Clinical Assessment of Individualized Glycemic Goals in Patients With Type 2 Diabetes: Formulation of an Algorithm Based on a Survey Among Leading Worldwide Diabetologists

Abstract

Objective: Observations over the past few years have demonstrated the need to adjust glycemic targets based on parameters pertaining to individual patient characteristics and comorbidities. However, the weight and value given to each parameter will clearly vary depending on the experience of the provider, the characteristics of the patient, and the specific clinical situation.

Research design and methods: To determine if there is current consensus on a global level with regard to identifying these parameters and their relative importance, we conducted a survey among 244 key worldwide opinion-leading diabetologists. Initially, the physicians were to rank the factors they take into consideration when setting their patients' glycemic target according to their relative importance. Subsequently, six clinical vignettes were presented, and the experts were requested to suggest an appropriate glycemic target. The survey results were used to formulate an algorithm according to which an estimate of the patient's glycemic target based on individualized parameters can be computed. Three additional clinical cases were submitted to a new set of experts for validation of the algorithm.

Results: A total of 151 (61.9%) experts responded to the survey. The parameters "life expectancy" and "risk of hypoglycemia from treatment" were considered to be the most important. "Resources" and "disease duration" ranked the lowest. An algorithm was constructed based on survey results. It was validated by presenting three new cases to 57 leading diabetologists who suggested glycemic targets that were similar to those calculated by the algorithm.

Conclusions: The resultant suggested algorithm is an additional decision-making tool offered to the clinician to supplement clinical decision making when considering a glycemic target for the individual patient with diabetes.

© 2015 by the American Diabetes Association. Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered.

Figures

Figure 1

Survey results. A: Box plot showing the mean, median, and IQR of the ranking of the parameters by the experts. The percentages above the columns indicate the % of experts who counted the parameter among the top 3. B: The glycemic targets recommended by the experts for each individual case. Case 1, ACCORD-type patient with severe micro- and macrovascular disease; case 2, nursing home resident with dementia; case 3, elderly patient with new-onset diabetes and long-standing coronary artery disease; case 4, elderly patient with mild dementia and long-standing diabetes treated with basal-bolus insulin regimen; case 5, middle-aged patient with new-onset diabetes; case 6, patient with schizophrenia, noncompliance, and microvascular complications.

Dr. Yosef Kleinman (1948–2013) was a renowned diabetologist in Israel. During his career as head of the Internal Medicine Section in a Jerusalem Hospital, he established and administrated a diabetic foot clinic for many years and devoted his life to the care of his patients. Personalization of care was one of his mottoes. He was the enthusiastic and passionate promoter of our survey and subsequent development of the algorithm. Unfortunately he did not live to see his work's culmination. This article is dedicated to his memory.