The implementation of the standards of care for diabetes has been suboptimal in most clinical settings. A recent report (24) indicated that only 37% of adults with diagnosed diabetes achieved an A1C of <7%, only 36% had a blood pressure <130/80 mmHg, and just 48% had a cholesterol <200 mg/dl. Most distressing was that only 7.3% of diabetes subjects achieved all three treatment goals.
While numerous interventions to improve adherence to the recommended standards have been implemented, the challenge of providing uniformly effective diabetes care has thus far defied a simple solution. A major contributor to suboptimal care is a delivery system that too often is fragmented, lacks clinical information capabilities, often duplicates services, and is poorly designed for the delivery of chronic care. The Institute of Medicine has called for changes so that delivery systems provide care that is evidence based, patient centered, and systems oriented and takes advantage of information technologies that foster continuous quality improvement. Collaborative, multidisciplinary teams should be best suited to provide such care for people with chronic conditions like diabetes and to empower patients??ving health care professional education regarding the standards of care through formal and informal education programs.
* Delivery of DSME, which has been shown to increase adherence to standard of care.
* Adoption of practice guidelines, with participation of health care professionals in the process. Guidelines should be readily accessible at the point of service, such as on patient charts, in examining rooms, in “wallet or pocket cards,” on PDAs, or on office computer systems. Guidelines should begin with a summary of their major recommendations instructing health care professionals what to do and how to do it.
* Use of checklists that mirror guidelines have been successful at improving adherence to standards of care.
* Systems changes, such as provision of automated reminders to health care professionals and patients, reporting of process and outcome data to providers, and especially identification of patients at risk because of failure to achieve target values or a lack of reported values.
* Quality improvement programs combining continuous quality improvement or other cycles of analysis and intervention with provider performance data.
* Practice changes, such as clustering of dedicated diabetes visits into specific times within a primary care practice schedule and/or visits with multiple health care professionals on a single day and group visits.
* Tracking systems with either an electronic medical record or patient registry have been helpful at increasing adherence to standards of care by prospectively identifying those requiring assessments and/or treatment modifications. They likely could have greater efficacy if they suggested specific therapeutic interventions to be considered for a particular patient at a particular point in time (225).
* A variety of nonautomated systems, such as mailing reminders to patients, chart stickers, and flow sheets, have been useful to prompt both providers and patients.
* Availability of case or (preferably) care management services, usually by a nurse. Nurses, pharmacists, and other nonphysician health care professionals using detailed algorithms working under the supervision of physicians and/or nurse education calls have also been helpful. Similarly dietitians using MNT guidelines have been demonstrated to improve glycemic control.
* Availability and involvement of expert consultants, such as endocrinologists and diabetes educators.
Evidence suggests that these individual initiatives work best when provided as components of a multifactorial intervention. Therefore, it is difficult to assess the contribution of each component; however, it is clear that optimal diabetes management requires an organized, systematic approach and involvement of a coordinated team of health care professionals.
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Martha M. Funnell, MS, RN, CDE
Michigan Diabetes Research and Training Center
University of Michigan Medical School
Ann Arbor, Michigan
Robert M. Anderson, EdD
Michigan Diabetes Research and Training Center
University of Michigan Medical School
Ann Arbor, Michigan
Shereen Arent, JD
National Director of Legal Advocacy
American Diabetes Association
American Diabetes Association Complete Guide to Diabetes
