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One Size Does Not Fit All: The Need for a Continuous Measure for Glycemic Control in Diabetes

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Background: The assessment of glycemic control, most commonly using glycosylated hemoglobin (A1C), has been a major measure for care of patients with diabetes. Historically, dichotomous thresholds have been set for intermediate outcomes such as A1C (in this case, > 9%) on the basis of levels associated with high risk, that is, thresholds for what would be considered poor control for all persons.

Limitations and Possible Unintended Consequences of Threshold Measures: Dichotomous threshold measures may not accurately reflect the true impact of care on population health because absolute risk reduction for micro- and macrovascular complications of diabetes is not linear but rather log-linear, with greater impact of a given improvement on patients with worse rather than better glycemic control. Also, an "all or none" measure for all patients set at "optimal" control may unfairly evaluate physician/health care performance.

A Conceptual Model for Assessing the Quality of Glycemic Control: A continuous measure of A1C, as the cornerstone in quality assessment for diabetes, can incorporate each of the Institute of Medicine's (IOM)'s quality domains: effectiveness and equity, patient safety, patient-centered care, timeliness, and efficiency.

Conclusions: A continuous measure of A1C can better capture than a dichotomous measure the complexity of glycemic control at a population level.

Document Type: Research Article

Publication date: October 1, 2007

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  • Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.

    David W. Baker, MD, MPH, FACP, executive vice president for the Division of Healthcare Quality Evaluation at The Joint Commission, is the inaugural editor-in-chief of The Joint Commission Journal on Quality and Patient Safety.

    Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety
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