Diabetologist Care Research Articles

Comorbity of eating disorders and depression in T1DM patients: challenges and tasks for dietetician - a pilot study

Aim of the studyThe aim was to assess the occurrence of eating disorders (ED) in type 1 diabetes (T1DM) patients being under regular diabetologist care, that qualify for a visit to a psychologist and to evaluate possible correlation of eating disorders with symptoms of depression and anxiety in this population.Subject or material and methodsThe study included a selected group of 27 adult patients (55.5%- women) with T1DM under the constant care at the diabetes clinic. The following tools were used: to assess depression and anxiety, used the Patient Health Questionnaire (PHQ-9) and Center for Epidemiological Studies Depression Questionnaire (CES-D); EAT-26 assessed ED screening and Mood Disorder Questionnaire (MDQ) – other problems.ResultsBased on the overall assessment of the EAT-26 test as many as 7% of group was problem, which manifested a high level of concern about dieting, body weight or problematic eating behaviors. Additional the 25.9% people reported high depressive. We showed a relationship between ED and depression.DiscussionThere was a similar frequency of eating disorders ED eating disorders have elevated glycated haemoglobin (HbA1c), however, in our study, the mean HbA1c was 6.85% (51 mmol/mol) - fairly good glycemic control. In addition, a correlation between ED and depression has been noted, and patients with type 1 diabetes are very sensitive to both disorders.ConclusionsPeople suffering from type 1 diabetes, due to the increased risk of eating disorders or depression, require comprehensive care of a therapeutic team, which should include a diabetologist, psychologist, psychiatrist, diabetes educator, nurse, nutritionist.

Depression and quality of sleep in patients with type 1 diabetes being under regular diabetes care

IntroductionResearch indicates that co-morbid diabetes and depression is common; however, the implications for clinical practice remain unclearObjectivesThe aim of the study was to check the prevalence of depression in patients with T1DM who are provided with optimal conditions of diabetes care and to identify possible risk factors connected with affective traitsMethodsOut of the 107 patients, 78 (54 females, 24 males) were included for the analysis (HbA1c [%] 7.11±1.0, BMI [kg/m2] 25.3, ± 5.6; Years of T1DM [N] 13.7±8.3). The patients filled in a set of questionnaires during their regular visit to the outpatient clinic. Three patients from the whole group were on intensive insulin therapy with Multiple Daily Injections (MDI) and Self-Monitoring of Blood Glucose (SMBG), all the rest were on various types of personal insulin pumps (years on insulin pump [N] 9.1±4.5). All the patients were on regular diabetologist care, with regular visits in a Centre for Advanced Technologies in Diabetes (at least every 6 months).ResultsIn QIDS-S 26 patients (33.8%) were screened positive for depression, in PHQ 57.7% of the patients (45 patients) had symptoms of depression (age was negatively correlated with PHQ score (r= -0.26; p=0.023)). In CES-D 16 (20%) of the patients assessed their present affect as depressed. Quality of sleep was highly correlated with depressive symptoms CESD (r=0.61, p=0.001), PHQ Score (r=0.62; p=0.001), QISD (r=0.68; p=0.001).ConclusionsThe prevalence of affective disorders and poor sleep quality in the examined T1DM patients was much higher than in the general population. Even if the patients have in general good glycemic control, their mental health condition should not be neglected. Well organized cooperation between patients, diabetologists, psychiatrists and psychotherapists is needed.Disclosure of InterestNone Declared

Assessment of the spectrum of depression and bipolarity in patients with type 1 diabetes.

