Fifteen years of continuous improvement of quality care of type 2 diabetes mellitus in primary care in Catalonia, Spain

Abstract

To assess the evolution of type 2 diabetes mellitus (T2DM) quality indicators in primary care centers (PCC) as part of the Group for the Study of Diabetes in Primary Care (GEDAPS) Continuous Quality Improvement (GCQI) programme in Catalonia.
Sequential cross-sectional studies were performed during 1993-2007. Process and outcome indicators in random samples of patients from each centre were collected. The results of each evaluation were returned to each centre to encourage the implementation of correcting interventions. Sixty-four different educational activities were performed during the study period with the participation of 2041 professionals.
Clinical records of 23,501 patients were evaluated. A significant improvement was observed in the determination of some annual process indicators: HbA(1c) (51.7% vs. 88.9%); total cholesterol (75.9% vs. 90.9%); albuminuria screening (33.9% vs. 59.4%) and foot examination (48.9% vs. 64.2%). The intermediate outcome indicators also showed significant improvements: glycemic control [HbA(1c) ≤ 7% (< 57 mmol/mol); (41.5% vs. 64.2%)]; total cholesterol [≤ 200 mg/dl (5.17 mmol/l); (25.5% vs. 65.6%)]; blood pressure [≤ 140/90 mmHg; (45.4% vs. 66.1%)]. In addition, a significant improvement in some final outcome indicators such as prevalence of foot ulcers (7.6% vs. 2.6%); amputations (1.9% vs. 0.6%) and retinopathy (18.8% vs. 8.6%) was observed.
Although those changes should not be strictly attributed to the GCQI programme, significant improvements in some process indicators, parameters of control and complications were observed in a network of primary care centres in Catalonia.

Full text

Fifteen years of continuous improvement of quality care
of type 2 diabetes mellitus in primary care in Catalonia,
Spain
M. Mata-Cases,
1,2
P. Roura-Olmeda,
3
M. Berengue
´-Iglesias,
4
M. Birule
´s-Pons,
5
X. Mundet-Tuduri,
2,6
J. Franch-Nadal,
2,7
B. Benito-Badorrey,
7
J. F. Cano-Pe
´rez,
8
on behalf of the Diabetes Study Group in
Primary Health Care (GEDAPS: Grup d’Estudi de la Diabetis a l’Atencio
´Prima
`ria de Salut, Catalonian
Society of Family and Community Medicine)*
Introduction
The benefits of controlling type 2 diabetes mellitus
(DM) and the associated cardiovascular risk factors
are well established and reflected in the current clini-
cal practice guidelines (1)4). However, the results of
several cross-sectional studies have highlighted the
difficulties in achieving the goals as well as the full
implementation of the clinical recommendations
(5)9). The results of consecutive cross-sectional
observational studies have shown some positive
trends on both process indicators and degree of dis-
ease control (10)17).
Moreover, the results of several clinical trials con-
ducted to evaluate different quality improvement
programmes at both primary and secondary care
centres have shown significant improvements in both
process and intermediate outcome indicators (degree
of glycemic control and other risk factors) with some
impact on final outcome indicators like hospital
admissions and health-related costs (18)20). The
feedback of the indicators¢results to the health pro-
viders is considered the basis for any quality
improvement intervention (21)23). In Spain, there is
limited information published in this regard, mainly
from cross-sectional studies (5–9,17).
SUMMARY
Aims: To assess the evolution of type 2 diabetes mellitus (T2DM) quality indica-
tors in primary care centers (PCC) as part of the Group for the Study of Diabetes
in Primary Care (GEDAPS) Continuous Quality Improvement (GCQI) programme in
Catalonia. Methods: Sequential cross-sectional studies were performed during
1993–2007. Process and outcome indicators in random samples of patients from
each centre were collected. The results of each evaluation were returned to each
centre to encourage the implementation of correcting interventions. Sixty-four dif-
ferent educational activities were performed during the study period with the par-
ticipation of 2041 professionals. Results: Clinical records of 23,501 patients were
evaluated. A significant improvement was observed in the determination of some
annual process indicators: HbA
1c
(51.7% vs. 88.9%); total cholesterol (75.9% vs.
90.9%); albuminuria screening (33.9% vs. 59.4%) and foot examination (48.9%
vs. 64.2%). The intermediate outcome indicators also showed significant improve-
ments: glycemic control [HbA
1c
£7% (< 57 mmol ⁄mol); (41.5% vs. 64.2%)]; total
cholesterol [£200 mg ⁄dl (5.17 mmol ⁄l); (25.5% vs. 65.6%)]; blood pressure
[£140 ⁄90 mmHg; (45.4% vs. 66.1%)]. In addition, a significant improvement in
some final outcome indicators such as prevalence of foot ulcers (7.6% vs. 2.6%);
amputations (1.9% vs. 0.6%) and retinopathy (18.8% vs. 8.6%) was observed.
Conclusions: Although those changes should not be strictly attributed to the
GCQI programme, significant improvements in some process indicators, parameters
of control and complications were observed in a network of primary care centres
in Catalonia.
What¢s known
The results of clinical studies have shown that
implementation of intervention programmes for the
management of type 2 diabetes mellitus has a
positive impact in quality of care. However, limited
data are currently available from primary care
settings.
What¢s new
The present study describes the impact of the
Group for the Study of Diabetes in Primary Care
intervention programme on type 2 diabetes mellitus
quality of care in primary care settings in Spain by
analysis of the trend of quality indicators.
1
Primary Care Center (PCC) La
Mina, Sant Adria
`de Beso
`s,
Barcelona, Spain
2
Barcelona Ciutat Research
Support Unit – IDIAP Jordi Gol,
redIAPP, Barcelona, Spain
3
PCC Badı
´a del Valle
´s,
Barcelona, Spain
4
PCC Florida Nord, L’Hospitalet
de Llobregat, Barcelona, Spain
5
PCC Poblenou, Barcelona,
Spain
6
PCC El Carmel, Barcelona,
Spain
7
PCC Raval, Barcelona, Spain
8
Servicio de Endocrinologia,
Hospital del Mar, Barcelona,
Spain
Correspondence to:
Manel Mata-Cases
PCC La Mina, C ⁄Mar s ⁄n.
