To the Editor.
—Both Dr Weiner and colleagues1 and Dr Leape2 presume that the standards for diabetes are correct, and therefore that primary care physicians are performing inadequately. We believe that assumption is incorrect. A diabetic patient known to have blood sugars out of control will not benefit from a glycosylated hemoglobin level.We have studied implementing intensive diabetes education—including medical, nutritional, and exercise components—in primary care practice with disappointing results.3 While knowledge of diabetes, attitudes and skills related to diabetic management, family behaviors, and performance assessments all significantly improved in the experimental group compared with the control group, at final follow-up there were no significant differences in fasting glycemia, glycosylated hemoglobin, or microalbuminuria.We believe noncompliant patients would be more likely to be in primary care practices than in practices of diabetologists. This difference may account for the findings of Dr Weiner and colleagues.1 Patients
Bowman MA, Konen JC. Quality of Outpatient Care: Diabetes. JAMA. 1995;274(20):1584. doi:10.1001/jama.1995.03530200020016