Evidence-based guidelines meet the real world: The case of diabetes care

OBJECTIVE - Improving diabetes care in the U.S. is critical because diabetes rates are increasing dramatically, particularly among minority and low-income populations. Although evidence-based practice guidelines for diabetes have been widely disseminated, many physicians fail to implement them. The objective of this study was to explore what happens to diabetes practice guidelines in real-world clinical settings. RESEARCH DESIGN AND METHODS - A qualitative research design was used. Open-ended semistructured interviews lasting 1-2 h were conducted with 32 key informants (physicians, certified diabetes educators, researchers, and agency personnel) selected for their knowledge of diabetes care in South Texas, an area with a high diabetes prevalence and a large proportion of minority and low-income patients. RESULTS - Health professionals stress that contextual factors are more important barriers to optimal diabetes care than physician knowledge and attitudes. Barriers exist at multiple levels and are interrelated in a complex manner. Examples include the following: time constraints and practice economics in the private practice setting; the need to maintain referral relationships and maldistribution of professionals in the practice community; low awareness and low socioeconomic status among patients; and lack of access for low-income patients, low reimbursement, and insufficient focus on prevention in the U.S. health care system. CONCLUSIONS - Contextual barriers must be addressed in order for diabetes practice guidelines to be implemented in real-world clinical practice. Suggested changes include an increased focus on prevention, improvements in health care delivery for chronic diseases, and increased attention to the special needs of minority and low-income populations.