The War Comes Home to Primary Care: What’s the “Right” Goal for HgbA1C in our Adult T2DM Patients?

I considered titling this, “When the Parents are Fighting, Where Should the Children Go?” but we PCPs are at risk of PTSD either way. This battle has been brewing for years, but formal hostilities broke out in March when the American College of Physicians (ACP), representing both the general internal medicine community and the subspecialist internists including endocrinology and diabetology, came out with recommendations on acceptable levels of glycated hemoglobin (HgbA1C) as a measure of glucose control in type 2 diabetes mellitus (T2DM)1 which differ from the recommendations of the American Diabetes Association (ADA) Standards of Medical Care in Diabetes.2 The contention of the ACP is that there is not sufficient evidence to support control tighter than necessary to produce HgA1C less than 8, especially in patients with life expectancy less than 10 years. My purpose in this blog is not to take a position on the battlefield, it is more as a peasant who lives on the land where the battle is taking place to decide how best to preserve my life, household, and livestock while the armies clash. I particularly liked the “medical minute” summary report of Dr. Susan Spratt from Duke as an introduction.3 Like you readers, I have a license to practice, a staff, and a practice whose needs I am trying to meet with the best quality care that I can. I have dealt with the issue of dueling guidelines before4, as subspecialty guidelines that conflicted with community standards rather than PCP vs other specialties. The closest we have come in my memory is the AAFP still has not endorsed the AHA-ACC hypertension management guidelines.5,6 Maybe my family analogy should be “adolescent rebellion” rather than “parental conflict”. I think it is significant and encouraging that we now have a generation of primary care folks who are sufficiently trained in healthcare science, not just practice, to critically evaluate clinical evidence for our organizations and inform our clinical policies.

Here is something PCPs CAN do something about. When I logged into the Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse (, I got the following message “The AHRQ National Guideline Clearinghouse (NGC, Web site will not be available after July 16, 2018 because federal funding through AHRQ will no longer be available to support the NGC as of that date.” I have depended on and its predecessors for nearly two decades for everything CPG (Clinical Practice Guideline). I am emailing my Congressional representative today to restore this funding. This is such a small expenditure for a service that benefits both providers like ourselves and our patients that have neither the time nor the training to critically review clinical practice guidelines.



Charles A. Sneiderman, MD, PhD, DABFP
“Guideline Guy” and Medical Director, Culmore Free Clinic
Falls Church, VA

Published on 5/1/18