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Commentary | Less Is More

The Other Side of Quality Improvement in Diabetes for Seniors:  A Proposal for an Overtreatment Glycemic Measure

Leonard Pogach, MD, MBA; David Aron, MD, MS
Arch Intern Med. 2012;172(19):1510-1512. doi:10.1001/archinternmed.2012.4392.
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The management of diabetes poses challenges at all levels, from affected individuals to society as a whole. Microvascular complications of diabetes have been attributed to poor glycemic control since the Joslin era. This hypothesis was confirmed for patients with type 1 diabetes mellitus by the results of the Diabetes Control and Complications Trial1 and for patients with type 2 diabetes mellitus by the UK Prospective Diabetes Study.2,3 The findings of these trials led to an increasing emphasis on tight glucose control for all persons with diabetes.4 The initial glycemic measure proposed by the Diabetes Quality Improvement Project was a glycohemoglobin concentration of less than 9.5% (subsequently decreased to 9.0%). However, by the middle late 2000s, the goal had become less than 7.0%,4 even though major trials testing this level of glucose control were still ongoing. In contrast, the potential consequences of overtreatment received short shrift, particularly in patients with type 2 diabetes, in whom hypoglycemia was thought to be relatively uncommon.

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