Surrogate Use in Diabetes: Compromising Care?

Surrogate Use in Diabetes: Compromising Care?

A recent analysis published in BMJ finds that the widespread use of surrogate endpoints in diabetes care puts the patient’s concerns on the back burner. The authors argue that easier-to-measure surrogate outcomes are often used instead of outcomes important to patients, such as death, quality of life, or functional capacity when assessing treatments. 

Diabetes care is largely driven by surrogates. Concentrations of glycated haemoglobin (HbA1c) are used as a surrogate marker for outcomes that are important to patients, such as blindness or amputation. Blood pressure, lipids, albumin excretion rates, and C-reactive protein are other surrogates physicians use to predict outcomes of cardiovascular disease and to guide clinical practice. However, according to the authors, “much of the evidence for clinical interventions is based on their effect on surrogate outcomes rather than those that matter to patients, such as quality of life or avoidance of vision loss or renal failure.”

Surrogates for outcomes such as glucose, lipid, and blood pressure thresholds are also used to evaluate quality of healthcare and influence reimbursements. Focus may then fall on reducing the level of the surrogate, regardless of the impact on a patient’s outlook. The authors maintain that these markers “begin to take on an existence of their own as new disease entities.”

Physician’s Weekly wants to know… Do you feel there is too much focus on surrogate use? Does surrogate use treat the individual as a biological being rather than a human?



  1. There may be some truth to this, but on the other hand, it is difficult to get patients to take the eventual consequences of poor management seriously, because they are not immediately evident. Factors like hyperlipidemia, elevated A1cs, etc. are concrete and setting goals to reach optimal levels are concrete. Of course, the practioner would want to tie the goals to the longterm consequences, but in my experience, just talking about those does not resonate with the majority of the target population.

  2. The physician has to be sensitive to the patient’s concerns as he/she evaluates the glycemic control using whatever markers are appropriate. Before there are complication, the doctor should try to educate the patient. It doesn’t matter whether the patient’s goal is keeping the sugars controlled, the weight at/or moving towards goal, or exercising (hopefully all of the above)-all should help maintain an acceptable A1c and benefit the patient.


Submit a Comment

Your email address will not be published. Required fields are marked *

4 × 2 =