The aim of the study was to check the prevalence of unipolarity (depression), bipolarity, as well as the quality of sleep and temperament traits in patients with type 1 diabetes (T1DM) who are provided with optimal conditions of diabetes care and to identify possible risk factors connected with affective traits. Out of the 107 T1DM patients, 78 (54 females, 24 males) were included for the analysis (HbA1c [%] 7.11±1.0, BMI [kg/m2 ] 25.3±5.6; Years of disease duration [N] 13.7±8.3). The patients filled in a set of questionnaires during their regular visit to the outpatient clinic. Three patients from the whole group were on intensive insulin therapy with Multiple Daily Injections (MDI) and Self-Monitoring of Blood Glucose (SMBG), all the rest were on various types of personal insulin pumps (years on insulin pump [N] 9.1±4.5). All the patients were on regular diabetologist care, with regular visits in a Centre for Advanced Technologies in Diabetes (at least every 6months). In QIDS-S (full explanation and abbreviation26 patients (33.8%) were screened positive for depression, in PHQ (full explanation and ab 57.7% of the patients (45 patients) had symptoms of depression (age was negatively correlated with PHQ score [r=-0.26; p=0.023]). In CES-D 16 (20%) of the patients assessed their present affect as depressed. None of the analysed clinical variables correlated with depression scores. In the Mood Disorder Questionnaire (MDQ), 16 patients reported having symptoms of bipolarity (20.5% vs. 79.5%). Hypomania Checklist (HCL) analysis indicated 10 patients with bipolar traits (>14) (14.9% vs. 85.1%). None of the analysed clinical variables correlated with HCL results. 11.5% of patients were indicated to be of morning type. Morningness was more often seen in younger patients (r=0.39; p=0.001). As many as 46.6% declared that they had poor sleep quality. The temperament traits analysis correlated with clinical parameters: Cyclothymic temperament trait was negatively correlated with age (r=-0.30; p=0.007) and positively with HbA1c level (r=0.30; p=0.025). Hyperthymic temperament was positively correlated with (BMI r=0.28; p=0.016). Quality of sleep was highly correlated with depressive symptoms CESD (r=0.61, p=0.001), PHQ Score (r=0.62; p=0.001), QISD (r=0.68; p=0.001) and bipolarity MDQ (p=0.50, p=0.001) and HCL (r=0.42, p=0.001). In addition, QIDS was shown to be correlated with the following features of temperament: depressive factor (r=0.41; p=0.001), irritable factor (r=0.53; p=0.001), cyclothymic factor (r=0.59; p=0.001), anxious factor (r=0.58, p=0.001). The prevalence of affective disorders and poor sleep quality in the examined T1DM patients was much higher than in the general population. Even if the patients have in general good glycaemic control, their mental health condition should not be neglected. Well organised cooperation between patients, diabetologists, psychiatrists and psychotherapists is needed (Clinical Trials Identifier: NCT04616391).

Changes in Glycemic Control and Body Weight After Initiation of Dapagliflozin or Basal Insulin Supported Oral Therapy in Type 2 Diabetes: A Primary Care Database Study.

Background:The aim was to compare changes in HbA1c and body weight after initiation of dapagliflozin or basal insulin supported oral therapy (BOT) in type 2 diabetes patients in primary care practices.Methods:Patients from 983 primary care practices who started dapagliflozin or BOT between December 2012 and July 2015 (index date, ID) were retrospectively analyzed (Disease Analyzer; Germany). Changes in HbA1c (%) and body weight (kg) were evaluated 90-270 days after ID. Propensity score (PS) matching (1:1) was used to adjust for differences in baseline clinical characteristics (180-0 days before ID: age, sex, health insurance, diabetologist care, glucose lowering therapy, HbA1c, body mass index) and duration (days) between start of therapies and last HbA1c or weight documentation after ID.Results:After PS matching, 766 dapagliflozin (mean ± SD; age: 63 ± 10 years; HbA1c: 8.9 ± 1.2%) and 766 BOT (age: 63 ± 10 years; HbA1c: 8.7 ± 1.1%) patients were included. HbA1c decreased by mean (SD) of 1.0% (1.3) in dapagliflozin and by 1.0% (1.4) in BOT patients after 90-270 days (HbA1c reduction; dapagliflozin vs BOT: –0.01%; P = .79). In 440 dapagliflozin users with available data, body weight (97.4 ± 19.9 kg) decreased by 3.1 (5.8) kg after 90-270 days, whereas no significant weight change was observed in 440 matched BOT patients (97.5 ± 19.9 kg) (weight reduction; dapagliflozin vs BOT: –3.0 kg; P < .05).Conclusions:Initiation of dapagliflozin therapy reduced HbA1c similar to basal insulin with the additional benefit of weight reduction in type 2 diabetes patients treated in general practices.

Calculated Daily Insulin Dosages Overestimate Prescribed Insulin Doses in Type 2 Diabetes: A Primary Care Database Study.

