Overcoming barriers to evidence-based diabetes care.

Despite evidence-based guidelines that advocate aggressive management of hyperglycemia, hypertension, and hyperlipidemia, patients with diabetes continue to suffer from high rates of cardiovascular and microvascular complications and can expect a lifespan reduction of 10 to 15 years. Our current inability to effectively and widely translate clinical evidence into usual practice represents a major barrier to reducing the burden of diabetes and its complications. Diabetes care represents a complex interaction between patients (and their families and communities), physicians (and other providers), and the health care system. Because multi-drug regimens are typically required to control hyperglycemia and the diabetes-related risk factors of hypertension and hyperlipidemia, polypharmacy is the natural consequence of providing evidence-based medical care to patients with type 2 diabetes. Within this context, we review the current evidence regarding the following three potential barriers to effective care: 1) Medication adherence in the setting of complex medical regimens, 2) Lack of medication adjustment among patients above risk factor goals, and 3) Limitations of currently organized care systems to manage complex chronic diseases such as diabetes. We also describe recent results of controlled trials of population-level, informatics-based interventions to improve diabetes care.