Debate over HbA1c target in pay for performance

EXPERTS have continued to question Federal Government proposals to introduce a pay-for-performance scheme for diabetes management in Australia, saying the appropriate HbA_1c target is being reconsidered internationally.

However, Australian experts argue that if GPs were to be remunerated for diabetes management, using higher glycaemic targets would be preferable to a lower target such as the 7% HbA_1c level introduced as a payment benchmark in the UK.

Two international diabetes experts said the recently introduced UK scheme rewarding GPs with a £3000 ($6200) payment for achieving HbA_1c levels below 7% in half their patients with type 2 diabetes (MO, 13 March) was simply not supported by trial evidence.

“Policymakers who want to use HbA_1c as a performance measure should use an upper limit, such as a level of greater than 9% to indicate possible inadequate care, rather than one that would invite clinicians to ignore patient burden, context and goals,” they said.

In 2008, the ACCORD study was stopped early due to increased mortality rates in the intensive glycaemic control group, and the ADVANCE and VADT trials found no cardiovascular benefit from intensive blood glucose lowering.

Given this evidence, Professor Duncan Topliss, director of the department of endocrinology and diabetes at Melbourne’s Alfred Hospital, agreed an upper limit might be a better pay-for-performance target.

However, he feared pay-for-performance could lead to doctors refusing to treat patients with poor glycaemic control for fear of being financially penalised.

“It is paradoxical that, at a time when the issue of appropriate targets is being scientifically re-examined... a simplistic concept of pay-for-performance is raised by health bureaucrats.”

Professor Hal Swerissen, dean, faculty of health sciences at Melbourne’s La Trobe University, who co-authored a paper recommending pay-for-performance to improve care of chronic disease patients, said an upper limit HBA_1c target of over 9% could be considered provided other recommendations including weight, smoking and physical activity were included.

Ann Intern Med, in press