Patient and physician perspectives regarding treatment of diabetes: compliance with practice guidelines

Managed care organizations are focusing on how physicians manage their patients with diabetes mellitus as an indicator of physician compliance with clinical practice guidelines. Assessment of physician compliance with published guidelines may reveal areas of disagreement between physicians and guidelines or between physicians and patients and may show areas for potential improvement of care. Compliance with the diabetes care guidelines was assessed in our clinics to determine physician beliefs and performance and patients' accommodation of recommended practices.

We interviewed 295 patients with diabetes and surveyed 47 providers at an academic family practice center to assess practices and beliefs regarding the care of patients with diabetes. We also reviewed a 1-year compilation of billing and referral records for physician use of glycosylated hemoglobin (hemoglobin A1c) testing and referral of patients for eye examinations.

We found that physician beliefs and practices were divergent and that provider performance of these nationally recommended activities was low. More than 75% of providers said that they recommended hemoglobin A1c testing, but only about 50% of patients had a documented test in the billing system. When questioned, one third of the patients reported that their physicians recommended this test. Similarly, nearly all physicians stated that they recommended annual eye examinations, although only 43% of patients said that their primary care physician recommended this referral.

Physicians can and must improve intervention and patient education in the care of diabetic patients. Patient knowledge, motivation, and practice must be augmented by physician efforts. Lack of compliance with guidelines may indicate deficiencies in physician knowledge, implementation problems, lack of belief in guidelines, or problems in patient compliance. Attention should be directed to all these areas.