Current effectiveness of diabetes health care in the U.S.. How far from the ideal?

Most people with diabetes in the U.S. are cared for by primary care physicians. Therefore, to assess the effectiveness of diabetes care in this country, the extent to which diabetes practice behaviors used by primary care physicians reflect both current and future standards of care for diabetes must be considered. Few studies have investigated this issue; however, the existing data suggest that there are considerable gaps between current recommendations for care and actual practices of primary care physicians. Specifically, when patients with insulin-dependent diabetes mellitus (IDDM) are treated, recommended insulin regimens, methods for assessing chronic glycemic control, and strategies for the screening and treatment of retinopathy, nephropathy, and foot problems are not uniformly applied. Even less adherence to recommended care strategies is evident in care for patients with non-insulin-dependent diabetes mellitus (NIDDM), particularly in detection of complications. Physician age, location, and specialty are associated with different levels of adherence to care recommendations. Older physicians often report lower rates of adherence to recommendations for the monitoring of glycemic control and use of multiple daily injections of insulin than do more recent graduates of medical school. Internal medicine physicians report greater adherence to many clinical and laboratory guidelines than do family practitioners. These data suggest that primary care physicians' knowledge and use of diabetes care standards should be aggressively addressed by postgraduate education. Improved access to support care resources and changes in reimbursement for care services are also needed to reverse these trends.