Highlights
- •The paper analyzes the quality of diabetic care provided by an Italian primary care practice.
- •HbA1c was >8% in 22% of patients and that figure did not change during the follow-up.
- •SBP and LDL-C was at target in a minority of patients.
- •Only a third of patients was prescribed statins.
- •Efforts are needed to improve the management of type 2 diabetes in primary care.
Abstract
Aims
Evidence-based guidelines provide targets and performance measures for the treatment
of type 2 diabetic patients but a wide gap separates guidelines-driven recommendations
from their clinical application, a phenomenon hindering the transfer of proven benefits
to affected populations.
Methods
We analyzed the quality of diabetic care delivered by 8 general practitioners joint
in a group practice attending 571 diabetic patients (5.6% of the total enlisted subjects)
by assessing process (% of HbA1c, SBP and LDL-C determinations) and intermediate outcome (% of patients with HbA1c <7% vs >8%, systolic BP <130 mmHg vs >140 mmHg, LDL-cholesterol <100 mg/dL vs >130 mg/dL) indicators.
Results
HbA1c was at target in 49% of patients and >8% in 22%; SBP and LDL-C determination was
available in about two-thirds of patients, only a minority at target for SBP and LDL-C.
Antihyperglycemic and antihypertensive treatment was prescribed in most patients but
only a third was on statins. During the post-evaluation phase, percentages of patients
with HbA1c >8%, SBP < 130 mmHg and LDL-C < 100 mg/dL and the drug prescription pattern did not change.
Conclusions
Several weaknesses affect primary care delivery to type 2 diabetic patients and efforts
are needed to improve the management of this high-risk group.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to Primary Care DiabetesAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Diabetes and cardiovascular disease: the Framingham study.JAMA. 1979; 241: 2035-2038
- Mortality from coronary heart disease and stroke in relation to degree of glycaemia: the Whitehall study.BMJ. 1983; 287: 867-870
- Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes.N. Engl. J. Med. 2003; 348: 383-393
- Standards of medical care in diabetes—2013.Diabetes Care. 2013; 36: S11-S66
- Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes.JAMA. 2004; 291: 335-342
- Glycemic control and morbidity in the Canadian primary care setting (results of the diabetes in Canada evaluation study).Diabetes Res. Clin. Pract. 2005; 70: 90-97
- Current level of glycaemic control and its associated factors in patients with type 2 diabetes across Europe: data from the PANORAMA study.Clin. Endocrinol. (Oxf.). 2014; 80: 47-56
- Baseline quality-of-care data from a quality-improvement program implemented by a network of diabetes outpatient clinics.Diabetes Care. 2008; 31: 2166-2168
- The clinical reality of guidelines for primary prevention of cardiovascular disease in type 2 diabetes in Italy.Atherosclerosis. 2008; 198: 396-402
- Quality of diabetes care predicts the development of cardiovascular events: results of the AMD-QUASAR study.Diabetes Care. 2011; 34: 347-352
- Quality of diabetes care in Italy: information from a large population-based multiregional observatory (ARNO diabetes).Diabetes Care. 2012; 35: e64
- Implementing a guideline for the treatment of type 2 diabetics: results of a cluster-randomized controlled trial (C-RCT).BMC Health Serv. Res. 2007; 7: 79
- Prevalence and antihyperglycemic prescribing trends for patients with type 2 diabetes in Italy: a 4-year retrospective study from national primary care data.Pharmacol. Res. 2008; 57: 358-363
- Chronic kidney disease and cardiovascular risk in hypertensive type 2 diabetics: a primary care perspective.Nephrol. Dial. Transplant. 2009; 24: 1528-1533
- Where on the healthcare continuum should we invest? The case for primary care?.Heart Lung Circ. 2009; 18: 108-113
- Pay-for-performance programs in family practices in the United Kingdom.N. Engl. J. Med. 2006; 355: 375-384
- (accessed 27.01.14)
- Network organizations of general practitioners: antecedents of formation and consequences of participation.BMC Health Serv. Res. 2010; 10: 118
Standard Italiani per la Cura del Diabete Mellito Tipo 2. Edizione per la medicina generale. @ http://www.simg.it/documenti/collaborazioni/amd/AMD_SID_SIMMG_2011%20definitivo.pdf.
- Clinical inertia.Ann. Intern. Med. 2001; 135: 825-834
- Quality of care and outcomes in type 2 diabetic patients: a comparison between general practice and diabetes clinics.Diabetes Care. 2004; 27: 398-406
- Management of type 2 diabetic patients attending diabetic outpatient clinics compared with those cared for by the general practitioners: an experience of integrated diabetes management.Ann. Ist. Super. Sanita. 2009; 45: 162-167
- Longevity and health expectancy in an ageing society: implications for public health in Italy.Ann. Ist. Super. Sanita. 2012; 48: 292-299
- Long-term effects of intensive glucose lowering on cardiovascular outcomes.N. Engl. J. Med. 2011; 364: 818-828
- Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: meta-analysis of randomised controlled trials.BMJ. 2011; 343: d4169
- Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy.Arch. Intern. Med. 2010; 170: 1648-1654
- Management of hyperglycaemia in type 2 diabetes: a patient-centered approach Position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).Diabetologia. 2012; 55: 1577-1596
- Group versus single handed primary care: a performance evaluation of the care delivered to chronic patients by Italian GPs.Health Policy. 2013; 113: 188-198
- General practitioners’ adherence to evidence-based guidelines: a multilevel analysis.Health Care Manage. Rev. 2012; 37: 67-76
- Determinants of quality in diabetes care process: the population-based Torino Study.Diabetes Care. 2009; 32: 1986-1992
- Women show worse control of type 2 diabetes and cardiovascular disease risk factors than men: results from the MIND.Nutr. Metab. Cardiovasc. Dis. 2013; 23: 235-241
- Feasibility and effectiveness in clinical practice of a multifactorial intervention for the reduction of cardiovascular risk in patients with type 2 diabetes: the 2-year interim analysis of the MIND.IT study: a cluster randomized trial.Diabetes Care. 2013; 36: 2566-2572
- Effects of intensive blood-pressure control in type 2 diabetes mellitus.N. Engl. J. Med. 2010; 362: 1575-1585
- List of authors Task Force Members: 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC).J. Hypertens. 2013; 31: 1281-1357
- MRC/BHF Heart Protection Study of cholesterol-lowering with simvastatin in 5963 people with diabetes: a randomised placebo-controlled trial.Lancet. 2003; 361: 2005-2016
- Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial.Lancet. 2004; 364: 685-696
- 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.Circulation. 2013; 12 (Epub ahead of print)
- The underuse of statin in type 2 diabetic patients attending diabetic clinics in Italy.Nutr. Metab. Cardiovasc. Dis. 2007; 17: 32-40
- Recurrence of cardiovascular events in patients with type 2 diabetes: epidemiology and risk factors.Diabetes Care. 2008; 31: 2154-2159
- Italy: health system review.Health Syst. Transition. 2009; 11: 1-216
- Avoiding pitfalls in chronic disease quality measurement: a case for the next generation of technical quality measures.Am. J. Manage. Care. 2001; 7: 1033-1043
Article info
Publication history
Published online: June 04, 2014
Accepted:
April 23,
2014
Received in revised form:
April 22,
2014
Received:
February 28,
2014
Identification
Copyright
© 2014 Primary Care Diabetes Europe. Published by Elsevier Inc. All rights reserved.
