In 1989, the American Diabetes Association first published the position statement titled "Standards of Medical Care for Patients With Diabetes Mellitus."¹ As our knowledge about treatments of diabetes and its complications has evolved, so have the standards of care. There have been several revisions since the original publication, and the Association now publishes these standards annually in a supplement to the journal Diabetes Care.

These guidelines are perhaps the most important document published by the American Diabetes Association for clinicians because they describe what is required for acceptable diabetes care. In addition, the various recommendations are evidence-based and represent a consensus opinion of experts in diabetes care.

When the Association originally published its Standards, Dr. David Robbins, then editor of Diabetes Care, wrote in an accompanying editorial that the Standards "should be considered required reading for any professional dealing with diabetic patients."² He also noted that "the guidelines only define a minimal level of quality . . . and are not intended to be all-inclusive."²

Dr. Robbins’s first point has been difficult to accomplish. One valid criticism of the Standards is that their content is not easily accessible to the majority of clinicians caring for individuals with diabetes. Diabetes Care is the Association’s primary journal for clinical research, and its readership is comprised mostly of clinicians specializing in the care of patients with diabetes. But most clinicians who manage diabetes are not specialists in the field, but rather primary health care providers. Therefore, we have decided to include the most recent version of the Standards in their entirety in Clinical Diabetes, the Association’s main vehicle for reaching primary care practitioners (p. 27).

Reflecting on Dr. Robbins’s second point, there is more reason for concern. If these guidelines are indeed "minimal," we must then conclude that we are falling far short of accomplishing good or even average medical care for patients with diabetes.³ For example, Parente and associates reported in 1995 that, for more than 97,000 Medicare patients with diabetes, 84% did not receive the recommended HbA_1c measurement, 54% did not see an ophthalmologist, and 45% did not receive a cholesterol screening.⁴ This is not necessarily a reflection on primary care providers, because endocrine fellows in training were also reported to be deficient in following these guidelines.⁵

It must also be appreciated that there will be occasions on which guidelines must give way to common sense. Recommended HbA_1c target levels are one example of this.⁶ One would and should tend to be less aggressive with glycemic control with a 77-year-old patient with coronary artery disease and severe emphysema, for instance, than with a 40-year-old with no other medical problems. An HbA_1c of 8.3% in the 77-year-old, although not ideal, would be considered acceptable by most clinicians.

It is for this reason that the rationale and evidence for each of the recommendations must be fully understood. Only when this occurs can we practice the best medicine possible in treating our patients with diabetes.

 REFERENCES

¹American Diabetes Association: Position Statement: Standards of medical care for patients with diabetes mellitus. Diabetes Care 12:365-68, 1989.

²Robbins DC: A bill of rights (editorial). Diabetes Care 12:371, 1989.

³Marrero DG: Current effectiveness of diabetes health care in the U.S: how far from the ideal? Diabetes Reviews 2:292-309, 1994.

⁴Parente ST, Garnick DW, Fowles J, Lawthers AG, Palmer RH: Variation in office-based quality: a claims-based profile of care provided to Medicare patients with diabetes. JAMA 273:1503-1508, 1995.

⁵Storal MW: Clinical management of the NIDDM patient: impact of the American Diabetes Association practice guidelines, 1985-1993. Diabetes Care 18:701-707, 1995.

⁶Skyler JS: Glucose control in type 2 diabetes. Ann Intern Med 127:837-38, 1997.

Irl B. Hirsch, MD, is an associate professor of medicine and medical director of the Diabetes Care Center at the University of Washington School of Medicine in Seattle. He is editor-in-chief of Clinical Diabetes.