The need to improve.

I n this issue of Diabetes Care, Massing et al. (1) present the results of their review of Medicare claims from 13,660 diabetic patients who received regular outpatient care from a primary care physician (n ϭ 1,749). During a 24-month period, 31% received no lipid profile, 24% received only one lipid profile, and 45% of the diabetic patients received two or more lipid profiles. Further analysis revealed that Caucasians compared with African Americans were 1.6 times more likely to receive a lipid panel, and patients with stroke or heart failure were also less likely to receive a lipid profile. There are clinical decisions pertaining to lipid screening made by the primary care physician that are not captured with Medicare claims data and may partially account for an under-representation of the adherence rates. One situation is a pa-tient's refusal to obtain a lipid profile. Another situation, which is rare, is the individual with a total cholesterol Ͻ100 mg/dl. In this case, the primary care physician may not request a full fasting lipid profile because the calculated LDL cholesterol goal will be Ͻ100 mg/dl and the additional information would not affect a clinical decision. The final clinical situation that has a practical application for diabetic patients is utilizing a direct LDL cholesterol measurement (2). The direct LDL cholesterol's Current Procedural Terminology (CPT) code is 83721, and this code was not used in the analysis by Massing et al. (1). The practical application of a direct LDL cholesterol measurement is that the sample can be obtained in a nonfasting state, unlike the calculated LDL cholesterol, which requires at least a 10-h fast. This is one solution to the difficult situation in which a diabetic patient treated with insulin has an office visit at 4:00 P.M. and must maintain a prolonged fast to obtain an accurate calculated LDL cholesterol measurement. Another indication for the direct LDL cholesterol measurement is if the serum triglyceride level exceeds 400 mg/dl. Even if these three situations were incorporated in the Medi-care claims data analysis, I suspect the adherence rate would still be low. The finding of Massing et al. of a low rate of adherence to the American Diabetes Association's recommendations for lipid testing in diabetic patients is concerning and underscores the need for improvement. Improvement is important because coronary heart disease is a major cause of mortality and morbidity in diabetic populations (3). Furthermore, trials have confirmed …