An editorial accompanying the meta-analysis discussed the challenges physicians face when evaluating individual patient needs against guidelines. In the United States, the movement toward reimbursement based on population health measures has raised questions about whether it makes sense for patients to be given multiple medications to achieve small improvements toward targets. Results must be weighed against increased side affects or large out-of-pocket expenditures.
A meta-analysis that covered more than 100,000 patient and studies than spanned nearly 50 years concludes giving patients with type 2 diabetes mellitus (T2DM) treatment to lower their blood pressure (BP) is associated with lower risk of cardiovascular disease (CVD) and events, as well as improved mortality.
The study appears today in the Journal of the American Medical Association. While the authors, led by Kazem Rahimi, DM, MSc, of the University of Oxford, confirmed the recommendation to treat BP, an accompanying editorial addressed the current controversy about overly rigid adherence to targets and guidelines.
The researchers reviewed large-scale randomized controlled trials of BP-lowering treatment including patients with T2DM, which appeared between 1966 and 2014. They identified 40 trials with low risk of bias that covered 100,354 participants to include in the meta-analysis. They found that each 10 mm Hg lower systolic BP was associated with a lower risk of mortality CVD events, coronary heart disease events, stroke, albuminuria (protein in the urine) and retinopathy.
However, the link between treatment for BP and most outcomes diminished once the systolic level went below 140 mm Hg. Data showed that further reduction below 130 mm Hg is associated with lower risk of stroke, retinopathy, and albuminuria.
In the editorial, Bryan Williams, MD, of University College, London, wrote that the findings support treating patients to get systolic BP toward 130 mm Hg, but not lower. He noted the balancing act for physicians that the results present, since those at risk for stroke, for example, might benefit from continued aggressive therapy.
In the United States, there has been discussion about too much reliance on guidelines since the arrival of CMS quality measures, which include 5 diabetes-related population health measures. Physicians and healthcare systems that have agreed to participate in either the Pioneer or Medicare Shared Savings Program have an incentive to get as many patients as possible to target for BP, glycated hemoglobin and LDL cholesterol.
But for some patients, adding more medications to address a small gap toward their target may not make sense, depending on other comorbidities, side effects, the patients’ ability to manage so many medications, and—increasingly—concerns about high out-of-pocket costs. Patrick J. O’Connor, MD, MA, MPH, a senior clinical investigator for HealthPartners, told Evidence-Based Diabetes Management last month that the concept of “minimally disruptive medicine” was gaining attention among clinicians and researchers, and deserved consideration. Evidence-Based Diabetes Management is a publication of The American Journal of Managed Care.
Dr Williams addressed this issue in his editorial: “This conundrum highlights the problems with clinician overreliance on guidelines and guideline overdependence on an often, uncritical adoption of evidence, despite the limitations of the clinical trials,” he wrote. “Guidelines are just that, and are necessarily conservative in providing population-based recommendations that physicians must interpret in the context of the individual patient being treated.”
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