Quality of Care and Outcomes in Type 2 Diabetic Patients A comparison between general practice and diabetes clinics GIORGIA DE BERARDIS, MSC (PHARM CHEM) 1 FABIO PELLEGRINI, MS 1 MONICA FRANCIOSI, MSC (BIOL) 1 MAURIZIO BELFIGLIO, MD 1 BARBARA DI NARDO, HSDIP 1 SHELDON GREENFIELD, MD 2 SHERRIE H. KAPLAN, PHD MPH 2 MARIE C.E. ROSSI, MSC (PHARM CHEM) 1 MICHELE SACCO, MD 1 GIANNI TOGNONI, MD 1 MIRIAM VALENTINI, MD 1 ANTONIO NICOLUCCI, MD 1 ON BEHALF OF THE QUED STUDY GROUP* OBJECTIVE — The role of general practice and diabetes clinics in the management of dia- betes is still a matter of debate. Methodological flaws in previous studies may have led to inaccurate conclusions when comparing the care provided in these different settings. We com- pared the care provided to type 2 diabetic patients attending diabetes outpatient clinics (DOCs) or being treated by a general practitioner (GP) using appropriate statistical methods to adjust for patient case mix and physician-level clustering. RESEARCH DESIGN AND METHODS — We prospectively evaluated the process and intermediate outcome measures over 2 years in a sample of 3,437 patients recruited by 212 physicians with different specialties practicing in 125 DOCs and 103 general practice offices. Process measures included frequency of HbA 1c , lipids, microalbuminuria, and serum creatinine measurements and frequency of foot and eye examinations. Outcome measures included HbA 1c , blood pressure, and total and LDL cholesterol levels. RESULTS — Differences for most process measures were statistically significantly in favor of DOCs. The differences were more marked for patients who were always treated by the same physician within a DOC and if that physician had a specialty in diabetology. Less consistent differences in process measures were detected when patients followed by GPs were compared with those followed by physicians with a specialty other than diabetology. As for the outcomes considered, patients attending DOCs attained better total cholesterol levels, whereas no major differences emerged in terms of metabolic control and blood pressure levels between DOCs and GPs. Physicians’ specialties were not independently related to patient outcomes. CONCLUSIONS — Being followed always by the same physician in a DOC, particularly if the physician had a specialty in diabetes, ensured better quality of care in terms of process measures. In the short term, care provided by DOCs was also associated with better intermediate outcome measures, such as total cholesterol levels. Diabetes Care 27:398 – 406, 2004 T he long-lasting debate on the role of generalists and specialists in the management of diabetes is still un- resolved. Nonetheless, the constant in- crease in the demand for diabetes care and the need for providing adequate and ho- mogeneous levels of care call for a deeper understanding of those structural and or- ganizational characteristics that can play an important role in reaching the desired health outcomes while minimizing un- necessary costs. Studies have consistently shown that specialist care is associated with better process outcomes in type 1 diabetes (1). However, the few existing studies in type 2 diabetes have generally found that al- though specialists tend to perform better in process measures than generalists, there are no substantial differences in terms of outcomes (2– 6). It has been recently underlined that to make accurate comparisons of quality of diabetes care between specialty groups, it is of fundamental importance to account for the differences in patient characteris- tics (case mix) as well as for the physician- level variation (clustering) (5,7). Studies that fail to take these important method- ological aspects into account may lead to spurious conclusions when comparing the care provided by generalists and specialists. Within the context of a nationwide outcomes research program in type 2 di- abetes, we evaluated the care provided during a 2-year period to patients attend- ing diabetes outpatient clinics (DOCs) or being followed by general practitioners (GPs). Our study involved a large number of GPs and DOC physicians and offered the opportunity to compare the quality of diabetes care provided by generalists and specialists while accounting for patient case mix and physician-level clustering. RESEARCH DESIGN AND METHODS The Italian health care system All Italian citizens are covered by a gov- ernment health insurance and are regis- tered with a GP. Primary care for diabetes is provided by GPs and in DOCs. Patients can choose one of these two ways of ac- cessing the health care system according to their preferences or they can be re- ferred to DOCs by their GPs. The DOCs are usually staffed by diabetologists, inter- nists, and/or endocrinologists, who are primarily responsible for diabetes care; ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Department of Clinical Pharmacology and Epidemiology, Istituto di Ricerche Farmacologiche Mario Negri, Consorzio Mario Negri Sud, S. Maria Imbaro, Chieti, Italy; and the 2 Center for Health Policy Research, University of California, Irvine, Irvine, California. Address correspondence and reprint requests to Antonio Nicolucci, MD, Department of Clinical Phar- macology and Epidemiology, Consorzio Mario Negri Sud, Via Nazionale, 66030 S. Maria Imbaro, Chieti, Italy. E-mail: nicolucci@negrisud.it. Received for publication 4 June 2003 and accepted in revised form 23 October 2003. *A complete list of the QuED Study Group can be found in the APPENDIX. Abbreviations: DOC, diabetes outpatient clinic; GP, general practitioner; TIBI, Total Illness Burden Index. A table elsewhere in this issue shows conventional and Syste `me International (SI) units and conversion factors for many substances. © 2004 by the American Diabetes Association. Epidemiology/Health Services/Psychosocial Research O R I G I N A L A R T I C L E 398 DIABETES CARE, VOLUME 27, NUMBER 2, FEBRUARY 2004