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OtherPractice

Treating to target: ready, fire, aim

Adrienne J. Lindblad, Mark Makowsky and G. Michael Allan
Canadian Family Physician June 2014; 60 (6) 541;
Adrienne J. Lindblad
Knowledge Translation and Evidence Coordinator with the Alberta College of Family Physicians.
ACPR PharmD
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Mark Makowsky
Associate Professor at the Faculty of Pharmacy and Pharmaceutical Sciences at the University of Alberta in Edmonton.
ACPR PharmD
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G. Michael Allan
Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
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Clinical question

Can we achieve guideline-specified surrogate marker targets (SMTs) in primary care (PC)?

Bottom line

Even in ideal settings, less than 25% of carefully selected patients achieve multiple SMTs. However, clinical outcomes improve with proven interventions (eg, statins, metformin, ACEIs) without achieving targets. Clinicians should focus more on using proven therapies than attaining exact SMTs.

Evidence

  • Multiple cohort studies found PC patients did not achieve SMTs (ie, cholesterol, blood pressure [BP], glycated hemoglobin [HbA1c]).

    • -Of 1706 patients with diabetes mellitus (DM), 7.3% achieved 3 targets (HbA1c < 7%, BP < 130/80 mm Hg, and cholesterol < 5.18 mmol/L)1; of 1701 Canadians, 24% had low-density lipoprotein (LDL) levels of < 2 mmol/L2; and of 3167 patients with coronary artery disease (CAD), 16% achieved 3 targets (BP < 130/80 to 85 mm Hg, LDL < 2.2 mmol/L, and acetylsalicylic acid use).3

  • Some RCTs have found achieving targets difficult (despite intense care, maximum doses, and multiple therapies).

    • -In a meta-analysis of 7 RCTs (29 395 patients), less than 50% attained LDL levels of less than 2 mmol/L with maximum statin dose.4

    • -In 3 RCTs of DM patients with CAD (5034 patients), about 23% achieved 4 targets (LDL < 2.5 mmol/L, systolic BP < 130 mm Hg, HbA1c < 7%, and not smoking).5

    • -In the Steno-2 RCT (160 DM patients), at 13 years, 1% hit 5 targets (HbA1c < 6.5%, cholesterol < 4.5 mmol/L, triglyceride < 1.7 mmol/L, SBP < 130 mm Hg, DBP < 80 mm Hg).6

  • Despite not achieving targets, proven therapies (eg, statins, ACEIs, metformin) improved clinical outcomes. Statins reduced CAD (eg, number needed to treat [NNT] of 27 for low-moderate dose and 91 for high dose over low dose).7 Proven therapies in Steno-2 study reduced death (NNT = 5) and cardiovascular disease (NNT = 4).6

Context

  • Targets in guidelines are primarily based on expert opinion (about 50%) and on lower-level evidence (about 40%) and rarely on RCTs.8

  • Multiple comorbidities are common in PC, particularly in older adults,9,10 but rare in clinical trials or guidelines, making application difficult.11

  • Some newer guidelines are relaxing (hypertension12 and DM13) or removing targets (cholesterol14).

Implementation

Small deviations from SMTs are of little clinical importance, and intensifying care exposes patients to side effects and increases costs.15 Using treatment targets as performance measures for clinicians does not account for these issues nor for patient preferences.16 Some guidelines now discourage use of target attainment as a performance measure.17 Some have suggested that “[o]nly when those who promulgate measures are held personally responsible for their decisions should they hold physicians on the front line personally responsible for their implementation.”16

Notes

Tools for Practice articles in Canadian Family Physician (CFP) are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in CFP are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Saydah SH,
    2. Fradkin J,
    3. Cowie CC
    . Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004;291(3):335-42.
    OpenUrlCrossRefPubMed
  2. 2.↵
    1. Joffres M,
    2. Shields M,
    3. Tremblay MS,
    4. Connor Gorber S
    . Dyslipidemia prevalence, treatment, control, and awareness in the Canadian Health Measures Survey. Can J Public Health 2013;104(3):e252-7.
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  3. 3.↵
    1. Brown TM,
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    . Achievement of optimal medical therapy goals for U.S. adults with coronary artery disease: results from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study. J Am Coll Cardiol 2014;63(16):1626-33. Epub 2014 Feb 26.
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    1. Josan K,
    2. Majumdar SR,
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    . The efficacy and safety of intensive statin therapy: a meta-analysis of randomized trials. CMAJ 2008;178(5):576-84.
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    . Risk factor control for coronary artery disease secondary prevention in large randomized trials. J Am Coll Cardiol 2013;61(15):1607-15.
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  6. 6.↵
    1. Gaede P,
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    . Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008;358(6):580-91.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Allan GM,
    2. Mannarino M
    . Tools for Practice [website]. Edmonton, AB: ACFP; 2012. How does high dose statin compare to low dose in people with heart disease. Available from: www.acfp.ca/Portals/0/docs/TFP/20120522_090852.pdf. Accessed 2014 Mar 25.
  8. 8.↵
    1. Tricoci P,
    2. Allen JM,
    3. Kramer JM,
    4. Califf RM,
    5. Smith SC Jr.
    . Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 2009;301(8):831-41.
    OpenUrlCrossRefPubMed
  9. 9.↵
    1. Fortin M,
    2. Bravo G,
    3. Hudon C,
    4. Vanasse A,
    5. Lapointe L
    . Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3(3):223-8.
    OpenUrlAbstract/FREE Full Text
  10. 10.↵
    1. Britt HC,
    2. Harrison CM,
    3. Miller GC,
    4. Knox SA
    . Prevalence and patterns of multimorbidity in Australia. Med J Aus 2008;189(2):72-7.
    OpenUrl
  11. 11.↵
    1. Tinetti ME,
    2. Bogardus ST Jr.,
    3. Agostini JV
    . Potential pitfalls of disease-specific guidelines for patients with multiple conditions. New Engl J Med 2004;351(27):2870-4.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. James PA,
    2. Oparil S,
    3. Carter BL,
    4. Cushman WC,
    5. Dennison-Himmelfarb C,
    6. Handler J,
    7. et al
    . 2014 Evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311(5):507-20.
    OpenUrlCrossRefPubMed
  13. 13.↵
    1. Imran SA,
    2. Rabasa-Lhoret R,
    3. Ross S
    . Clinical practice guidelines: targets for glycemic control. Can J Diabetes 2013;37(Suppl 1):S31-S34.
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  14. 14.↵
    1. Stone NJ,
    2. Robinson J,
    3. Lichtenstein AH,
    4. Bairey Merz CN,
    5. Lloyd-Jones DM,
    6. Blum CB,
    7. et al
    . 2013 ACC/AHA guidelines on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013 Nov 7. Epub ahead of print.
  15. 15.↵
    1. Hayward RA
    . All-or-nothing treatment targets make bad performance measures. Am J Manag Care 2007;13(3):126-8.
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  16. 16.↵
    1. Pogach L,
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    . Sudden acceleration of diabetes quality measures. JAMA 2011;305(7):709-10.
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    6. Nauck M,
    7. et al
    . Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012;35(6):1364-79.
    OpenUrlFREE Full Text
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Canadian Family Physician: 60 (6)
Canadian Family Physician
Vol. 60, Issue 6
1 Jun 2014
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Treating to target: ready, fire, aim
Adrienne J. Lindblad, Mark Makowsky, G. Michael Allan
Canadian Family Physician Jun 2014, 60 (6) 541;

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Adrienne J. Lindblad, Mark Makowsky, G. Michael Allan
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