The aim was to compare the prescribed and calculated daily insulin dosages based on prescription data in type 2 diabetes patients in a general practice database. A total of 17 782 type 2 diabetes patients (age: 70.0 ± 11.5 years; 52% males; 16% diabetologist care) with ≥2 insulin prescriptions from 834 practices were analyzed (Disease Analyser: 01/2011-12/2015). Prescribed daily dosage (PDD) (physician documentation) and calculated daily dose (CDD) (pack size × strength × volume / days between 2 prescriptions) were calculated for short-acting, long-acting, and premixed insulins. PDD and CDD were compared using paired t-tests. Linear regression models assessed the associations of insulin dosage difference (CDD-PDD) with age, sex, diabetologist care, private health insurance, obesity, HbA1c, hypertension, hyperlipidemia, macro- and microvascular complications. Mean [SD] CDDs were higher than PDDs for short-acting (52 [28] vs 48 [26] units/day), long-acting (30 [20] vs 24 [15] units/day), and premixed (46 [26] vs 40 [21] units/day) insulins (all P < .05). In regression models, age (per year) was associated with higher CDD-PDD differences (+0.11, +0.04, +0.10; P < .01) for short-, long-acting, and premixed insulins, respectively. Diabetologist care was related to lower differences (-2.92, -1.02, -3.65; all P < .05). HbA1c was associated with higher differences in long-acting and premixed insulins, but was related to a lower difference in short-acting insulins (all P < .05). CDD in primary care database studies substantially overestimate the PDD (8-25%). Age, diabetologist care, and glycemic control were related to CDD-PDD differences. Priming and safety shots with pens, dosing errors, or the accumulation of insulin reserves by patients may be underlying reasons.

Changes in HbA1c, body weight, and systolic blood pressure in type 2 diabetes patients initiating dapagliflozin therapy: a primary care database study.

AimsTo investigate changes in glycated hemoglobin (HbA1c), body weight (BW), and systolic blood pressure (SBP) in type 2 diabetes (T2D) primary care patients initiating dapagliflozin treatment.MethodsT2D patients who started dapagliflozin in 985 general and 32 diabetologist practices (Disease Analyzer, Germany: December 2012–October 2014) were analyzed (3- and 6-month follow-up). Multivariate linear regression analyses were used to identify clinical characteristics and comorbidity associated with changes in HbA1c, BW, and SBP.ResultsThe study included 1,169 T2D patients (age: 62.5 years; men: 59.3%; diabetologist care: 23%) with newly initiated dapagliflozin therapy. At the 3-month stage, dapagliflozin significantly reduced HbA1c (−0.8%±1.4%) compared to the baseline (8.5%±1.5%) (P<0.001). Changes were maintained after 6 months (−0.8%±1.5%) (P<0.001). Patients with high baseline HbA1c values (>9%) showed greater reductions in HbA1c than the overall sample (3 months −1.8%, 6 months −1.8%; both P<0.05). BW and SBP also showed statistically significant reductions with dapagliflozin over 3 and 6 months (−2.2 kg, P<0.001; −2.2 mmHg, P=0.003 and −2.5 kg, P<0.001; −2.3 mmHg, P=0.011, respectively). After 3 months, 53% of patients achieved a reduction in both HbA1c and BW; the same holds true for 45% of patients at the 6-month mark. Similar results were observed both in general and diabetologist practices. In multivariate analyses, baseline HbA1c (parameter estimate: −0.6479) and diabetologist care (−0.2553) were independent predictors of HbA1c change (6 months) (all P<0.05).ConclusionT2D patients treated with dapagliflozin therapy achieved statistically significant reductions in HbA1c, BW, and SBP in a real-world primary and diabetologist care setting. The changes were comparable to the results of the dapagliflozin clinical trial program.

Clinical and Patient-Related Variables Associated with Initiating GLP-1 Receptor Agonist Therapy in Type 2 Diabetes Patients in Primary Care in Germany.

AimsTo investigate real-world clinical and patient-related variables associated with initiating GLP-1 receptor agonist (GLP-1RA) treatment relative to initiation of other glucose-lowering therapies in type 2 diabetes (T2D) patients of primary care in Germany.MethodsData for 938 T2D patients who started therapy with a GLP-1RA within 823 practices of primary care throughout Germany were retrospectively analyzed (Disease Analyser: 01/2011–03/2014). 5,197 T2D patients who initiated other non-GLP-1RA antidiabetic therapies were selected as controls. Multivariate logistic regression analyses were applied to identify factors associated with GLP-1RA initiation in primary care.ResultsMean age (SD) of GLP-1RA users was 57.8 (11.8) years (males: 55.5%) and the average BMI was 36.1 (6.7) kg/m2. 22.8% were in diabetologist care and 12.0% had private health insurance. In multivariate regression, choice of GLP-1RA therapy instead of a different glucose-lowering drug class was associated with obesity (odds ratio: 1.68; 95% CI: 1.34–2.10), private health insurance (2.42; 1.89–3.09), younger age (0.94; 0.93–0.95 per year), male sex (0.85; 0.73–0.99), diabetologist care (2.11; 1.73–2.57), and geographic practice location (East vs. West-Germany; 1.25; 1.05–1.49). Among co-medication, angiotensin II antagonists (increased) and non-steroidal antirheumatic agents (decreased) were related to GLP-1RA prescriptions (both p<0.001).ConclusionsConsistent with German guidelines, GLP-1RA is mainly prescribed preferentially in T2D patients who are obese. GLP-1RA drugs were more frequently used than other options in privately health insured patients and in patients seeing a diabetologist.

Predictors of early discontinuation of basal insulin therapy in type 2 diabetes in primary care

AimsTo identify patient-related characteristics and other impact factors predicting early discontinuation of basal insulin therapy in type 2 diabetes in primary care. MethodsA total of 4837 patients who started basal insulin therapy (glargine: n=3175; NPH: n=1662) in 1072 general and internal medicine practices throughout Germany were retrospectively analyzed (Disease Analyser Database: 01/2008–03/2014). Early discontinuation was defined as switching back to oral antidiabetic drugs (OAD) therapy within 90 days after first basal insulin prescription (index date, ID). Patient records were assessed 365 days prior and post ID. Logistic regression models were used to adjust for age, sex, diabetes duration, diabetologist care, disease management program participation, HbA1c, and comorbidity. ResultsWithin 3 months after ID, 202 (6.8%) of glargine patients switched back to OAD (NPH: 130 (8.5%); p<0.05). In multivariable logistic regression, predictors of early basal insulin discontinuation were ≥1 documented hypoglycemia before ID (adjusted Odds ratio; 95% CI: 2.20; 1.27–3.82), diagnosed depression (1.31; 1.01–1.70) and referrals to specialists within 90 days after ID (2.06; 1.61–2.63). Diabetologist care (0.57; 0.36–0.89) and glargine treatment (vs. NPH: 0.78; 0.61–0.98) were related to a lower odds of having early insulin discontinuation. ConclusionsLess than 10% of type 2 diabetes patients switched back to oral antidiabetic drugs within 90 days after start of basal insulin therapy. In particular, patients with baseline depression and frequent or severe hypoglycemia have a higher likelihood for early discontinuation of basal insulin, whereas use of insulin glargine and diabetologist care are related to an increased chance of continuous insulin treatment.

Diabetes treatment in people with type 2 diabetes and schizophrenia: Retrospective primary care database analyses

AimsAim of this study were to compare outcomes (HbA1c, BMI) and antidiabetic treatment of type 2 diabetes patients with and without schizophrenia under real-life conditions in primary care practices in Germany. Methods1321 type 2 diabetes patients with and 1321 matched controls (age, sex, diabetes duration, diabetologist care, practice) without schizophrenia in 1072 general practices throughout Germany were retrospectively analyzed (Disease Analyser: 01/2009–12/2013). Antidiabetic treatment, HbA1c and BMI were compared using paired t-tests, McNemar tests and conditional logistic regression adjusting for macro- and microvascular comorbidity (ICD-10). ResultsMean age (±SD) of patients and controls was 67.4±13.2 years (males: 38.9%). Diabetes duration was 5.7±4.3 years, 6% were in diabetologist care. Private health insurance was less often found among patients with schizophrenia than controls (2.2% vs 6.3%; p<0.0001). There was no difference in the mean HbA1c values (cases: 7.1±1.4%; controls: 7.2±1.5%) (54.1 vs. 55.2mmol/mol) (p=0.8797) and in the average BMI (32.4±6.6 vs. 31.0±5.0kg/m2; p=0.2072) between the two groups. Novel cost-intensive antidiabetic agents (DPP-4- or SGLT2-inhibitors, GLP-1 receptor agonists) were less often prescribed in cases (15.3 vs. 18.3%; p=0.0423). However, in multivariable logistic regression, schizophrenia (odds ratio, 95%CI: 1.101; 0.923–1.317) was not associated with prescription use of novel antidiabetic agents (reference: other antidiabetic agents) after adjusting for private health insurance (OR: 2.139; 1.441–3.177) and comorbidity. ConclusionsThere is no evidence that type 2 diabetes patients with schizophrenia have worse diabetes control than those without a severe mental illness in general practices.

