October 2026

Next month, November is National Diabetes Month, providing an opportunity to reinforce evidence-based diabetes management and improve outcomes for patients living with diabetes. Early identification and management of diabetes-related complications can reduce morbidity, improve quality of life, and positively impact quality measures.  

This year, we encourage providers to focus on three key diabetes measures:

• EED: Eye Exam for Patients with Diabetes
• GSD: Glycemic Status Assessment for Patients with Diabetes
• KED: Kidney Health Evaluation for Patients with Diabetes

EED: Eye Exam for Patients with Diabetes

Why It Matters: 

Diabetic retinopathy remains one of the leading causes of preventable blindness among adults. Regular retinal screening enables early detection and intervention before vision loss occurs.

Quality Measure Overview

The measure assesses the percentage of patients 18-75 years of age with diabetes who receive appropriate retinal eye screening or monitoring for diabetic retinopathy during the measurement year.

Best Practices

• Refer patients annually for a retinal or dilated eye examination- exams that are negative for retinopathy qualify for compliance for two years.
• Obtain and document reports from ophthalmologists and optometrists
• Use EHR reminders for overdue screenings
• Educate patients that diabetic eye disease may develop without symptoms
• Follow up on referrals to ensure exam completion

Provider Tip: Schedule eye exam referrals before patients leave the office to improve completion rates. 

Patient tip sheet: download this informational tipsheet as a resource for your patients. 

 

GSD: Glycemic Status Assessment for Patients with Diabetes

Why It Matters:

Effective glycemic management helps prevent diabetes-related complications including kidney disease, neuropathy, retinopathy, cardiovascular disease, and amputation. (References: ncqa.org, hopkinsmedicine.org)

Quality Measure Overview

This measure evaluates the percentage of patients 18 to 75 years of age with diabetes whose most recent glycemic status assessment demonstrates:

• Glycemic Status <8.0%
• Glycemic Status >9.0% (poor control)

The measure uses the patient’s most recent HbA1c or glucose management indicator (GMI) during the measurement period. (References: ncqa.org, hopkinsmedicine.org)

Best Practices

• Order HbA1c testing at recommended intervals
• Review medication adherence at every visit
• Optimize treatment plans for patients above target
• Address social determinants of health (SDoH) barriers such as affordability, transportation, and health literacy
• Consider Continuous Glucose Monitoring (CGM) data when appropriate
• Proactively outreach patients with uncontrolled diabetes (References: ncqa.org, hopkinsmedicine.org)

Provider Tip: Patients without a documented glycemic assessment during the measurement year are considered noncompliant for the measure. (Reference:hopkinsmedicine.org)

 

KED: Kidney Health Evaluation for Patients with Diabetes

Why It Matters:

Diabetes and hypertension are the leading causes of chronic kidney disease (CKD). Early detection allows timely intervention and can slow disease progression. [ncqa.org]

Quality Measure Overview

The KED measure evaluates the percentage of patients 18-85 years of age with diabetes who receive the following during the measurement year. Both tests must be completed to satisfy the measure. [ncqa.org]

• Estimated Glomerular Filtration Rate (eGFR)
• Urine Albumin-to-Creatinine Ratio (uACR)

Best Practices

• Order annual eGFR testing
• Order annual quantitative urine albumin-creatinine ratio (uACR)
• Review abnormal results promptly
• Consider nephrology referral when appropriate
• Educate patients on kidney disease prevention
• Monitor blood pressure and glycemic control closely in patients with CKD risk factors [ncqa.org]

Provider Tip: A serum creatinine test alone does not satisfy the KED measure. Both eGFR and uACR are required. [ncqa.org]

October and November Action Items for Providers

• Review Open Care Gaps
• Identify patients with diabetes who are missing:
  • Eye exams (EED)
  • Glycemic status assessments (GSD)
  • Kidney health evaluations (KED)
• Use routine appointments to:
  • Schedule overdue screenings
  • Discuss medication adherence
  • Reinforce self-management education
  • Update care plans
  • Engage the Care Team 

• Use: 
  • Care managers
  • Population health teams
  • Referral coordinators
  • Pharmacists
  • Diabetes educators

Together, we can improve diabetes outcomes through early detection, comprehensive monitoring, and timely intervention. 

This article is the second in a four-part SCOPE series on pain management. Part one, published in the September issue, discussed opioid use in pregnancy and other high-risk populations. Future installments will explore how to recognize progress beyond pain scores and the role of opioids in chronic pain treatment. Together, these articles aim to support a patient-centered approach that balances safety, function, quality of life, and appropriate medication use.

One of the most challenging aspects of chronic pain management is helping patients understand what success looks like. Many patients seeking treatment understandably hope their pain will be eliminated. While complete pain relief may be achievable for some acute pain conditions, it is often unrealistic in the management of chronic pain.

When patients view pain elimination as the primary goal of treatment, they may become discouraged even when meaningful improvements have occurred. Likewise, clinicians may feel compelled to continue escalating therapy despite limited evidence that additional treatment will meaningfully improve outcomes.

Primary care providers are uniquely positioned to establish realistic expectations early, helping patients understand that the goal of treatment is often not the complete absence of pain, but rather improved function, participation in meaningful activities, independence, and quality of life. The CDC's 2022 opioid prescribing guideline specifically emphasizes improving function and quality of life as core treatment objectives.

Reframing the Goal of Treatment

Providers routinely help patients understand that chronic disease management is not always about curing a condition. For example, benzodiazepines and other anxiety treatments are not intended to eliminate every feeling of worry, nervousness, or stress. Rather, the goal is to reduce symptoms to a level that allows patients to function, maintain relationships, work, sleep, and participate fully in life.

Asthma treatment is often aimed at reducing symptom frequency, preventing exacerbations, and improving daily functioning rather than eliminating every episode of cough, wheeze, or shortness of breath.

Chronic pain management often follows a similar principle. Treatment may reduce symptoms and improve daily functioning even when some pain remains. Helping patients understand this concept early on can reduce frustration, improve satisfaction with care, and support more productive long-term treatment planning.

The Limitations of Pain Scores

Pain intensity remains an important component of assessment, but pain scores provide only a narrow view of the patient's overall experience.

Pain scores reflect a patient's experience at a particular moment in time. Factors such as poor sleep, stress, anxiety, illness, increased activity, or a temporary flare of the underlying condition can influence how pain is perceived on a given day. As a result, pain intensity ratings should be interpreted within the broader context of the patient's overall function, quality of life, and progress toward meaningful goals.

Research increasingly supports evaluating multiple domains of health rather than focusing exclusively on pain intensity. The Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) recommends assessing physical functioning, emotional functioning, patient perception of improvement, symptoms, and quality of life alongside pain severity.

When treatment discussions focus only on a numerical pain score, clinicians may miss opportunities to recognize meaningful improvements that matter most to patients.

Asking a Better Question

One of the most useful questions a clinician can ask is: "What is your pain preventing you from doing?"  This simple shift changes the conversation from symptom measurement to functional impact.

Why Goal Setting Matters

Goal setting is more than simply creating a treatment plan. It helps align therapy with outcomes that are personally meaningful to the patient.

In a randomized controlled trial involving patients with chronic low back pain, a combination of education and patient-led goal setting resulted in clinically meaningful improvements in disability, pain intensity, quality of life, self-efficacy, and fear of movement compared with a standard exercise program. Benefits were maintained at 12 months.

Similarly, systematic reviews evaluating Goal Attainment Scaling (GAS) suggest that individualized patient goals may capture meaningful changes that traditional outcome measures fail to detect. Goal-oriented approaches may also improve patient satisfaction and increase engagement in treatment.

More recent evidence suggests that behavioral interventions incorporating goal setting may improve pain-related disability and functional outcomes in patients with chronic musculoskeletal pain.

Taken together, these findings support the idea that helping patients identify meaningful goals is not merely a communication strategy. It is an evidence-based approach that may contribute to better patient outcomes.

Characteristics of Effective Functional Goals

Goals are most effective when they are specific, measurable, achievable, realistic, and timely (SMART). Most importantly they should be made by the patient/caregiver and meaningful to their circumstances.

Instead of: "I want my pain to go away."

Providers can help patients establish goals such as:

• Walk for 15 minutes three times per week.
• Attend a grandchild’s wedding.
• Sleep at least six hours most nights.
• Return to gardening this spring.
• Complete grocery shopping independently.
• Participate in physical therapy sessions consistently.
• Work a full shift three days per week.

These goals provide a more actionable framework for treatment and create opportunities to recognize progress over time.

Managing Expectations Around Medications

Medication discussions provide an ideal opportunity to reinforce functional goals.

Patients may assume that opioids, non-opioid analgesics, or adjuvant medications are intended to eliminate pain entirely. When these expectations remain unaddressed, dissatisfaction frequently follows.

Instead, clinicians can explain that medications often provide value by making pain more manageable, enabling patients to engage in activities that improve health and well-being. A medication that allows a patient to participate in physical therapy, improve sleep, increase activity levels, or spend more time with family may be providing substantial benefit even if pain remains present.

This approach can help patients better understand the role of pharmacotherapy while reducing the temptation to pursue progressively riskier treatments solely in pursuit of lower pain scores.

Bottom Line

Primary care providers play an essential role in helping patients redefine success in chronic pain management.

While pain intensity remains important, it should not be the sole measure of treatment effectiveness. By focusing on function, participation, independence, and quality of life, clinicians can help patients establish realistic expectations and recognize meaningful progress.

Looking Ahead: Part 3

Next month, Recognizing Progress Beyond Pain Scores will explore practical tools and strategies for measuring success in chronic pain management. Topics will include functional assessment, activity goals, quality-of-life measures, patient-reported outcomes, and simple approaches to tracking meaningful progress in clinical practice.

 

Article references available upon request.

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