228 CANADIAN JOURNAL OF DIABETES Several recent publications have clearly demonstrated that dia- betes care has not changed dramatically over the past 10 years (1). According to the National Health and Nutrition Examination Survey database, the number of individuals with glycosylated hemoglobin (A1C) <7.0% actually decreased from 44.5 to 35.8% over the past decade (1).This discouraging lack of improvement in diabetes care is surprising, as during this time major diabetes organizations, including the Canadian Diabetes Association, lowered their recommended A1C and glycemic targets (2). In addition, more treatment options have become available, including new oral antihyperglycemic agents, insulin analogues, more advanced insulin pumps and pens, and smaller, easier-to-use, blood glucose meters. The National Ambulatory Medical Care Survey database provided more information about how outpatient diabetes care has changed recently in the United States (US) (3). More than 4700 primary care visits by patients with diabetes between 1991 and 2004 were analyzed, and revealed that the number of patients taking oral antihyperglycemic agents increased from 37 to 51%; however, the percentage of patients receiving these medications remained surprisingly low. More worrisome, the percentage of individuals treated with insulin decreased from 25 to 15%.With respect to vascular protection, the number of patients treated with antihypertensive agents increased from 36 to 42%, and with lipid-lowering agents from 4 to 17%; howev- er, once again, the percentage remained low. Diabetes-related outpatient services (e.g. blood pressure [BP] measurement, lipid testing, dietary counselling, smoking cessation classes and exercise counselling) did not increase.The proportion of visits lasting >20 minutes increased slightly from 18 to 21%. In this issue of Canadian Journal of Diabetes, Ludwig and col- leagues provide important information about recent trends in diabetes care in Canada (4). The authors analyzed data from Manitoba’s Drug Programs Information Network and the Manitoba Diabetes Database from 1996 to 2001.Their data is similar to that from the US. Over the 5 years analyzed, treat- ment with oral antihyperglycemic agents, antihypertensive agents and lipid-lowering agents increased significantly (17%, 27% and 137%, respectively); however, use of all 3 indications of medications remained disappointingly low: 42% of patients with diabetes were not prescribed any antihyperglycemic medication and only 42.4% and 26.5% received antihyper- tensive and lipid-lowering agents, respectively. The study by Ludwig and colleagues clearly highlights the fact that diabetes care is not just dependent on new therapeu- tic developments. Barriers to effective care can exist at 3 lev- els: physician, patient and medical systems (5,6).At the physi- cian level, education is not enough. There is often a discrepancy between a physician’s competence (what they know) and their performance (what they actually do in prac- tice). One study that assessed diabetes care in 30 US academ- ic medical centres found that, despite high testing rates for A1C and lipid levels, there were low rates of medication adjustment among patients with values above target levels (7). All physicians face significant time constraints and lack of clin- ical resources that likely contribute to clinical inertia in initi- ating and adjusting therapy in patients with diabetes. In addition, patients often lack the knowledge and motivation to improve their self-care. Many face challenges regarding the costs of medications and diabetes supplies (8). Current med- ical systems do not support physicians and patients well. Recent trials have demonstrated that intensive, protocol- driven, nurse-practitioner-run clinics organized to control individual risk factors (hyperglycemia, hypertension, hyperlipi- demia) in patients with diabetes result in significant improve- ment in risk factor management (9-12). Other studies have demonstrated that interventions that encourage patients to take a more active role in their diabetes management result in improved BP, glycemic and lipid control (13).A key element in the success of the Diabetes Control and Complications Trial was frequent clinic visits involving nurses and dietitians, and the extensive telephone access to these healthcare professionals afforded to patients in the intensive intervention group (14). Those of us working on the front lines of diabetes care in Canada know that introducing new initiatives in diabetes management in the real world of clinical practice is extreme- ly difficult and resource-limited. The wheels of change grind slowly and, at the end of the day, inertia in changing how we provide diabetes care may well be the biggest challenge we face in improving diabetes care in Canada. Robyn L. Houlden MD FRCPC Division of Endocrinology,Faculty of Health Sciences Queen’s University Kingston, Ontario, Canada REFERENCES 1. Koro CE, Bowlin SJ, Bourgeois N, et al. Glycemic control from 1988 to 2000 among U.S. adults diagnosed with type 2 dia- betes: A preliminary report. Diabetes Care. 2004;27:17-20. 2. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 clini- Editorial Commentary Is Clinical Inertia the Biggest Challenge to Diabetes Care?