Early discontinuation and related treatment costs after initiation of Basal insulin in type 2 diabetes patients: a German primary care database analysis.

The aim was to compare early discontinuation and related treatment costs in type 2 diabetes in primary care after initiation of insulin glargine or human basal insulin (NPH). Overall, 2765 glargine and 1554 NPH patients from 1072 general practices were analyzed (Disease Analyser). Early discontinuation was defined as switching to a different basal insulin or another insulin treatment regimen within 90 days after first basal insulin prescription (index date, ID). Treatment costs were assessed 365 days prior and post ID in both groups. Propensity score matching and linear regression was used to adjust cost differences (post vs prior ID: discontinued vs continued patients) for age, sex, diabetes duration, antidiabetic comedication, diabetologist care, disease management program participation, costs before ID, and Charlson Comorbidity Index. Within 3 months after ID, 13% of glargine patients switched to other insulin treatment regimens (NPH: 18%; P < .05). After propensity score matching, adjusted cost differences in 146 discontinued versus 1342 continued glargine patients were calculated (NPH: 146 vs 1342). Diabetes-related prescription costs were lower among persistent glargine patients compared to persistent NPH patients (EUR-49 [19]; P = .0109). Mean cost difference for diabetes-related prescriptions was lower among those who persisted on glargine compared to those who switched to other treatment regimens (EUR-74 [42], P = .0780). Treatment persistence within 3 months after basal insulin initiation was significantly higher under insulin glargine compared to NPH. Diabetes-related prescription costs were significantly lower among patients who adhered to insulin glargine compared to persistent NPH patients.

Glycemic control after initiating basal insulin therapy in patients with type 2 diabetes: a primary care database analysis.

BackgroundWhen target glycated hemoglobin (HbA1c) levels are not reached, basal insulin therapy should be considered in type 2 diabetes. The objective of this report was to describe the predictors of glycemic control (strict criterion: HbA1c ≤6.5%) during the first year after initiating basal insulin therapy in primary care.MethodsThe study applied a retrospective approach using a nationwide database in Germany (Disease Analyzer, IMS Health, January 2008 to December 2011, including 1,024 general and internal medicine practices). Potential predictors of glycemic control considered were age, sex, duration of diabetes, type of basal insulin, comedication with short-acting insulin, baseline HbA1c, previous oral antidiabetic drugs, diabetologist care, private health insurance, macrovascular and microvascular comorbidity, and concomitant medication. Multivariable logistic regression models were fitted with glycemic control as the dependent variable.ResultsA total of 4,062 type 2 diabetes patients started basal insulin (mean age 66 years, males 53%, diabetes duration 4.8 years, mean HbA1c 8.8%), of whom 295 (7.2%) achieved an HbA1c ≤6.5% during the one-year follow-up. Factors positively associated with HbA1c ≤6.5% in logistic regression were male sex (odds ratio 1.59, 95% confidence interval 1.23–2.04), insulin glargine (reference neutral protamine Hagedorn; odds ratio 1.43, 95% confidence interval 1.09–1.88), short-acting insulin (odds ratio 1.33, 95% confidence interval 1.01–1.76), and prior treatment with metformin, dipeptidyl peptidase-4 inhibitors, and diuretics. Lipid-lowering drugs were associated with a lower odds of reaching the glycemic target.ConclusionFew type 2 diabetes patients (7%) reached the glycemic target (HbA1c ≤6.5%) after one year of basal insulin therapy. Achievement of the glycemic target was associated with type of basal insulin, additional short-acting insulins, previous antidiabetic medication, and other comedication, eg, diuretics or lipid-lowering drugs.

