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Overall quality of diabetes care in a defined geographic region: different sides of the same story.

BACKGROUND
In diabetes care, knowledge about what is achievable in primary and secondary care is important. There is a need for an objective method to assess the quality of care in different settings. A quality-of-care summary score has been developed based on process and outcome measures. An adapted version of this score was used to evaluate diabetes management in different settings.


AIM
To evaluate the quality of diabetes management in primary and secondary care in a defined geographic region in the Netherlands, using a quality score.


DESIGN OF STUDY
Cross-sectional study.


SETTING
Thirty general practices in the Netherlands.


METHOD
A study of 2042 patients with type 2 diabetes (1640 primary care and 402 secondary care) was conducted. Quality of diabetes management was assessed by a score of process and outcome indicators (range 0-40). Clustering at practice level and differences in patient characteristics (case mix) were taken into account.


RESULTS
At the outpatient clinic, patients were younger (mean age 64.1 years, standard deviation (SD)=12.5 years, versus mean age 67.1 years, SD=11.7, P<0.001), had more diabetes-related complications (macrovascular: 39.7% versus 24.3%, P<0.001; and microvascular: 25.9% versus 7.3%, P<0.001), and lower quality-of-life scores (EuroQol-5D: mean=0.60, SD=0.29, versus mean=0.80, SD=0.21, P<0.001). After adjusting for case mix and clustering, there was a weak association between the setting of treatment and haemoglobin A1c (primary care: mean 7.1%, SD=1.1, versus secondary care: mean 7.6%, SD=1.2, P<0.016), and between setting and systolic blood pressure (primary: mean 145.7 mmHg, SD=19.2, versus secondary care: 147.77 mmHg, SD 21.0, P<0.035). Quality-of-care summary scores in primary and secondary care differed significantly, with a higher score in primary care (mean 19.6, SD=8.5 versus, mean 18.1, SD=8.7, P<0.01). However, after adjusting for case mix and clustering, this difference lost significance.


CONCLUSION
GPs and internists are treating different categories of patients with type 2 diabetes. However, overall quality of diabetes management in primary and secondary care is equal. There is much room for improvement. Future guidelines may differentiate between different categories of patients.