Which people with Type 2 diabetes achieve good control of intermediate outcomes? Population database study in a UK region

Aims To measure quality of vascular risk factor measurement and control in people with Type 2 diabetes after comprehensive pay-for-performance implementation and to examine variation by patient and practice characteristics. Methods Multi-level regression analysis of 10 191 patients with Type 2 diabetes registered with 59 practices in the Tayside region. Quality measures examined were recording of glycated haemoglobin (HbA_1c), blood pressure (BP), cholesterol and smoking status in the last 12 months; achievement of recommended intermediate outcome targets (HbA_1c≤ 7.4%, BP < 140/80 mmHg, cholesterol ≤ 5.0 mmol/l, not smoking); and simple and all-or-none composite measures. Results Ninety-five per cent of all recommended processes were received by patients, with 88% of patients receiving all four. Half of all intermediate outcomes targets were achieved, but only 16% of patients achieved all four targets. Process and outcome of care were consistently worse for 1523 (15.0%) patients aged < 55 years. HbA_1c and BP targets were progressively less likely to be achieved as body mass index increased. Women were less likely to achieve cholesterol targets, but apart from smoking status, there were no associations with socio-economic status. Conclusion Under comprehensive pay-for-performance, process of care is remarkably reliable, but intermediate outcome control less so. Previously identified socio-economic variations in diabetes care have been largely eliminated, but gender inequality is persistent. Younger people were considerably less likely to achieve intermediate outcome targets. Mitigating increased vascular risk in younger patients with Type 2 diabetes presents major challenges for health services in the face of the evolving epidemics of obesity and diabetes.