Features of primary care associated with variations in process and outcomeof care of people with diabetes

Background: There is now clear evidence that tight control of blood glucose and blood pressure significantly lowers the risk of complications in both type I and type II diabetes. Although there is evidence that primary care c an be as effective as secondary care in delivering care for people with dia betes, standards in primary care are variable. Previous studies have shown that practice, patient or organisational factors may influence the level of care of patients with diabetes. However, these studies have been conducted in single geographical areas and involved only small numbers of practices. Aim: To determine the standard of diabetes care in general practice and to determine which features of practices are associated with delivering good q uality care. Design of study: A questionnaire survey and analysis of multi-practice audi t data. Setting: Three health authorities in England, comprising 169 general practi ces. Method: This study was conducted with a total population of 1 182 872 patie nts and 18 642 people with diabetes. Linkage analysis was carried out on da ta collected by a questionnaire, routinely collected health authority data, and multi-practice audit data collected by primary care audit groups. Prac tice annual compliance was measured with process and outcome measures of ca re, including the proportion of patients who had an examination of their fu ndi, feet, blood pressure, urine, glycated haemoglobin, and the proportion who had a normal glycated haemoglobin. Results: Median compliance with process and outcome measures of care varied widely between practices: fundi were checked for 64.6% of patients (interq uartile range [IQR] = 45.3-77.8%), urine was checked for 71.4% (IQR = 49.7 = 84.3%), feet were checked for 70.4% (IQR = 51.0-84.4%), blood pressure fo r 83.6% (IQR = 66.7%-91.5%), and glycated haemoglobin was checked for 83.0% of patients (IQR = 69.4-92.0%). The glycated haemoglobin was normal in 42. 9% of patients (IQR = 33.0-51.2%). In multiple regression analysis, complia nce with measures of process of care were significantly associated with sma ller practices, fundholding practices, and practices with a recall system. Practices with more socioeconomically deprived patients were associated wit h lower compliance with most process measures. Practices with a greater pro portion of patients attending hospital clinics had lower compliance with pr ocess and outcome measures. Being a training practice, having a diabetes mi ni-clinic, having more nurses, personal care, and general practitioner or n urse interest in diabetes were not associated with compliance of process or outcome of care. Conclusions: Despite recent evidence that complications of diabetes may be delayed or prevented, this study has highlighted a number of deficiencies i n the provision of diabetes care and variations in care between general pra ctices. Provision of high quality diabetes care in the United Kingdom will present an organisational challenge to primary care groups and trusts, espe cially those in deprived areas.