A longitudinal study examining adherence to guidelines in diabetes care according to different definitions of adequacy and timeliness

PLoS One. 2011;6(9):e24278. doi: 10.1371/journal.pone.0024278. Epub 2011 Sep 8.


Background: Performance indicators assessing quality of diabetes care often look at single processes, e.g. whether an HbA1c test was conducted. Adequate care, however, consists of consecutive processes which should be taken in time (clinical pathways). We assessed quality of diabetes care by looking at single processes versus clinical pathways. In addition, we evaluated the impact of time period definitions on this quality assessment.

Methodology: We conducted a cohort study in 2007-2008 using the GIANTT (Groningen Initiative to Analyse type 2 diabetes Treatment) database. Proportions of patients adequately managed for HbA1c, systolic blood pressure (SBP), LDL-cholesterol (LDL-C), and albumin/creatinine ratio (ACR) were calculated for the pathway of (1) risk factor level testing, (2) treatment intensification when indicated, (3) response to treatment evaluation. Strict and wide time periods for each step were defined. Proportions of patients adequately managed regarding the overall pathway and single steps, using strict or wide time periods were compared using odds ratios (OR) with 95% confidence intervals.

Findings: Of 11,176 patients diagnosed with type 2 diabetes, 9439 with complete follow-up were included. The majority received annual examination of HbA1c (86%) and SBP (86%), whereas this was 67% for LDL-C and 49% for ACR. Adequate management regarding the three-step pathway was observed in 73%, 53%, 46%, 41% of patients for HbA1c, SBP, LDL-C, and ACR respectively. Quality scores reduced significantly due to the second step (OR 0.43, 0.18, 0.44, 0.74), but were not much further reduced by the third step. Timely treatment evaluation occurred in 88% for HbA1c, 87% for SBP, 83% for LDL-C, and 76% for ACR. The overall score was not significantly changed by using strict time windows.

Conclusion: Quality estimates of glycemic, blood pressure and cholesterol management are substantially reduced when looking at clinical pathways as compared to estimates based on commonly used simple process measures.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Blood Glucose / analysis
  • Blood Pressure / physiology
  • Creatinine / blood
  • Critical Pathways / standards
  • Critical Pathways / statistics & numerical data
  • Databases, Factual / statistics & numerical data
  • Diabetes Mellitus, Type 2 / blood
  • Diabetes Mellitus, Type 2 / physiopathology
  • Diabetes Mellitus, Type 2 / therapy*
  • Female
  • Follow-Up Studies
  • Glycated Hemoglobin A / analysis
  • Guideline Adherence / standards*
  • Guideline Adherence / statistics & numerical data
  • Humans
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Practice Guidelines as Topic / standards*
  • Primary Health Care / standards*
  • Primary Health Care / statistics & numerical data
  • Quality of Health Care / standards
  • Quality of Health Care / statistics & numerical data
  • Serum Albumin / analysis
  • Time Factors


  • Blood Glucose
  • Glycated Hemoglobin A
  • Serum Albumin
  • Creatinine