title: Patients and nurses determine variation in adherence to guidelines at Dutch hospitals more than internists or settings.
abstract: OBJECTIVE
  To measure adherence to recently developed diabetes guidelines at Dutch hospital outpatient clinics and distinguish determinants for variations in care on hospital, internist and patient levels.
  
  
  METHODS
  Thirteen general hospitals with 58 internists recruited 1950 diabetic patients. Data were extracted from medical files (n = 1915) and from patient questionnaires (n = 1465). Multilevel logistic regression analysis was performed to explain differences in adherence rates to the guidelines.
  
  
  RESULTS
  Adherence to process measures was high, except for the examination of feet, calculation of the body mass index and patient education activities (the mean of 12 process measures was 64%). Adherence to intermediate outcome indicators was moderate. The mean percentage of patients with HbA(1c) < 7.0% was 23%. Adherence variation on a hospital level was very small (0.6-7.9%), on an internist level moderate (0.4-18.8%) and on a patient level high (74.4-98.8%). Adherence to all process measures and most of the intermediate outcome indicators was highest in the patients seen by a diabetes specialist nurse.
  
  
  CONCLUSIONS
  More focus on patient involvement in diabetic care and the contribution of diabetes specialist nurses may be important factors in improving the quality of diabetes care.
authors.affiliation: Centre for Quality of Care Research, University Medical Centre St Radboud, Nijmegen, The Netherlands. r.dijkstra@wok.umcn.nl
authors.forename: R F
authors.initials: RF
authors.lastname: Dijkstra
authors.forename: J C C
authors.initials: JC
authors.lastname: Braspenning
authors.forename: Z
authors.initials: Z
authors.lastname: Huijsmans
authors.forename: S
authors.initials: S
authors.lastname: Peters
authors.forename: E
authors.initials: E
authors.lastname: van Ballegooie
authors.forename: P
authors.initials: P
authors.lastname: ten Have
authors.forename: A F
authors.initials: AF
authors.lastname: Casparie
authors.forename: R P T M
authors.initials: RP
authors.lastname: Grol
mesh_terms: D015992:Body Mass Index; D003920:Diabetes Mellitus / Q000628:therapy*; D005123:Eye; D005260:Female; D005528:Foot; D006801:Humans; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D009732:Nursing Care / Q000592:standards*; D010043:Outcome and Process Assessment, Health Care / Q000592:standards; D010349:Patient Compliance; D010353:Patient Education as Topic; D010808:Physical Examination; D017410:Practice Guidelines as Topic