08930, Sant Adria
`de Beso
`s,
Barcelona, Spain
Tel.: + 34 93 381 1593
Fax: + 34 93381 2141
Email: manelmatacases@
gmail.com
*See Appendix.
Disclosure
The authors have nothing to
declare.
Re-use of this article is
permitted in accordance with
the Terms and Conditions set
out at http://
wileyonlinelibrary.com/
onlineopen#OnlineOpen_Terms
ORIGINAL PAPER
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298. doi: 10.1111/j.1742-1241.2011.02872.x 289

In 1992, the Group for the Study of Diabetes in
Primary Care (GEDAPS) was founded by the Catalan
Society of Community and Family Medicine to
implement the aims of the Saint Vincent Declaration
(1). In 1993, the group published the first edition of
the ‘Guidelines for Diabetes Management in Primary
Health Care in Spain’ that included both clinical and
organisational recommendations and also defined a
set of quality care indicators. The guidelines were
updated in the following years (1995, 1998, 2000 and
2004) (2). In parallel, the group developed the GED-
APS continuous quality improvement (GCQI) com-
puter programme to facilitate clinical audits. The
programme constructed automatically process and
outcome indicators based on the data recorded by
the participant centres from random samples of
patients¢medical records. In 1996, the programme
was expanded to other Spanish regions (17). The
GCQI programme was mainly based on the feedback
of the results of the clinical indicators to the partici-
pating centres to promote interventions to improve
quality of care.
In 1993, the first evaluation of quality of care of
type 2 DM in primary care settings took place in
Catalonia. The evaluation was repeated in 1995,
1998, 2000, 2002 and 2007. At the same time, as part
of the intervention, a series of workshops and semi-
nars were launched to publicise and implement the
GEDAPS guidelines as well as the recommendations
to improve early detection of the disease, treatment,
management of diabetes complications and specific
workshops to analyse quality indicators and propose
local interventions to improve patient¢s quality of
care.
The aim of the present study was to describe the
impact of the GEDAPS intervention programme on
type 2 DM quality of care in primary care settings,
by analysing the trend of quality indicators collected
in assessments that took place between 1993 and
2007 in Catalonia, Spain.
Research design and methods
Study design
The GCQI programme gathered information from
primary care centres (PCC) on process and outcomes
indicators in a sample of their patients. To promote
their participation, letters by ordinary mail and elec-
tronic mails (years 2000–2002) were sent to all PCC
in Catalonia. The planned 2005 survey was not con-
ducted because the medical records were being com-
puterised during the previous years. During the last
evaluation (2007), several investigator meetings
around the territory were conducted to encourage
participation in the study, regardless of their partici-
pation in the previous evaluations and to present
changes in data entry using a webpage (http://
www.redgdps.org/).
Health providers entered patient data using the
GCQI computer programme that immediately pro-
vided the results of a set of disease-specific processes
and outcomes indicators. Data were subsequently
sent by disk (1993–2000), electronic mail (2002) or
introduced directly in the redgedaps.org web (only in
2007). The GCQI computerised programme was spe-
cifically designed to perform periodic evaluations
(audits) in primary care centres. The programme was
based in two principles: data collection from each
participant centre (each participant centre had a
nurse or physician responsible of the survey) and
subsequent data feedback to the centres. Thus, each
centre was able to compare their data during subse-
quent assessments (internal comparison) and with
data from other centres (external comparison). The
gold standard for each indicator in each evaluation
was the overall result of all the participating centres.
Each centre then compared their own results with
the global results (gold standard) to find differences
that required to be improved.
Health providers were instructed to obtain a ran-
dom sample from the medical records of type 2 DM
patients with a follow-up greater than 6 months
since diagnosis. A total sample of five patients multi-
plied for the number of basic care units (physi-
cian ⁄nurse), with a minimum of 30 patients per
centre, was required. A preselection of medical
records with an additional 20% was performed. In
those cases that did not fulfil the inclusion criteria
the medical record was replaced by the next one of
the same gender. Exclusion criteria included: type 1
DM; follow-up exclusively by an endocrinologist and
short life expectancy (terminal patients or those that
received home care).
Because of the retrospective nature of the study,
based only on clinical records, patients were not
required to give written informed consent. To assure
anonymity, data were collected and recorded using
two different files: one included demographic vari-
ables and the other one included clinical variables
linked by a consecutive record number. The study
design and the GCQI programme were presented
and approved by the Consell Assessor de la Diabetis
(Advisory Board on Diabetes) of the Health Depart-
ment of the Autonomous Government in Catalunya
that behaved as Institutional Review Board.
Data were collected from paper medical records
from 1997 to 2002 and from electronic records in
2007. Data about the characteristic of the centre
(rural or urban), number of doctors and nurses team
(basic care units), total population and prevalence of
290 Primary care interventions for diabetes mellitus
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298

diabetes were fulfilled by the professional responsible
of the evaluation.
GCQI programme interventions
The GCQI programme was mainly based on the
feedback of the results of clinical indicators that were
sent after each evaluation to the participating centres
to promote interventions to improve quality of care.
On the other hand, as part of the intervention pro-
gramme, 55 courses, seminars and workshops were
conducted during the study period to disseminate
the GEDAPS Guidelines and its recommendations,
and a total of 2041 health professionals (physicians
and nurses) attended. The main aim of the courses
and workshops was to encourage the global manage-
ment of the disease, not only to improve glycemic
control but also to promote the proper management
of other cardiovascular risk factors as well as the per-
formance of annual activities leading to early detec-
tion and treatment of diabetes complications. In
relation to the nurses clinical activities, a special
emphasis was put on reviewing the educational inter-
ventions, annual screening activities and the degree
of disease control in each patient, and not be limited
to explain diet or performing clinic measurements,
that is the traditional role of nurses in our country.
Moreover, after the evaluations that took place in
1995 and 1998, nine decentralised workshops with
the participation of 289 health professionals from
151 primary care teams (43% of the primary care
centres of Catalonia), were conducted to analyse the
results and identify healthcare difficulties to propose
local corrective interventions.
Variables
Demographic and clinical characteristics
Age; gender; weight; height; body mass index (BMI),
blood pressure; glycated haemoglobin (HbA
1c
); total
cholesterol and HDL-cholesterol; year of diabetes
diagnosis; number of doctor or nurse visits, number
of educational interventions recorded per year; antid-
iabetic treatment and smoking status.
Process and outcome indicators of quality of care
The following indicators, that have been previously
described elsewhere, were studied (17): Process indi-
cators: (i) related to the organisation: No visit related
to diabetes recorded; less than three nursing visits;
less than three educational interventions of different
topic (whatever the number of visits required to per-
form the intervention for each topic); practice of
self-monitoring blood glucose; (ii) laboratory mea-
surements: at least one HbA
1c
determination; two or
more HbA
1c
determinations; at least one total choles-
terol determination; at least one HDL-cholesterol
determination; at least one microalbuminuria screen-
ing determination; (iii) physical examinations: weight
measurements (three or more times a year); fundus-
copy done by an ophthalmologist; foot examination;
Outcome indicators: (i) intermediate outcomes: Good
glycemic control (HbA
1c
£7% or 57 mmol ⁄mol);
acceptable glycemic control (HbA
1c
£8% or
68 mmol ⁄mol); very poor glycemic control (HbA
1c
> 10% or 89 mmol ⁄mol); HDL-Cholesterol
>40mg⁄dl (1.03 mmol ⁄l); total cholesterol £250
mg ⁄dl(6.47 mmol ⁄l) (acceptable control); total choles-
terol £200 mg ⁄dl (5.17 mmol ⁄l) (strict control);
BMI < 30 kg ⁄m
2
;BP£140 ⁄90 mmHg (acceptable
control); BP £130 ⁄80 mmHg (strict control); active
smoking; (ii) final outcomes: diabetic foot
(ulcers + amputations); diabetic foot ulcers; amputa-
tions of lower limbs; nephropathy (microalbuminuria
or macroalbuminuria); retinopathy; amaurosis; coro-
nary artery disease (including angina); stroke (includ-
ing transient ischaemic attack); hospital admissions
because of amputation, hypoglycemia or any other rea-
son, but with plasma blood glucose
> 500 mg ⁄dl(27.28 mmol ⁄l).
Statistical considerations
Continuous variables were described using the mean
and standard deviation. Categorical variables are
described as percentage with the confidence interval
of 95% (95% CI). The SPSS.11 statistical program
was used for all statistical analyses.
Results
During the study period (1993–2007) 55 seminars were
conducted and a total of 2041 health professionals
(physicians and nurses) from 1084 centres attended.
Table 1 summarises the characteristics of the primary
care participant centres. The PCC covered one-third of
the population of Catalonia (7,364,068 individuals in
2007). The number of participant centres increased
over time, from 1993 to 2002, with a decline during the
last evaluation (2007). More than half of the centres
were urban, reaching 67.3% in 2007. The prevalence of
type 2 DM increased over time, from 3.3% in 1993 to
5.4% in 2007 (relative increase of 63%).
Patients¢characteristics
The clinical records of 23,501 patients were evalu-
ated. Table 1 summarises the characteristics of
patients in each evaluation. Mean age increased from
65.2 years (SD: 10.2; range: 30–93) in 1993 to
67 years (SD: 10.9; range: 31–99) in 2007, with a sig-
nificant progressive increase in the percentage of
patients > 65 years old (50.9% vs. 60.2%). Other sig-
Primary care interventions for diabetes mellitus 291
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298

nificant differences found between 1993 and 2007 eval-
uation included: lower number of female patients
(56.6% vs. 48.5%); higher prevalence of obesity (37%
vs. 50%); shorter time of diabetes duration (7.5 years
vs. 7 years) and lower HbA
1c
concentration (7.7% or
64 mmol ⁄mol vs. 6.8% or 55 mmol ⁄mol).
Throughout the study, more than half of the partici-
pants received oral antidiabetic treatment, whereas
approximately 20% of the patients received insulin
(alone or in combination therapy). Among this latter
patient population, the percentage that received com-
bined treatment (insulin + oral antidiabetics) increased
significantly over time (2.1% vs. 10%) (Table 1).
Process indicators
Related to organisation
Throughout the study the number of patients that
did not have any diabetes-related visit recorded
significantly decreased (5.1% in 1993 vs. 2% in
2007), with an increase in the percentage of patients
that visited the nurse more than three times per year
(27.3% in 1993 vs. 31.5% in 2007). Doctors and
nurses visits tend to decrease progressively, but
increased in 2007. Likewise, a significant decrease
was observed in the percentage of patients receiving
less than three different annual educational interven-
tions (74.6% in 1993 vs. 58.3% in 2007) (Table 2).
Control parameters
A significant increase in the number of annual ana-
lytical determinations of HbA
1c
(51.7% in 1993 vs.
88.9% in 2007) and total cholesterol (75.9% vs.
90.0%) was observed (Table 2 and Figure 1A).
Complications screening
As for regular checkups, there has been improvement
in the percentage of patients that have been tested
Table 1 Participant centres and patient characteristics in each evaluation*
1993 1995 1998 2000 2002 2007
Characteristics of participant centres
Number of participating centres 57 75 75 78 96 52
Urban centres (%) 54.4 (41.1–66.9) 56 (44.8–67.2) 56.6 (45.4–67.8) 52.6 (41.5–63.7) 57.3 (47.4–67.2) 67.3 (54.5–80.0)
Number of basic care units
(physician + nurse)
433 565 609 680 846 637
Total assigned population 954,126 1,251,689 1,367,639 1,474,242 1,888,593 1,126,532
Assigned population
over 14 years old
694,450 982,567 1,058,903 1,203,310 1,541,618 938,429
Number of patients with diabetes
over 14 years
22,663 38,697 51,776 63,831 83,859 55,350
Prevalence of diabetes in patients
over 14 years (%)
3.3 (3.0–3.5) 4.0 (3.8–4.2) 4.9 (4.7–5.1) 5.3 (5.1–5.5) 5.4 (5.2–5.5) 5.4 (5.2–5.6)
Patients’ characteristics
Number of participants 2239 3532 4217 4564 5819 3130
Gender (% female) 56.6 (54.5–58.6) 54.5 (52.9–56.1) 52.9 (51.4–54.4) 52.1 (50.6–53.5) 51.8 (50.5–53.1) 48.5 (46.7–50.2)
Age (years), mean (SD) 65.2 (10.2) 66.3 (10.3) 67.2 (10.6) 67.1 (10.8) 67.3 (10.9) 68 (11.7)
> 65 years old patients (%) 50.9 (48.8–53.0) 55.4 (53.8–57.0) 59.6 (58.1–68.1) 60.0 (58.6–61.4) 60.5 (59.2–61.8) 60.2 (58.5–61.9)
Diabetes duration (years),
mean (SD)
7.5 (7.1) 7.8 (7.5) 8.2 (7.1) 7.6 (6.8) 8.0 (6.9) 7 (5.6)
Prevalence of obesity
(BMI ‡30 kg ⁄m
2
) (%)
37.0 (35.0–39.0) 37.0 (35.4–38.6) 39.2 (37.7–40.7) 40.5 (39.1–41.2) 42.6 (41.3–43.9) 50.3 (48.5–52.0)
HbA
1c
(%), mean (SD) 7.7 (1.9) 7.6 (1.6) 7.1 (1.6) 7.0 (1.7) 7.1 (1.4) 6.8 (1.4)
Physician visits related to diabetes,
mean (SD)
3.7 (3.4) 2.9 (3.7) 2.7 (2.7) 2.8 (2.7) 2.6 (2.4) 4.1 (4.0)
Nurse visits related to diabetes,
mean (SD)
5.1 (3.7) 5.1 (4.2) 4.6 (3.3) 4.2 (3.2) 3.6 (2.6) 4.8 (4.1)
Antidiabetic treatment (%)
Diet and exercise alone 25.7 (23.9–27.5) 27.7 (26.2–29.2) 29.4 (28.0–30.8) 27.9 (26.6–29.2) 25.4 (24.3–26.5) 22.3 (20.8–23.7)
Oral antidiabetic drugs 52.2 (50.1–54.3) 50.0 (48.3–51.2) 49.9 (48.4–51.4) 51.7 (50.2–53.1) 54.6 (53.3–55.9) 60.5 (58.8–62.2)
Insulin (monotherapy) 20.0 (18.3–21.7) 20.2 (19.9–21.5) 17.8 (16.6–18.9) 15.2 (14.2–16.2) 12.3 (11.5–13.1) 7.3 (6.4–8.2)
Insulin + oral antidiabetic drug 2.1 (1.5–2.7) 2.0 (1.5–2.5) 2.8 (2.3–3.3) 5.2 (4.6–5.8) 7.6 (6.9–8.3) 10.0 (8.9–11.0)
*Data expressed as absolute numbers, means (standard deviation, SD) or percentages (95% confident interval)
292 Primary care interventions for diabetes mellitus
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Int J Clin Pract, March 2012, 66, 3, 289–298

Table 2 Evolution of process and outcome indicators*
1993 (n= 2239) 1995 (n= 3532) 1998 (n= 4217) 2000 (n= 4567) 2002 (n= 5819) 2007 (n= 3130) Difference
Process indicators
Related to the organisation
No diabetes-related visit recorded 5.1 (4.2–6.0) 3.0 (2.4–3.6) 1.7 (1.3–2.1) 2.1 (1.7–2.5) 2.2 (1.8–2.6) 2.0 (1.5–2.5) )3.1 ()4.1 to )2.0)
Less than three nursing visits 27.3 (25.5–29.2) 27.6 (26.1–29.1) 28.4 (27.0–29.8) 32.8 (31.4–34.2) 35.9 (34.7–37.1) 31.5 (29.9–33.1) +4.2 (1.8 to 6.7)
Less than three educational interventions 74.6 (72.8–76.4) 56.3 (54.7–57.9) 61.2 (59.7–62.7) 67.2 (65.8–68.6) 64.6 (63.4–65.8) 58.3 (56.6–60.0) )16.3 ()18.8 to )13.8)
Control parameters
At least one blood pressure measurement 94.5 (93.6–95.4) 93.0 (92.2–93.8) 93.9 (93.2–94.6) 92 (91.2–92.8) 92.2 (91.5–92.9) 92.3 (91.4–93.2) )2.2 ()3.5 to )0.9)
At least one HbA
1c
measurement 51.7 (49.6–53.4) 70.2 (68.7–71.7) 77.6 (76.3–78.9) 82.8 (81.7–83.9) 85.3 (84.4–86.2) 88.9 (87.8–90.0) +37.2 (34.9 to 39.5)
Two or more HbA
1c
measurements 30.0 (28.1–31.9) 41.1 (39.5–42.7) 40.6 (39.1–42.1) 42.2 (40.8–43.6) 55.5 (54.2–56.8) 40.4 (38.7–42.1) +10.4 (7.8 to13.0)
At least one total cholesterol measurement 75.9 (74.1–77.7) 80.5 (79.2–81.8) 83.1 (82.0–84.2) 84.4 (83.4–85.5) 86.5 (85.6–87.4) 90.9 (89.9–91.9) +15.0 (13.0 to 17.1)
Weight control (three or more times a year) 44.9 (42.8–47.0) 32.7 (31.2–34.3) 31.3 (29.9–32.7) 33.5 (32.1–34.9) 40.5 (39.2–41.8) 40.2 (38.5–41.9) )4.7 ()7.4 to )2.0)
Screening for complications
Funduscopy performed by an ophthalmologist 52.2 (50.1–54.3) 48.4 (46.8–50.1) 52.6 (51.1–54.1) 52.2 (50.8–53.7) 54.3 (53.0–55.6) 49.0 (47.3–50.8) )3.2 ()5.9 to )0.5)
Foot examination 48.9 (46.8–51.0) 58.3 (56.7–59.9) 54.3 (52.8–55.8) 54.1 (52.7–55.6) 56.6 (55.3–57.9) 64.2 (62.5–65.9) +15.3 (12.6–17.9)
Determination of microalbuminuria 33.9 (31.9–35.9) 49.0 (47.4–50.7) 62.5 (61.0–64.0) 68.7 (67.4–70.0) 72.8 (71.7–73.9) 59.4 (57.7–61.1) +25.5 (23.6–27.4)
Outcome indicators
Intermediate outcomes
Good glycemic control (HbA
1c
£7%) (57 mmol ⁄mol) 41.5 (39.5–43.5) 42.2 (40.6–43.8) 54.7 (53.2–56.2) 58.7 (57.3–60.1) 56.5 (55.2–57.8) 64.2 (62.5–65.9) +22.7 (20.1 to 25.3)
Acceptable glycemic control (HbA
1c
£8%) (68 mmol ⁄mol) 62.6 (60.6–64.6) 65.4 (63.8–67.0) 74.0 (72.7–75.3) 77.6 (76.4–78.8) 78.6 (77.6–79.7) 83.3 (82.0–84.6) +20.7 (18.3 to 23.1)
Very poor glycemic control (HbA
1c
‡10%) (89 mmol ⁄mol) 13.4 (12.0–14.8) 10.4 (9.4–11.4) 5.7 (5.0–6.4) 5.7 (5.0–6.4) 4.6 (4.1–5.1) 4.2 (3.5–4.9) )9.2 ()10.8 to )7.6)
HDL-cholesterol > 40 mg ⁄dl (1.03 mmol ⁄l) 74.7 (72.9–76.5) 72.2 (70.7–73.7) 77.2 (75.9–78.5) 78.0 (76.8–79.2) 77.6 (76.5–78.7) 83.0 (81.7–84.3) +8.3 (6.5 to10.5)
Total cholesterol £250 mg ⁄dl (6.47 mmol ⁄l) 73.1 (71.3–74.9) 77.0 (75.6–78.4) 77.4 (76.1–78.7) 85.8 (84.8–86.8) 87.0 (86.1–87.9) 92.4 (91.5–93.3) +19.3 (17.2 to 21.3)
Total cholesterol £200 mg ⁄dl (5.17 mmol ⁄l). 25.5 (23.7–27.3) 29.4 (27.9–30.9) 31.9 (30.5–33.3) 41.3 (39.9–42.7) 46.3 (45.0–47.6) 65.6 (63.9–67.3) + 40.1 (37.6 to 42.5)
Body mass index < 30 kg ⁄m
2
63.0 (61.0–65.0) 63.0 (61.4–64.6) 60.8 (59.3–62.3) 56.9 (55.5–58.3) 57.4 (56.1–58.7) 49.7 (48.0–51.5) )13.3 ()16.0 to )10.6)
BP £140 ⁄90 mmHg 45.4 (43.3–47.5) 47.4 (45.8–49.1) 50.1 (48.6–51.6) 54.9 (53.5–56.3) 58.8 (57.5–60.1) 66.1 (64.4–67,8) +20.7 (18.0–23.3)
BP £130 ⁄80 mmHg 22.0 (20,3–23,7) 23.3 (21.9–24.7) 24.6 (23.3–25.9) 26.8 (25.5–28.1) 30.5 (29.3–31.7) 35.0 (33.3–36.7) +13 (10.6–15.4)
Active smoking 13.4 (12.0–14.8) 14.3 (13.2–15.5) 15.0 (13.9–16.1) 14.4 (13.4–15.4) 15.4 (14.5–16.3) 13.6 (12.4–14.8) )0.2 ()2.1 to 1.6)
Final outcomes (prevalence on complications)
Diabetic foot (ulcers plus amputations) 9.5 (8.3–10.7) 6.0 (5.2–6.8) 4.2 (3.6–4.8) 3.5 (3.0–4.0) 3.0 (2.6–3.4) 3.2 (2.6–3.8) )6.3 ()7.7 to )5.0)
Diabetic foot ulcers 7.6 (6.5–8.7) 5.4 (4.7–6.2) 3.4 (2.8–4.0) 2.7 (2.2–3.2) 2.3 (1.9–2.7) 2.6 (2.0–3.2) )5()6.8 to )3.2)
Amputations of lower limbs 1.9 (1.3–2.4) 1.6 (1.2–2.0) 0.8 (0.5–1.1) 0.8 (0.5–1,1) 0.7 (0.5–0.9) 0.6 (0,3–0,9) )1.3 ()1.9 to )0.7)
Nephropathy (micro or macroalbuminuria) 7.1 (6.0–8.2) 6.7 (5.9–7.5) 7.1 (6.3–7.9) 7.0 (6.3–7.7) 7.1 (6.4–7.8) 9.9 (8.8–11.0) +2.8 (1.3 to 4.3)
Retinopathy 18.8 (17.2–20.4) 14.5 (13.3–15.7) 13.5 (12.5–14.5) 10.3 (9.4–11.2) 9.8 (9.0–10.6) 8.6 (7.6–9.6) )10.2 ()12.1 to )8.3)
Amaurosis 2.7 (2.0–3.4) 3.3 (2.7–3.9) 3.1 (2.6–3.6) 2.1 (1.7–2.5) 2.1 (1.7–2.5) 0.3 (0.1–0.5) )2.4 ()3.1 to 1.7)
Coronary artery disease 12.9 (11.5–14.3) 12.0 (10.9–13.1) 12.5 (11.5–13.5) 11.2 (10.3–12.1) 12.5 (11.7–13.4) 11.3 (10.2–12.4) )1.6 ()3.4 to 0.2)
Stroke 6.8 (5.8–7.8) 6.8 (6.0–7.6) 6.6 (5.9–7.4) 5.9 (5.2–6.6) 5.7 (5.1–6.3) 6.3 (5.5–7.2) )0.5 ()1.8 to 0.9)
Hospital admission for amputation, hypoglycemia or
glycemia > 500 mg ⁄dl (27.76 mmol ⁄l)
3.8 (3.0–4.6) 4.9 (4.2–5.6) 6.3 (5.6–7.0) 7.6 (6.8–8.4) 6.8 (6.2–7.5) 6.8 (5.9–7.7) +3.0 (1.8 to 4.2)
*All results are expressed as percentage with 95% confident interval related to the population of the year evaluated.
Primary care interventions for diabetes mellitus 293
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298

for microalbuminuria (33.9 in 1993 vs. 72.8% in
2002), although a fall was observed in 2007 (59.4%).
The funduscopy examination initially improved, but
then remained stable with some downward trend in
the last assessment (52.2% vs. 49%). In addition,
foot exploration increased significantly throughout
the study (48.9% vs. 64.2%) (Table 2).
Outcome indicators
Trends in intermediate outcome indicators
Throughout the study significant improvements were
observed in glycemic control, increasing the percent-
age of patients with HbA
1c
£8% or 68 mmol ⁄mol
(from 62.6% to 92% and reducing the number of
patients with very poor glycemic control
(HbA
1c
‡10% or 89 mmol ⁄mol) from 13.4% to
4.2%. In addition, a significant increase in the per-
centages of patients with acceptable control of total
cholesterol (£250 mg ⁄dl-6.47 mmol ⁄l), (from 73%
to 92.4%) and blood pressure control
(£140 ⁄90 mmHg) (from 45.4% to 57.1%) was also
noted (Table 2 and Figure 1B). Using more strict
control criteria, HbA
1c
£7% or 57 mmol ⁄mol
increased from 41.5% to 64.2%, total cholesterol
(£200 mg ⁄dl-5.17 mmol ⁄l) from 25.5% to 65.6%
and blood pressure (£130 ⁄80 mmHg) from 22% to
35% (Table 1 and Figure 1C). In contrast, no change
in the percentage of active smokers (13.4% and
13.6%) and an increase in obese patients (BMI ‡30)
(from 37% to 50%) were noted (Table 2).
Trends in final outcome indicators
There has been a significant decrease in the preva-
lence of retinopathy (from 19.8% to 8.6%) and a
slight increase in the prevalence of nephropathy
(micro or microalbuminuria, from 7.1% to 9.9%)
(Table 2). Prevalence of diabetic foot ulcers (from
7.6% to 2.6%) and amputation (from 1.9% to 0.6%)
has also significantly decreased. In contrast, reduc-
tions in macrovascular complications have been
much poorer: ischaemic heart disease (12.9% vs.
11.3%) and stroke (6.8% vs. 6.3%). The number of
patients that required hospital admission because of
hyperglycemic decompensation increased significantly
throughout the study (from 3.8% to 6.8%).
Discussion
The present study analyses the evolution of type 2
DM management in primary care settings in Catalo-
nia. During the study period, a significant increase in
the prevalence of DM2 and obesity was observed,
probably related to the epidemic increase in the
prevalence of obesity in the western countries during
94.5 93 93.9 92.2 92.3
100
HbA1c Cholesterol Blood pressure
853
88.9
80.5
83.1 84.4 86.5 90.9
92
90
77.6
82.8
.
75.9
70
80
51.7
70.2
60
50
Foot exploration Fundus examination Albuminuria
68.7
72.8
70
75
80
58.3
54.3 54.1 56.6
64.2
52.2
62.5
59.4
55
60
65
48.9 48.4
52.6 52.2 54.3
49
49
40
45
50
33.9
30
35
100
HbA1c < or = 8% Cholesterol < or = 250 mg/dl BP< or = 140/90 mmHg
77 77.4
85.8 87
92.4
80
90
65.4
74 77.6 78.6
83.3
73.1
66.1
60
70
62.6 65.4
454 47.4 50.1
54.9 58.8
40
50
45.4
30
1993 1995 1998 2000 2002 2007
1993 1995 1998 2000 2002 2007
1993 1995 1998 2000 2002 2007
Equivalencies: 250 mg/dl = 6.47 mmol/l; 8% = 68 mmol/mol
Equivalencies: 200 mg/dl = 5.17 mmol/l ; 7% = 57 mmol/mol
(A)
(B)
(C)
(D)
Figure 1 (A) Process indicators: HbA
1c
, total cholesterol
and blood pressure. Percentage of patients with at least one
annual measurement. (B) Process indicators: complications
screening. Percentage of patients with annual foot
exploration, fundus examination and albuminuria screening.
(C) Intermediate outcome indicators: percentage of patients
with acceptable control of HbA
1c
, total cholesterol and
blood pressure. Equivalencies: 250mg ⁄dl = 6.47 mmol ⁄l;
8% = 68 mmol ⁄mol. (D) Intermediate outcome indicators:
percentage of patients with strict control of HbA
1c
, total
cholesterol and blood pressure. Equivalencies:
200mg ⁄dl = 5.17 mmol ⁄l; 7% = 57 mmol ⁄mol
294 Primary care interventions for diabetes mellitus
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298

the last decades. However, there were no important
changes in the mean age and sex distribution, dura-
tion of the disease and steps of treatment.
The significant improvements observed in some of
the process indicators, in particular glycemic control,
blood pressure and cholesterol, may have contributed
to the reduction of key chronic complications associ-
ated with the disease, such as retinopathy and dia-
betic foot. These improvements meet the
expectations of reducing the percentage of complica-
tions included among the goals of the Declaration of
Saint Vincent (1).
The analysis of the evolution of process indicators
highlight the improvement of laboratory measure-
ments (HbA
1c
, cholesterol, and albuminuria) that are
essential to assess the need or the effect of treatments as
well as patient risk. However, the limited improvement
observed in foot and funduscopy examinations noted
in the study should be carefully analysed because such
explorations are essential to early detection.
The improvements in type 2 DM process indica-
tors observed in the present study are comparable
with the trends described in other studies. Thus, the
results of a population-based study that compared
the results of successive cross-sections in 1988 (1024
patients) and 2006 (13,078 patients) to assess
changes in quality of type 2 DM care in United
States by using standardised measures showed a sig-
nificant improvement in HbA
1c
(from 34% to 51%),
funduscopy (from 63.2% to 67.7%) and foot exami-
nation (from 65.4% to 68.3%) (10). Similarly, in
another study conducted among Medicare beneficia-
ries with diabetes between 1992 (150,000 patients)
and 2001 (230,000 patients) the number of HbA
1c
and funduscopy examinations significantly increased
(from 31% to 76% and from 49% to 57% respec-
tively) (11). Other studies conducted in the UK,
Israel, Netherlands, Sweden and U.S. also show
improvements in the indicator trends although such
studies had limitations regarding the number of
patients analysed (reduced sample sizes) and length
of follow-ups (< 5 years) (13)16). The effect of pay-
for performance on the quality of primary care has
been recently evaluated in England (16).
The improvement in all composite measures of
quality (80% and 90% in the determination of
HbA
1c
, blood pressure and lipids) confirmed the
benefits of such strategy. In addition, between 1998
and 2007 foot exploration increased from 57.4% to
91.5% and funduscopy examination from 69.4% to
81.1%. Such increases were significantly higher than
those observed in our study.
With regard to intermediate outcomes in the Brit-
ish intervention, the proportion of patients who
achieved the target A
1C
value (£7.5%) increased from
59.1% to 66.7%, the proportion that achieved the tar-
get BP (£145 ⁄85 mmHg) increased from 70.9% to
80.2%, and finally, the proportion that achieved the
target TC value (£5 mmol ⁄l) increased from 72.6%
to 83.6%
16
. Although the differences in the targets
between the British intervention and our study does
not allow a head-to-head comparison of the results;
nevertheless both showed a similar positive trend.
In the Spanish health system the role of nurses in
the management of type 2 DM has increased steadily
over the past 20 years. Nurses often perform, in
addition to educational endeavours, foot examination
as well as analytical determinations and funduscopy
examination requests. Therefore, it is important to
highlight their potential role in the improvements
obtained in the present study. In fact, different expe-
riences in the U.S. have shown that nurses can
achieve equal or better results compared with physi-
cians, especially when are provided with software
tools to help decision-making (24–26).
Concerning the changes observed in the present
study with regard to intermediate and final outcome
indicators should not be attributable solely to the
GCQI programme, but instead, are a reflection of
the progressive changes in type 2 DM disease man-
agement experienced by our health system. This time
trend of improvement in diabetic control has also
been observed in prior cross-sectional studies con-
ducted in US (10,11) and Europe (12,14,15). More-
over, an improvement in outcome indicators has
also been described in a prior study conducted in the
US. Thus, medical records from Medicare patients,
analysed between 1992 (150,000 patients) and 2001
(230,000 patients) showed a reduction of foot ampu-
tations in 22% associated with a 4% increase in the
prevalence of retinopathy (11).
The significant reduction observed in diabetic foot
lesions and retinopathy may reflect the educational
and prevention interventions conducted by the health
professionals. However, these improvements may also
be due in part to the intensification of type 2 DM
diagnosis screenings, the lowering of the glycemic
cut-offs in the 1997 diagnostic criteria from 140 to
126 mg ⁄dl (7.77–7 mmol ⁄l) and the improvement in
diagnosis registration. Such changes have led to the
inclusion of patients in earlier stages of the disease
and therefore increasing the percentage of patients
belonging to the less severe category. This could
explain the fact that the HbA
1c
percentage and the
prevalence of microvascular complications or time
since diagnosis have decreased in recent assessments.
However, the prevalence of heart disease and stroke
has not decreased and this could be because of the
similar mean age of patients in each evaluation and
the limited impact of glycemic control on macrovas-
Primary care interventions for diabetes mellitus 295
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298

cular complications (27). Finally, one unexpected
result is the slight increase observed in hospital
admissions that could be explained by an improve-
ment in clinical records, but we cannot exclude an
increase in severe hypoglycemia because of the inten-
sification of pharmacological treatment. As the indi-
cator only includes the number of admissions, but
not the reason, it is impossible to discard the possible
effect of the feedback of the results on glycemic con-
trol that could lead to an overtreatment of some
patients. However, as the results about glycemic con-
trol are from the whole centre and not at individual
level (nor doctor neither patient) it seems improbably
that the feedback could affect directly their patients.
At the same time, the threshold for the intensification
of treatment in our GEDAPS guidelines and in the
pay-for-performance of our institution was 8% and
this relatively soft threshold could protect our
patients from overtreatment. The registration of the
number of severe hypoglycemic episodes would be a
very interesting indicator to add to future audits.
The main limitations of this study include the
design of the study, based on quality interventions
rather than epidemiological or investigational pur-
poses, and the lack of a control group. Because of
the voluntary participation of the centres and the
length of the study it has been impossible to recruit
a group of centres from other areas or regions acting
as a control group. In relation to the validity of col-
lected data, studies of quality improvement are based
on the principle that all unregistered activity is con-
sidered not being made. Taking into account the
overloaded conditions of working in primary care it
can be assumed that health professionals were not
able to perform a comprehensive record of the activ-
ities, especially in educational issues. In the study
period, the computerised medical record was general-
ised throughout primary care in Catalonia from 2003
to 2004, therefore almost all the medical records
reviewed until 2002 were handwritten. In contrast, in
the 2007 assessment results were collected from elec-
tronic medical records, which may explain the
increased number of visits or foot examinations reg-
istered in the last assessment. However, no improve-
ments in funduscopy examination or nephropathy
screening were observed. As for any study of contin-
uous quality improvement programme, it should not
be ruled out that the observed improvements are
merely a reflection of an upgrading in medical record
registration (23,28). However, some studies suggest
that improvements in electronic management system
are not always accompanied by improvements in
health outcomes (20).
Another possible limitation of the study is that
participation was voluntary, therefore it could be
hypothesised that only more motivated centres for
diabetes control participated in the assessments.
However, the fact that the health provider responsi-
ble for data reviewing was motivated did not pre-
clude that the remaining professionals of the PCC
were motivated for diabetes management.
Finally, we must raise the question of whether
improvement in process indicators involves improve-
ments in health outcomes indicators. Most interven-
tions show an improvement of the process indicators
and intermediate outcomes (21–23,28). The compre-
hensive registration of activities does not guarantee a
strict clinical attitude and therefore treatment modi-
fication or intensification could not be associated
with achievement of treatment goals. However, there
is consensus that process indicators are the only tools
to monitor the impact of quality interventions
because final outcome indicators are neither consid-
ered sensitive nor specific as quality of care measures
(28).
It can be concluded that during the study period
there have been improvements in the registry of
health activities as well as performance of physical
examinations and laboratory tests. The improve-
ments achieved in glycemic control and other risk
factors may have contributed to the reduction in foot
amputations and diabetic retinopathy observed.
Although those changes should not be attributed
strictly to the GCQI programme, they reflect an
improvement in the health of type 2 DM patients
managed in primary care in our country.
Acknowledgements
All the members of the GEDAPS group, physicians
and nurses included in Appendix 1, without whose
commitment to quality of care it would not have
been possible to carry out this study and Sofı
´a Perea,
Pharm D, PhD, who provided medical writing
support funded by Merck Sharpe & Dohme Spain,
S.A. The GEDAPS group Continuous Quality
Improvement Programme has received financial sup-
port from Bayer, Novo Nordisk, GlaxoSmithKline,
Merck Sharp & Dhome Spain, and the Fundacio
´
d‘Atencio
´Prima
`ria. The authors of the manuscript
have nothing to declare.
Authors’ contributions
MCM, ROP, BIM, BPM, MTX, FNJ, BBB, and CPJF
participated in the conception and design of the
study, acquisition of data, analysis and interpretation
of data, drafting the article or revising it critically for
important intellectual content, and final approval of
the version to be submitted.
296 Primary care interventions for diabetes mellitus
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298

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Appendix 1: List of
participating investigators in
the GEDAPS evaluations
Mª Victoria Abellan, Mª Teresa Adell;
Raquel Adoer; Mª Eugenia Adzet; Carina
Aguilar; Emilia Alabau; Inmaculada
Alegre; Merce
´Algans; Herminia Algilaga;
Mercedes Aliaga; Rosa Alie; Josep Alins;
Carmen Almirall; Josep Almirall; Amelia
Alonso; Otilia Alonso; Tomas Alonso;
Judit Alsina; Ana Marı
´a Altaba; Isabel
Alvarez; Mercedes Alvarez; Merce
´Alvarez;
Francesc Anguera; Gloria Anto
´n; Charo
An
˜an
˜os; J. Ignacio Aoiz; Enric Aragone
´s;
Eugenia Arasa; Mª Josefa Arasa; Teresa
Areny; Teresa Arnau; Enric Arroyo; Car-
men Asensio; Merce
´Aubanell; Francisco
Avila; Teresa Avin
˜o; Pilar Babi; Marı
´a
Badenes; Rosa Maria Badia; Pilar Baillo;
Josep Lluı
´a Ballve
´; Carmen Baquer; Elena
Barnat; Mª Carmen Barrero; Joan Barrot;
Rosa Ana Bas; Nu
´ria Bastida; Enric Bay-
ona; Domenech Benaigues; Mª Rosa
Benedicto; Bele
´n Benito; Carmina Bentue;
Marı
´a Berengue
´; Marta Berga; Francisco
Berlanga; Martı
´Birules; Alba Blanch; Mª
Isabel Bobe
´; Miriam Boira; Neus Bon-
amusa; Neus Boque
´; Eulalia Borrell;
Manel Borrell; Montserrat Bosch; Con-
cepcio
´n Bou; Consol Bou; Javier Buil;
Magda Bundo; Esther Caballe
´; Isabel
Caballero; Mª Carmen Caballero; Josep
Caballero; Rosa Caballol; Teresa Cabases;
Juan Josep Cabre
´; Mª Angels Calaf; Glora
Mª Calleja; Maria Luisa Calvet; Ramo
´n
Camps; Rosa Canals; Silvia Canivell; Juan
Francisco Cano; Josep Can
˜ellas; Dolors
Capdevilla; Anna Carabi; Carmen Carre-
tero; Carolina Carrillo; Ricart Carillo; Mª
Angels Casals; Jordi Casanovas; Nieves
Casbas; Pilar Casellas; Mª Jose
´Castany;
Merce
´Castan
˜o; Mª Jose Castelar; Carme
Castello
´; Joan Castells; Dolors Catala
´;
Matilde Catala
´; Mª Jesu
´s Cerain; Enc-
arnacio
´n Checa; Ester Chiveches; Carmen
Ciria; A. Claramunt; Purificacio
´n Claver;
Joan Clotet; Yolanda Coccor; Fina Coll;
Josep Coll; Montserrat Coma; Vicent
Primary care interventions for diabetes mellitus 297
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298

Coma; Josefina Comas; Joan Conxat; Fer-
ran Cordon; Carmen Coronado; Carme
Cortina; Francesc Xavier Cos; Pilar Co-
scullera; Engracia Costa; Joan Costa;
Xavier Costa; Jose Mª Cots; Ramon Cre-
us; Ine
´s Cruz, Lourdes Cruz; Nuria Culi;
Montserrat Dalmau, Josep Davins; M.
Teresa de Cos; Josep Anton de la Fuente;
Nuria de la Iglesia; Merce
´de la Torre;
Juan A de Luna; Lourdes de Marcos;
Rosa Mar de Miguel; Marta de Puig;
Marta del Moral; Carmen Delgado; Fran-
cisca Delgado; Cecilia Domenech; Jose
´
Marı
´a Domingo; Marı
´a Isabel Domingo;
Roser Dot; Carme Echevarria; Pilar Ens-
en
˜at, Mª Luisa Escando
´n; Merce
´Escarra
´;
Alex Escosa; Lı
´dia Escur; Jordi Espina
´s;
Montserrat Espuga; Teresa Esquerra;
Maria
`Esquerra
´; Josefa Estany; Montserrat
Estruch; Sion Fabregat; Antonia Fargas;
Assumpta Farra
´s, Pere Farra
´s; Montserrat
Farru
´s; Eugeni Fau;Montserrat Fernandez;
Carmen Ferna
´ndez; Maria Rosario Fern-
a
´ndez; Pablo Ferna
´ndez; Mª Carmen
Ferna
´ndez; Judit Ferragutcasas; Maria
Ferre
´; Daniel Ferrer-Vidal; Xavier Figu-
eras, Xavier Flor; Carme Florensa; Pere
M.Flores; Quintı
´Foguet; Mar Foix; Pilar
Font; Jordi Forcada; Maria Carme Forn;
Josep Franch; Rosa Freixedes; Miquel
Fuentes; Jose
´Mª Fuste; Pilar Fuste
´; Car-
men Galera; Gisela Galindo; Roser Galito
´;
Anna Mª Garcia; Eva Garcia; Isabel Gar-
cia; J. Manel Garcia; Laura Garcia; Vega
Garcia; Gracia Garcia; Concepcio
´Garcia;
M. Teresa Garcia; Jose Maria Garrido;
Anna Gasol; M. Amparo Gaytano; Dolors
Gelabert; Jordi Gentille; Francesc German;
Faustino Gerri; Rosa M Gimbert; Virginia
Golobart; Josep Goma
`; Albert Gomez;
Alicia Gonzalez; Clementina Gonzalez; J.
Carles Gonzalez; Matilde Gonzalez;
Tamara Gonzalez; Maria Gonzalez; Mª
Rosa Gorgot; