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Current approaches to assessing quality of diabetes care do not account for the heterogeneity of older patients.We sought to compare conclusions regarding adequacy of glucose and blood pressure control using current quality assessment approaches and a stratified approach based on geriatric care guidelines.This was a cross-sectional evaluation of diabetes care.We studied patients older than 65, living with diabetes (n = 554) attending clinics of an academic medical center.We measured the proportion of patients with and without markers of poor health (life expectancy ≤5 years, age ≥85, 4–6 activities of daily living dependencies, or Charlson Comorbidity Index Score ≥5) achieving treatment goals.Under general population goals (glycosylated hemoglobin [HbA1C] ≤6.5% or <7%; systolic blood pressure [SBP] <130 mm Hg), a small proportion of our subjects met glucose (24–36%) or SBP control (30%) targets. Under new guidelines, less-intense targets (HbA1C ≤ 8%, SBP < 140 mm Hg) would be applied to patients with diminished health, with general population goals reserved for healthier patients. With this stratified approach, the proportion of sicker patients achieving their specified glucose (61–83%) and SBP goals (37–64%) generally was high, depending on the criteria for poor health, whereas the proportion of healthier patients achieving their goals remained low.A stratified approach to assessing the quality of diabetes care leads to distinct care conclusions for older patients with and without markers of diminished health. An approach to quality assessment and quality improvement that acknowledges patient heterogeneity could help ensure the clinical relevance of such efforts for older patients.