The Impact of Adherence to Screening Guidelines and of Diabetes Clinics Referral on Morbidity and Mortality in Diabetes

Abstract

Despite the heightened awareness of diabetes as a major health problem, evidence on the impact of assistance and organizational factors, as well as of adherence to recommended care guidelines, on morbidity and mortality in diabetes is scanty. We identified diabetic residents in Torino, Italy, as of 1st January 2002, using multiple independent data sources. We collected data on several laboratory tests and specialist medical examinations to compare primary versus specialty care management of diabetes and the fulfillment of a quality-of-care indicator based on existing screening guidelines (GCI). Then, we performed regression analyses to identify associations of these factors with mortality and cardiovascular morbidity over a 4 year- follow-up. Patients with the lowest degree of quality of care (i.e. only cared for by primary care and with no fulfillment of GCI) had worse RRs for all-cause (1.72 [95% CI 1.57–1.89]), cardiovascular (1.74 [95% CI 1.50–2.01]) and cancer (1.35 [95% CI 1.14–1.61]) mortality, compared with those with the highest quality of care. They also showed increased RRs for incidence of major cardiovascular events up to 2.03 (95% CI 1.26–3.28) for lower extremity amputations. Receiving specialist care itself increased survival, but was far more effective when combined with the fulfillment of GCI. Throughout the whole set of analysis, implementation of guidelines emerged as a strong modifier of prognosis. We conclude that management of diabetic patients with a pathway based on both primary and specialist care is associated with a favorable impact on all-cause mortality and CV incidence, provided that guidelines are implemented.

Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: a controlled clinical trial

“…More specifically, patients receiving structured or specialized diabetes care were more frequently treated according to the guidelines for type 2 diabetes [14,28,29]. The lower costs associated with managed care compared to usual care is comparable with recent studies showing that an increasing level of structured care was associated with decreased costs [15,30]. In these studies, information on costs was obtained by claims paid for covered health care use.…”

A Multicenter Italian Survey on Diabetes Care Units Reveals a Somewhat Slow Attitude in Treatment Guideline Implementation: Are We Dealing With Therapeutic Inertia?

“…13,[35][36][37] Inertia has been mostly thought to depend on (i) low GP propensity to changes, (i) poor care management DCU organization and eventually (iii) temporary unavailability of a specific drug 38,39 but our study showed that something eventually prevented even diabetologists from following best practice recommendations since the first visit.…”

“…11,13,14,23 This is easily explained by the fact that diabetologists may focus more closely upon diabetes-related issues and have direct access to patient education resources and other specialists to collaborate with. Moreover, as apart from their renowned skills, Italian diabetologists hold power, being the only allowed prescribing innovative diabetes-related drugs.…”

“…As a consequence of that, recommended best practices meant at improving outcomes are often ignored and this constitutes a case of clinical inertia in terms of management and quality aspects. 7,13 On such premises it is difficult to build-up a positive metabolic memory 4,11,21 as in real life adequate glucose levels are still far from being reached, and poorly controlled T2DM patients are much more than expected. 5,14,22,23 Based on the above mentioned considerations, the aim of this study was to verify how diabetes specialists started/modified drug regimens of their freshly referred patients to reach individualized HbA1c targets in case of HbA1c levels >7% (>53 mmol/mol), a cut-off chosen to define good metabolic control according to Italian Standards of Care, which in fact fully incorporate the latest ADA-EASD positions statement.…”

Membership in a Diabetes Care Network Improves General Practitioners’ Practices for HbA1c and Microalbuminuria Monitoring: A Cohort Study Among Patients With Type 2 Diabetes

“…Following these guidelines can decrease all-cause mortality and cardiovascular morbidity (1). France, like other countries, has sought to improve diabetes management, specifically by establishing diabetes care networks (DCNs) that coordinate care, provide continuing medical education for health care professionals, and educate network patients.…”