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
JAMA. 2019;321(19):1865-1866. doi:10.1001/jama.2019.4310

Optimal diabetes care is predicated on balancing the immediate and long-term sequelae of the disease and its therapies, improving patient health and well-being, and mindfully stewarding health care resources for both the patient and society. Professional societies, public health organizations, regulatory agencies, patients, and clinicians have focused on hemoglobin A1c (HbA1c) levels to gauge the quality of diabetes care.1 Over time, HbA1c level has supplanted other indicators of the quality of diabetes care, such as blood glucose levels and symptoms of hyperglycemia, despite being a surrogate rather than a direct marker of glycemic control, and reflecting average levels of glycemia during the preceding 3 months. Although potentially more challenging to measure or difficult to change, other measures of the quality of diabetes care may better represent the outcomes that are truly meaningful to people living with diabetes, including immediate symptoms of hypoglycemia or hyperglycemia, burden of treatment,2 quality of life, and long-term sequelae of inadequately controlled diabetes.

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    1 Comment for this article
    Diabetes, it’s not about the sugar!
    Michael Plunkett, MD MBA | Community hospital
    That’s right. It’s not about the sugar, and certainly not about bragging rights to the lowest surrogate marker—A1c.

    Among the cognoscenti it’s about outcomes. Did they live longer? Did they live better? And better doesn’t mean having a better surrogate marker number. It means, did they keep their feet? Did they have fewer heart attacks? Fewer Strokes? Less dialysis? Less blindness? Less painful neuropathy?

    And the evidence that a point or two of lower A1c will do any of this is nearly nonexistent. And at what expense? Insulin and gliptins etc cost ~$700 per month. Statins and
    blood pressure pills cost pennies a day and are proven to improve meaningful outcomes.

    It’s not about the sugar.