Prevention and Management of Diabetes Quality Improvement Program

Family physicians care for patients of all ages and treat a variety of conditions, both acute and chronic, in numerous clinical settings. While there are many clinical guidelines to assist clinicians, the sheer number of them can be overwhelming. Guidelines meant to assure high-quality, evidence-based care for patients are complex and may contradict clinical recommendations. It is also important to note that family physicians, though woefully underrepresented in the healthcare system, are usually the first line of defense to screen, diagnose and treat chronic diseases such as diabetes.

Much like primary care practices, patients are often faced with contextual barriers that prevent them from seeking treatment for their serious health conditions. Patients who have prediabetes or diabetes who are not adequately screened, who go undiagnosed, or who are diagnosed but do not adequately control their disease can experience a host of complications. As a result, diabetes has become an epidemic of mass proportions which can only be overcome through clear practice guidelines, a clinical understanding of a patient’s contextual barriers to care, and a priority to maximize the practice team to implement meaningful patient interventions.

Now more than ever, family physicians and their care teams need appropriate education and training on how to screen and diagnose patients with prediabetes and diabetes, which will help to decrease the number of patients who go undiagnosed and untreated.

The purpose of this project is to assist physicians and their practice teams to improve the care provided to patients in the prevention and management of diabetes.

This module aligns with the following standards:

For additional information, please visit the Clinical Introduction & References page

Learning Objectives

Participants in this module will:

  1. Understand the importance of practice team engagement on improving outcomes for patients with diabetes/prediabetes.
  2. Determine the gaps in the care given to patients with diabetes, those with prediabetes, and those at risk for diabetes.
  3. Put interventions into practice, work for improvement in lifestyle, medical therapy, and/or monitoring for patients with diabetes.
  4. Demonstrate improvements in patient care as a result of systems changes identified through quality improvement initiatives.


  • Ryan Kauffman, MD, (Project Champion)
  • Anna McMaster, MD
  • Terry Wagner, DO
  • Douglas Harley, DO
  • Gary LeRoy, MD


  • Melinda Fritz, MD
  • Evan Howe, MD
  • Erin Jech
  • Erin Moushey, MD
  • Mary Krebs, MD
  • Kate Mahler, CAE
  • Steve Zitelli, MD

Faculty Disclosure

The Ohio Academy of Family Physicians (OAFP) adheres to the conflict of interest policy of the American Academy of Family Physicians (AAFP) as well as to the guidelines of the Accreditation Council for Continuing Medical Education (ACCME) and the American Medical Association (AMA). Current guidelines state that participants in continuing medical education (CME) activities should be made aware of any affiliation or financial interest that may affect a faculty member’s participation in the activity.

The members of this expert panel have completed conflict of interest statements. Disclosures do not suggest bias but provide readers with information relevant to the evaluation of the contents of these recommendations.


This module was supported, in part, by the Cooperative Agreement Number 2 B01 OT 009042 funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.

System Requirements

Hardware/Software requirements include · Windows 7+ - Internet Explorer 9.0+ · OS X 10.7+ · Safari, Google Chrome 42.0.0+ · Broadband connection (DSL/cable) recommended.