Lower incidence of recorded cardiovascular outcomes in patients with type 2 diabetes using insulin aspart vs. those on human regular insulin: observational evidence from general practices

Insulin aspart has a higher ability to treat postprandial glucose than regular human insulin, which may have favourable cardiovascular effects. The aim was to collect and compare the incidence of recorded macro- and microvascular events in patients with type 2 diabetes with insulin aspart or regular human insulin in general practices. Computerized data from 3154 aspart and 3154 regular insulin users throughout Germany (Disease Analyzer, January 2000 to July 2011) were analysed after matching for age (60 ± 10 years), sex (men: 57%), health insurance (private: 5.8%) and diabetes treatment period in practice (2.2 ± 2.5 years). Hazard ratios (HR; Cox regression) for macro- or microvascular outcomes (follow-up: 3.5 years) were further adjusted for diabetologist care, practice region, hypertension, hyperlipidaemia, co-medication (basal insulin, oral antidiabetics, antihypertensives, lipid-lowering agents and antithrombotic drugs), previous treatment with rapid-acting insulins, hypoglycaemia and the Charlson co-morbidity score. Furthermore, adjustment was carried out for baseline microvascular complications when analysing macrovascular outcomes and vice versa. Overall, the risk of combined macrovascular outcomes was 15% lower for insulin aspart users (p = 0.01). For insulin aspart there was also a decreased risk incident stroke [HR: 0.58; 95% confidence interval (CI): 0.45-0.74], myocardial infarction (HR: 0.69; 95% CI: 0.54-0.88) and peripheral vascular disease (HR: 0.80; 95% CI: 0.69-0.93). For microvascular complications (retinopathy, neuropathy and nephropathy), no significant differences were observed (HR: 0.96; 95% CI: 0.87-1.06). Use of the rapid-acting insulin analogue aspart was associated with a reduced incidence of macrovascular outcomes in type 2 diabetes in general practices. It is important to confirm this finding in a randomized controlled trial.

Micro- and macrovascular outcomes in Type 2 diabetic patients treated with insulin glulisine or human regular insulin: a retrospective database analysis

Insulin glulisine has a higher efficacy in reducing postprandial glucose excursions and in restoring normal postprandial microcirculation than rapid human insulin. The aim was to compare the incidence of macro- and microvascular outcomes in Type 2 diabetic patients treated with insulin glulisine or regular human insulin. Computerized data from 952 glulisine (age: 61 ± 11 y) and 11,157 regular insulin (65 ± 11 y) users in general practices throughout Germany (Disease Analyzer, 11/2004 to 3/2010) were analyzed. Hazard ratios (HR; Cox regression) for 3.5-year-risk of macro- or microvascular outcomes were adjusted for age, sex, diabetes duration, diabetologist care, hypertension, hyperlipidemia, depression, and comedication (basal insulin, oral antidiabetics). Furthermore, adjustment was carried out for baseline microvascular complications when analyzing macrovascular outcomes and vice versa. Overall, risk for macro- or microvascular outcomes was 20% lower for insulin glulisine users (p < 0.05). There was a decreased risk for coronary heart disease (HR; 95%CI: 0.78; 0.62 - 0.99), and an indication for a lower risk for incident myocardial infarction (HR: 0.66; 0.43 - 1.02). Also for microvascular complications, the adjusted hazard ratios for retinopathy, nephropathy and neuropathy were below 1.0, indicating a lower risk for the insulin glulisine group, however, which was significant for neuropathy only (HR: 0.74; 0.58 - 0.93). Prescription of the rapid-acting insulin analog glulisine was associated with a reduced incidence of macro- and microvascular outcomes in Type 2 diabetes under real-life conditions. Given that this was a retrospective database analysis, it is important to confirm this finding in a randomized controlled trial.

Determinants of Quality in Diabetes Care Process

OBJECTIVETo 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 METHODSWe 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.RESULTSAfter 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.CONCLUSIONSDespite 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.