Revisiting Disparities in Quality of Care Among US Adults With Diabetes in the Era of Individualized Care, NHANES 2007–2010

In 1999, standards for diabetes quality of care and performance measurement were established by the National Committee for Quality Assurance's (NCQA's) Health Plan Employer Data and Information Set (HEDIS).1 The HEDIS measure for comprehensive diabetes care includes the intermediate outcome measures of hemoglobin A1c (A1C) and low-density lipoprotein cholesterol (LDL) control, for example, A1C < 8% and LDL < 100 mg/dL. These NCQA HEDIS diabetes quality measures have been influential tools for performance measurement, public reporting, and reimbursement as they are endorsed by the National Quality Forum and are used by the Centers for Medicare and Medicaid Services in a variety of programs, including the Physician Quality Reporting System. Although the American Diabetes Association (ADA) has always endorsed a lower A1C < 7.0% goal for the majority of patients with diabetes, since 2002, they have also recommended an individualized approach to diabetes goal setting.2 In 2012, the ADA and European Association for the Study of Diabetes (EASD) published a position statement strengthening their support for a patient-centered approach to managing hyperglycemia.3 This position statement was in response to major diabetes trials which found little benefit, or even harm, from very intensive glycemic control (eg, A1C < 6.5%), especially for patients with cardiovascular disease.4–7 Thus, in addition to uniform goals, diabetes guidelines strongly support personalized glycemic goals based on a combination of risks associated with hypoglycemia or other adverse events, disease duration, life expectancy, important comorbidities, established vascular complications, and social resources. For example, patients with cardiovascular disease are recommended an A1C < 8% goal, as opposed to