Table 1

Clinical definitions of ‘at-goal’ status for each intervention condition

Non-communicable diseaseManagement metric‘At-goal’ definition
Type II diabetes mellitusHaemoglobin A1c OR fasting blood sugarHaemoglobin A1c <7.5 OR fasting blood sugar <130*
HypertensionBlood pressureSystolic blood pressure <130 mm Hg or patient-tailored goal per risk stratification†
Chronic obstructive pulmonary diseaseExacerbation status<2/3 Anthonisen criteria‡
  • *Type II diabetes mellitus: The 2018 American Diabetes Association guidelines32 call for a goal A1c <7% for most patients or A1c <8% in ‘patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in whom the goal is difficult to achieve despite diabetes self-management education, appropriate glucose monitoring, and effective doses of multiple glucose-lowering agents including insulin’. For our clinicians, we established 7.5% as our goal to pragmatically accommodate both populations.

  • †Hypertension: Based on the 2017 update to the Joint National Committee-7 guidelines,33 we established <130 mm Hg as a default treatment goal, with patient-tailored goals for select patients (≥65 years of age, multiple comorbidities, limited life expectancy, clinical judgement, patient preference).

  • ‡Chronic obstructive pulmonary disease (COPD): The 2017 update to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines‡, 53 define COPD exacerbation as an ‘acute worsening of respiratory symptoms that results in additional therapy’. We used the Anthonisen criteria of worsening sputum volume, sputum purulence and increased dyspnoea to define the ‘worsening of respiratory symptoms’ specified in the GOLD guidelines. We established a threshold of no more than one Anthonisen criterion as a pragmatic tool for determining clinical status.