Promoting Health and Reducing Disparities in Populations

Recommendations c Treatment decisions should be timely, rely on evidence-based guidelines, and be made collaboratively with patients based on individual preferences, prognoses, and comorbidities.B c Providers should consider the burden of treatment and self-efficacy of patients when recommending treatments.E c Treatment plans should align with the Chronic Care Model, emphasizing productive interactions between a prepared proactive practice team and an informed activated patient.A c When feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools to meet patient needs.B DIABETES AND POPULATION HEALTHClinical practice guidelines are key to improving population health; however, for optimal outcomes, diabetes care must be individualized for each patient.Thus, efforts to improve population health will require a combination of system-level and patient-level approaches.With such an integrated approach in mind, the American Diabetes Association (ADA) highlights the importance of patient-centered care, defined as care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions (1).Practice recommendations, whether based on evidence or expert opinion, are intended to guide an overall approach to care.The science and art of medicine come together when the clinician is faced with making treatment recommendations for a patient who may not meet the eligibility criteria used in the studies on which guidelines are based.Recognizing that one size does not fit all, the standards presented here provide guidance for when and how to adapt recommendations for an individual. Care Delivery SystemsOver the last 10 years, there has been steady improvement in the proportion of patients with diabetes who are treated with statins and who achieve recommended hemoglobin A1C (A1C), blood pressure, and LDL cholesterol levels (2).The mean A1C nationally among people with diabetes has declined from 7.6% (60 mmol/mol) in 1999-2002 to 7.2% (55 mmol/mol) in 2007-2010 based on the National Health and Nutrition Examination Survey (NHANES), with younger adults less likely to meet treatment targets than older adults (2).This has been accompanied by improvements in cardiovascular outcomes and has led to substantial reductions in end-stage microvascular complications.Nevertheless, 33-49% of patients still do not meet targets for glycemic, blood pressure, or cholesterol control, and only 14% meet targets for all three measures while also avoiding smoking (2).Evidence suggests that progress in cardiovascular risk factor control (particularly tobacco use) may be slowing (2,3).Certain segments of the population, such as young adults and patients with complex comorbidities, financial or other social hardships, and/or limited English proficiency, face particular challenges to goal-based care (4-6).Even after adjusting for these patient factors, the persistent variability in the quality of diabetes care across providers and practice settings indicates that substantial system-level improvements are still needed. Chronic Care ModelNumerous interventions to improve adherence to the recommended standards have been implemented.However, a major barrier to optimal care is a delivery Suggested citation: American Diabetes Association.Promoting health and reducing disparities in populations.Sec. 1.In Standards of Medical Care in Diabetesd2017.