title: Does higher quality of primary healthcare reduce hospital admissions for diabetes complications? A national observational study.
abstract: OBJECTIVE
  To determine if hospital admission rates for diabetes complications (acute complications, chronic complications, no complications and hypoglycaemia) were associated with primary care diabetes management.
  
  
  METHODS
  We performed an observational study in the population in England during the period 2004-2009 (54 741 278 people registered with 8140 general practices). We used multivariable negative binomial regression to model the associations between indirectly standardized hospital admission rates for complications and primary healthcare quality, supply and access indicators, diabetes prevalence and population factors.
  
  
  RESULTS
  In multivariate regression models, increasing deprivation (incidence rate ratio: 1.0154; P < 0.001, 95% CI 1.0141-1.0166) and diabetes prevalence (incidence rate ratio: 1.0956; P < 0.001, 95% CI 1.0677-1.1241) were risk factors for admission, while most healthcare covariates, i.e. a larger practice population (incidence rate ratio 0.9999, P = 0.013, 95% CI 0.9999-0.9999), better patient-perceived urgent and non-urgent access to primary care (incidence rate ratio: 0.9989, P = 0.023; 95% CI 0.9979-0.9998 and incidence rate ratio: 0.9988; P = 0.003, 95% CI 0.9980-0.9996, respectively) and better HbA1c target achievement (incidence rate ratio: 0.9971; P < 0.001, 95% CI 0.9958-0.9984), were protective. Diabetes admissions decreased significantly during the period 2004-2009.
  
  
  CONCLUSIONS
  After controlling for population factors, better scheduled primary care access and glycaemic control were associated with lower hospital admission rates across most complications. There is little rationale to restrict primary care-sensitive condition definitions to acute complications. They should be revised to improve the usefulness of hospital admission data as an outcome measure, and to facilitate international comparisons. The risk of emergency hospital admission should be monitored routinely.
authors.affiliation: Department of Microbiology, Preventative Medicine and Public Health, Aragon Health Research Institute, Zaragoza, Spain.
authors.forename: A
authors.initials: A
authors.lastname: Calderón-Larrañaga
authors.forename: M
authors.initials: M
authors.lastname: Soljak
authors.forename: E
authors.initials: E
authors.lastname: Cecil
authors.forename: J
authors.initials: J
authors.lastname: Valabhji
authors.forename: D
authors.initials: D
authors.lastname: Bell
authors.forename: A
authors.initials: A
authors.lastname: Prados Torres
authors.forename: A
authors.initials: A
authors.lastname: Majeed
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease; D048909:Diabetes Complications / Q000628:therapy*; D004739:England; D004812:Epidemiologic Methods; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards