Compliance with Clinical Practice Guidelines for Type 2 Diabetes in Rural Patients: Treatment Gaps and Opportunities for Improvement Ellen L. Toth, M.D., Sumit R. Majumdar, M.D., M.P.H., Lisa M. Guirguis, M.Sc.Pharm., Richard Z. Lewanczuk, M.D., Ph.D., Tzu K. Lee, M.D., and Jeffrey A. Johnson, Ph.D. The level of compliance with clinical practice guidelines for patients with type 2 diabetes was evaluated in 368 patients from two health regions in rural northern Alberta, Canada. Data were collected from patient interviews, drug histories, physical and laboratory assessments, and a self-report questionnaire to assess clinical status, indicators of diabetes management, and health care utilization. Treatment of three clinical indicators of diabetes—hemoglobin A 1c (A1C), blood pressure, and low-density lipoprotein cholesterol (LDL)— has been shown to reduce the morbidity and mortality associated with type 2 diabetes. Mean ± SD values for this cohort of patients were as follows: A1C 7.25% ± 1.54%, blood pressure 131.7 ± 18.2/76.2 ± 12.7 mm Hg, and LDL 105.2 ± 32 mg/dl. Despite these results, only 10.4% of the patients met all three recommended targets for control of glycemia: A1C below 7%, blood pressure below 130/85 mm Hg, and LDL below 100 mg/dl. Of patients not at target levels, 14.4%, 27.5%, and 86.7% reported receiving no therapy for hyperglycemia, hypertension, and dyslipidemia, respectively. Of those taking oral hypoglycemic agents who were not at target levels, only 35% were receiving combination therapy. Of patients at or above LDL target levels, 87% were not receiving any therapy. Only 22% of patients were taking aspirin, although this therapy would be recommended for the entire cohort according to clinical practice guidelines. Despite the availability of proved effective therapies, treatment gaps were present for this cohort of patients. (Pharmacotherapy 2003;23(5):659–665) Clinical practice guidelines for management of diabetes mellitus are based in part on the results of randomized, controlled trials. Evidence supports the benefit of lowering the levels of blood glucose, blood pressure, and lipids in patients with type 2 diabetes. 1–3 Aspirin therapy also has been recommended, with respect to cardiovascular risk reduction. 4 Aggressive management of diabetes not only should decrease its morbidity and mortality by reducing associated long-term complications but also may significantly decrease costs associated with these complications. 5, 6 Most morbidity and mortality in patients with type 2 diabetes are associated with macrovascular disease. 7–11 The latest version of the Canadian Diabetes Association’s clinical practice guidelines, published in 1998, recommends standards of care for management of diabetes and its compli- cations, such as hypertension and dyslipidemia. 4 The Canadian guidelines are, for the most part, concordant with United States and European guidelines. 12 However, despite intensive and expensive efforts to disseminate clinical practice guidelines, studies have demonstrated that many physicians do not follow them. 13–16 Reports have indicated low or variable levels of basic manage- ment and preventive services in diabetes care provided by physicians. 17–19 In evaluations of clinical practice guidelines for diabetes management, low-to-moderate (6–88%) levels of adherence to recommended diabetes practices