Determinants of Quality in Diabetes Care Process: The population-based Torino Study

OBJECTIVE: To investigate the role of clinical and socioeconomic variables as determinants of adherence to recommended diabetes care guidelines and assess differences in the process of care between diabetologists and general practitioners. RESEARCH DESIGN AND METHODS: We identified diabetic residents in Torino, Italy, as of 31 July 2003, using multiple independent data sources. We collected data on several laboratory tests and specialist medical examinations registered during the subsequent 12 months and performed regression analyses to identify associations with quality-of-care indicators based on existing guidelines. RESULTS: After 1 year, only 35.8% of patients had undergone a comprehensive assessment. In the multivariate models, factors independently and significantly associated with lower quality of care were age ≥75 years (prevalence rate ratio [PRR] 0.66 [95% CI 0.61–0.70]) and established cardiovascular disease (0.89 [0.86–0.93]). Disease severity (PRR for insulin-treated patients 1.45 [1.38–1.53]) and diabetologist consultation (PRR 3.34 [3.17–3.53]) were positively associated with high quality of care. No clear association emerged between sex and socioeconomic status. These differences were strongly reduced in patients receiving diabetologist care compared with patients receiving general practitioner care only. CONCLUSIONS: Despite widespread availability of guidelines and simple screening procedures, a nonnegligible portion of the diabetic population, namely elderly individuals and patients with less severe forms of the disease, are not properly cared for. As practitioners in diabetes centers are more likely to adhere to guidelines than general practitioners, quality in the diabetes care process can be improved by increasing the intensity of disease management programs, with greater participation by general practitioners.