Many randomized controlled intervention trials have demonstrated that lowering glycemia (1,2), LDL cholesterol (3), and blood pressure (4) will markedly benefit the complications from diabetes. Based on these data, the American Diabetes Association has recommended the following targets for glycemic, lipid, and blood pressure outcome measures, A1C 7.0%, LDL cholesterol 100 mg/dl, and blood pressure 130/80 mmHg, respectively (5). 

 

Most diabetic patients do not meet these recommended goals. Approximately half of the National Health and Nutrition Examination Survey cohort met the glycemic goal (6). In other larger reported populations, 21–43% of patients had A1C levels 9.5%, only 22–46% of diabetic patients met the LDL cholesterol goal, and 29–33% met the blood pressure goal (7). Far fewer, 2–10%, met the combined American Diabetes Association goals for glycemia, lipids, and blood pressure (7).

 

Many approaches have been tried to improve diabetes care but, with one exception,

have been mostly ineffective. These include simply reminding patients about appointments; providing laboratory information on the patient to the physician, even when specific treatment recommendations for the individual patient were included; case management when the case manager could not make independent treatment decisions; education of physicians; and multifaceted quality improvement interventions in the practice setting (7).

 

The small amount of time a physician has to spend with a patient is an important limiting factor. This was amply illustrated in a study (8) in which eight process measures agreed upon by the physician group and whether the patient was due to receive them were displayed on the physicians’ computer screens at the time of the patient visit. The measures due were performed or ordered only one-third of the time. Physicians pinpointed lack of time and other problems that needed attention as primary obstacles to carrying out the agreed-upon recommendations.