I write in reference to the recently updated and circulated “Standards of Medical Care in Diabetes,” in particular part II, “Screening for Diabetes,” which were recently updated and published in the American Diabetes Association (ADA) 2006 Clinical Practice Recommendations (1). I would like to take issue with the use of the phrase “standards of medical care in diabetes,” which is used to title all the individual components of these recently updated ADA guidelines. I think this phrase is unhelpful for both the health care community and the public at large, in that it strongly suggests that these guidelines are the definitive source to inform a “standard of care” for diabetes. Any deviation from the guideline may then be interpreted as “substandard care.”

A number of these guideline recommendations cite a level of evidence “E” (i.e., based on “[e]xpert consensus or clinical experience”). In most taxonomies, this is considered the weakest level of evidence available. The U.S. Preventive Services Task Force (USPSTF), in their most recently circulated guidelines, assigns an “I” (“inconclusive”) rating to whether asymptomatic individuals should be routinely screened for type 2 diabetes and a “B” rating (“fair evidence that the services improve important health outcomes and concludes that benefits outweigh harms”) to screening adults with hypertension or hyperlipidemia.

Given the importance of defining a standard of care for any disease management, I teach medical students that well-constructed guidelines developed by a nonpartisan group and based on a good level of evidence (such as the “B” rating by USPSTF) are the best informants of standard of care. Given the “I” rating by USPSTF, there clearly is room for clinical judgment when it comes to screening the general population. I respectfully suggest that it would be more helpful if the ADA guidelines, instead of being titled “Standard of Medical Care in Diabetes,” were titled something like “ADA Consensus Panel Guidelines.”

American Diabetes Association: Standards of medical care in diabetes–2006 (Position Statement).
Diabetes Care
Suppl. 1
US Preventive Services Task Force:
The Guide to Clinical Preventive Services 2005: Recommendations of the U.S. Preventive Services Task Force, U.S. Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ)
. Rockville, MD, AHRQ, 2005 (publ. no. 05-0570). Available at http://www.ahrq.gov/clinic/uspstfix.htm