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To the Editor.—We are intrigued by the data of Dr Hayward and colleagues¹ on the treatment of type 2 diabetes by generalists, but we question their conclusions. They found mean hemoglobin A_1c (HbA_1c) levels in all patients to be 8%, better than in earlier studies. Sixteen percent of patients not taking insulin initially began insulin and had 0.9% lower HbA_1c levels a year later. Despite this improvement, 60% of these patients failed to reach an 8% (0.08) HbA_1c level that indicated acceptable control. Short-term costs of starting insulin included a few more visits and tests and a 4-fold increase in glucose self-testing.

The authors emphasize that insulin treatment was "rarely effective in achieving tight glycemic control." In contrast, we are impressed that the overall mean HbA_1c level was as good as 8% (0.08), reflecting more effective treatment than usual. Also, intervention trials^2-3 have shown that reducing HbA_1c levels . . . [Full Text of this Article]

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Starting Insulin Therapy in Patients With Type 2 Diabetes: Effectiveness, Complications, and Resource Utilization
Rodney A. Hayward, Willard G. Manning, Sherrie H. Kaplan, Edward H. Wagner, and Sheldon Greenfield
JAMA. 1997;278(20):1663-1669.
ABSTRACT