From the 1960s to 2000, there was very little improvement in diabetes care in the United States. However, since 2000, there has been substantial improvement. Median A1C reached 7.18% nationally in 2005. In adults with diabetes, median LDL cholesterol is now ~ 85 mg/dl, and median blood pressure is ~ 130/78 mm Hg.1,2 Endocrinologists and diabetes educators have led the charge, but most of the diabetes care in the United States is provided by primary care physicians, and the national improvements reflect better diabetes care in primary care practices in recent years.
Yet primary care is currently in crisis. Increased patient demand, a reduced number of providers, and the demands of working in an information-rich environment leave too little time to meet patient needs. Unaddressed societal health problems that include obesity and unhealthy lifestyles may lead to future decline in the overall health of the American population. The growing shortage of primary care physicians, in the face of the growing number of Americans with chronic diseases, mandates new approaches to care delivery that expand access through team models within primary care settings—perhaps most importantly for those with diabetes and related conditions.
One of the most important clinical revolutions in diabetes care in the past 10 years is the realization that ~ 70% of those with diabetes die of heart attacks or strokes. Moreover, it is not only elevated A1C that drives these catastrophic events; it is also elevated blood pressure, elevated LDL cholesterol, and tobacco use. National quality measures for diabetes have now evolved to what is known as a “comprehensive measure” widely endorsed by advocacy groups, health care delivery organizations, and payers. The 2008 diabetes comprehensive measure requires that a given patient's diabetes be counted as “controlled” only if the patient reaches goals.