Treat the numbers or treat the patient?
- Victor M Montori
- Aust Prescr 2011;34:94-5
- 1 August 2011
- DOI: 10.18773/austprescr.2011.054
Current practice guidelines, regardless of healthcare system and country of origin, increasingly carry a similar message: treat to target. These targets are often expressed in terms of laboratory parameters which are presumed to reflect the control of a patient's condition, and by extension their health and prognosis. The assumption is that 'normalising' parameters, such as lipids, blood pressure and blood glucose in patients with type 2 diabetes, will lead to better outcomes. However, these parameters are surrogate outcomes and do not guarantee long-term clinical benefits.
Is the assumption of benefit from intense control of these parameters based on high quality evidence? Some evidence suggests that there is no benefit, but there may be marginal harm associated with intensive control of risk factors in patients with diabetes.1-3 Benefits may still accrue for younger less sick patients, but this remains speculative. Even if true, those benefits would have to offset the downside of treatment, a task made difficult by the relative good health of the patients and the necessarily prolonged course of treatment. In these younger and healthier patients, intense lifestyle modification – smoking cessation, diet, exercise, stress reduction – may be more compelling than intensive drug treatment.
Treat-to-target often requires clinicians to prescribe more drugs at higher doses. This in turn calls for more laboratory testing to determine the efficacy of these interventions on the parameters of interest and to monitor the safety of the drugs on the patient's body. Treat-to-target requires patient self-monitoring and self-management in response to the monitoring results plus more visits to nurses and physicians. Higher doses and combination therapy may also increase the likelihood of adverse effects, which in turn may require increased medical attention and reduce the patient's capacity to do patient work.
The increasing demand for treatments, investigations and visits will test the capacity of the patient and their caregivers to implement these complex programs. By some estimates, the work of being a patient with diabetes requires more than two hours every day.4 Patients are expected to prioritise this 'part-time job' – to understand, plan and enrol others to help with the plan, to implement and adhere to the plan, and to reflect and value the treatment enough to keep going day after day. They have to fit this around the work of being a parent, sibling, child, spouse or relative, the work of being an employee or boss, and the work of being a citizen, a hobbyist, or a sports player.
The extent to which the patient's other 'jobs' are flexible enough to accommodate the ever-increasing work of being a patient and the ability of patients to enrol others to assist with the tasks of 'patienthood' may vary over time. Eventually, the expansion of patient workload may exceed the capacity of the patient or their caregivers to accommodate its demands. This forces the patient to prioritise, compromise and do only part of the expected patient work. They may then appear to be non-adherent to treatment.
The clinician may notice this non-adherence as missed appointments, incomplete self-monitoring data and in test results that reflect poor control. The clinician at this point, under a treat-to-target approach, may feel obliged to intensify the therapy. This carries the unintended consequence of increasing the treatment workload, further overflowing the patient's capacity to execute the plan, with ongoing deterioration not only of disease control but also of the patient–clinician relationship.
Our research group is exploring how best to respond to this form of non-adherence, which reflects the constraints of many competing demands that patients face. What can clinicians do in the meantime?
While these are early days in our journey, I would think clinicians should consider rejecting treat-to-target as not being consistent with evidence-based medicine. Why? Because the targets are not always based on high quality evidence and may be promoted and enforced without consideration of patient context and goals. We should redefine targets, prioritising goals that patients value, and involve patients with this prioritisation. Treatment burden should be favourably balanced by treatment value expressed in the answer to questions, such as, will this treatment or procedure (for example checking your glucose daily) increase the odds that you will live longer, feel better, or live unhindered by complications of disease or treatment? These are the new targets and not many treatments achieve these goals. Let us focus on treating to these patient goals and make healthcare fit the lives of our patients. That is the basis for minimally disruptive medicine.5
Conflict of interest: none declared
Professor of Medicine, Knowledge and Evaluation Research Unit and Healthcare Delivery Research Program, Division of Endocrinology and Diabetes, Mayo Clinic, Rochester, Minnesota, USA