One Size Does Not Fit All: The Need for a Continuous Measure for Glycemic Control in Diabetes
Authors: Aron, David C.; Pogach, Leonard M.
Source: Joint Commission Journal on Quality and Patient Safety, Volume 33, Number 10, October 2007 , pp. 636-643(8)
Publisher: Joint Commission Resources
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Abstract:
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
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