Organization of Diabetes Care: Time to Move from Theory to Action

Abstract

Decades of study has demonstrated the proportion of patients who are not meeting evidence-based targets for management of their diabetes. In this issue of the Journal, Shah et al add to this literature, showing that about one-fifth of the people living with diabetes in Ontario in 2019 had a glycated hemoglobin (A1C) of >8% (1). In their study from Brazil, Bergonsi de Farias and colleagues show that two thirds of their study population were not meeting A1C target levels (2). Patry and colleagues used the framework of structure, process and outcome measures and showed that, despite excellent achievement in structure and process indicators for diabetic foot ulcer management, the outcomes remained suboptimal; the authors hypothesize that additional structural supports are needed to address patient-level factors (3).Why do these gaps in care persist? First, it is crucial to recognize that targets are theoretical and may not be achievable or appropriate at a given time for a given patient. System-level and structural issues conspire to make it difficult for many patients to achieve targets. However, some of the observed gaps between ideal and actual diabetes care are amenable to actions that health-care professionals can take to reduce risk for their patients. Of course, asking health-care professionals to simply "try harder" is no way to sustainably improve quality of care. Telling hard-working health professionals that they are not doing enough, without helping them to systematically practice more effectively, efficiently and equitably, is a recipe for burnout.To help our patients in the best way possible, we need to work smarter, not harder. Changing how we provide care-by implementing best practices in our organization of care-can have as much impact as adding more medicines. Furthermore, improvements in organization of care can efficiently lead to improvements in large groups of those patients who need improvements most, rather than relying on burnout-inducing, one-by-one, try-a-littleharder-next-time strategies (4).Many trials have shown that, in general, common quality improvement strategies, such as audit and feedback, clinician education and reminders, and patient self-management support, are It is time we shift our health services research and policy focus from measuring gaps in care to ensuring best practices for implementation of evidence-based organization of care, at scale, in a sustainable fashion.