Patient archetypes, physician archetypes, and tailored diabetes care.

Evidence-based diabetes care guidelines specify several important clinical goals. Reducing glycated hemoglobin (A1c) levels to less than 7%, blood pressure to less than 130/80 mm Hg, and lowdensity cholesterol levels to less than 100 mg/dL; using aspirin; and stopping smoking have each been shown to reduce microvascular or macrovascular complication of diabetes. About 70% of adults with diabetes die of a heart attack or stroke, and aggressive control of these risk factors reduces rates of major cardiovascular event or mortality by at least 30% to 50%. The most common error primary care physicians make in diabetes care is failure to move toward reducing the levels of hemoglobin A1c, lowdensity cholesterol, and blood pressure, or prescribing aspirin for a patient who has not yet reached one or more of these important evidencebased goals. Studies have shown that primary care physicians are knowledgeable about important evidence-based goals and believe that most patients, with the exception of the terminally ill or seriously functionally impaired, should be managed aggressively. Yet, when we encounter a patient who could benefit from better control of hemoglobin A1c levels, blood pressure, or low-density cholesterol levels, we make a move only about 12% of the time. Most of us believe that the main problem in diabetes care is not the physician, but the patient. We often claim that we do not initiate or intensify therapy because our patients will not let us. Many medical groups, however, have improved mean hemoglobin A1c levels, low-density cholesterol levels, or blood pressure substantially in recent years simply by setting specific improvement goals and organizing office systems with diabetes registries to enable monitoring, prioritization, visit planning, and active outreach to patients. Office systems that include registries often reduce mean hemoglobin A1c levels about an absolute 1%, but it is clear that we need to do more to get most patients to reduce hemoglobin A1c levels to less than 7%, systolic blood pressure to less than 130 mm Hg, and low-density cholesterol levels to less than 100 mg/dL. Once our offices are organized, the critical next step is to find effective ways to change the behavior of our patients. The work of Peterson and Hughes in this issue of the Journal implies that tailoring diabetes care to specific patient characteristics, such as readiness to change, could lead to improvements in both effectiveness and efficiency of diabetes care. Tailored care might be more effective because we can select interventions that match the needs and expectations of specific patients. Tailored care can be more efficient because we can match the intensity of care and the responsiveness of the patient to our efforts. An extensive body of literature supports the effectiveness of tailored messages, and tailoring care to patients has been an important hallmark of primary care for generations. The success of any tailoring strategy is likely to increase if we can develop a simple way to classify patients and apply this method systematically to all diabetes patients. Informal assessment of patient motivation to improve diabetes care is known to be inaccurate. The introduction of simple tools, such as those described by Peterson and Hughes, that can be used systematically in routine office practice to assess readiness to change allows us to tailor our management to the particulars of the patient. Tailoring care to our patients’ readiness to change is a key concept, but there are other patient characteristics that require additional clinical and research attention. What determines a patient’s Submitted 15 March 2002. From HealthPartners Research Foundation, Minneapolis. Address reprint requests to Patrick O’Connor, MD, HealthPartners Research Foundation, 8100 34th Avenue South, Minneapolis, MN 55440-1524.