Diabetes Algorithm Helps Determine Glycemic Goals in Patients with Type 2 Diabetes
Commentary by Itamar Raz, MD and Paolo Pozzilli, MD
Researchers have developed a diabetes algorithm to supplement clinical decision-making when establishing glycemic goals for patients with type 2 diabetes, according to a study reported in the December issue of Diabetes Care.
“The glycemic targets we aim for differ in individuals with type 2 diabetes depending upon their comorbidities, life expectancy, etc,” explained study coauthor Itamar Raz, MD, Head of the Diabetes Unit, Hadassah Ein Kerem Hospital, Jerusalem, Israel. “To determine the ideal glycemic target is time consuming both for the expert and surely for the family physician, as, she/he needs to simultaneously consider multiple parameters of different relative importance. Furthermore, there is much variability in the estimated glycemic target even amongst leading diabetologists. Therefore, when setting a glycemic target, we decided to rely upon the ‘wisdom of the crowd.’”
A total of 224 worldwide opinion leading diabetologists were asked to rate the importance of 11 parameters identified in recent guidelines from the American Diabetes Association/ European Association for the Study of Diabetes as important elements to use when determining the glycemic target. They were additionally asked to propose glycemic targets for 6 clinical vignettes. A total of 151 experts (61.9%) responded to the survey.
The experts ranked “life expectancy” and “risk of hypoglycemia from treatment” as the most important parameters to consider when determining glycemic targets. “Disease duration” and “resources and support system” were the lowest ranked parameters.
“We checked their responses for repeatability,” Prof. Raz explained. “Based upon their responses, we composed an algorithm that computes the patient’s individual target according to his/her unique characteristics (Table). The algorithm reflects the mean of the experts’ opinions and thus improves the physician’s ability to simultaneously assess multiple aspects of the patient.”
“The algorithm includes 5 ‘objective’ parameters that can be extrapolated from the electronic medical record and 3 ‘subjective’ parameters,” Prof. Raz explained (Table). “The algorithm’s output is an HbA1c range (6.5%-8.5%) extending to a maximal width of 0.5% based upon the objective parameters, and a number, not necessarily in mid-range, which is determined by the patient's subjective parameters (cognitive function, motivation, and resources).”
The relative weight of each parameter is multiplied by the score (1, 2, or 3 depending on risk) and the products are summed (Table). The formula is then calculated as:
- Glycemic target = 6.5 + (sum of products – 100)/100
Algorithm May Supplement Clinical Judgment
“The algorithm is not meant to replace clinical intuition, but rather to supplement it with a decision-making tool based upon expert opinion,” Dr. Raz said. “The target proposed by the algorithm may prompt the physician to reconsider the target that she/he had initially considered. Additionally, the patient him/herself may use the algorithm to assess his glycemic target and take an active part in his care.”
“We wish to extend the validation of the algorithm to larger populations and evaluate the overall matching between the glycemic targets it proposes to those which the physician would recommend,” Prof. Raz said.
“The implications of this article will be of great impact on the day-to-day management of diabetes,” commented Paolo Pozzilli, MD, Professor and Head of the Department of Endocrinology and Metabolic Diseases at the University Campus Bio-Medico, Rome, Italy. “This is a very interesting paper that highlights the relevance of a guided algorithm for diabetes treatment. This work was presented in a paper published in 2010 in Diabetes Metabolism Research & Reviews by the same group of authors including myself. The paper called ABCD algorithm (Age, Body weight, Complications, Duration of disease) pioneered the concept of personalization of therapy in type 2 diabetes.”
December 23, 2015