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Outcomes can be improved when the blood pressure (BP) is kept below 130/80 in patients with diabetes mellitus. However, physicians and patients achieve this target less than 50% of the time. The purpose of this study was to determine the reasons for this apparent quality deficit from the perspective of a small random sample of family physicians.Nine family physicians completed interviews about encounters with diabetic patients with BP ≥130/80 for whom no change in management was recorded. Four investigators analyzed the transcribed interviews to identify and categorize reasons for failure to intervene.Ninety-eight (62%) of 159 patients had BP ≥130/80 at the index visit. No change in management was recorded in 73 (74%). Physicians gave 175 reasons for nonintervention in 3 broad categories, physician-related, patient-related, and information/measurement-related reasons, and 10 subcategories. In most cases they gave more than one reason (mean 2.4) per case. The most frequent subcategories were limited treatment options (47/73; 64%), inadequate information on which to intervene (43/73; 59%), and patient nonadherence (27/73; 37%). Competing demands were mentioned in 10 cases (13.7%). Physicians differed with regard to the kinds of reasons given.Physicians have a variety of clinical reasons for not responding to elevated BP in diabetic patients. Some might be addressed with better technology (eg, more reliable BP measurements) or health care system reforms (eg, less expensive medications). Others (eg, patient nonadherence) are more challenging. Methods for measuring quality must be robust enough to account for legitimate clinical reasons for not achieving BP targets. Physician-based interventions will need to take into account different physician personalities and practice styles.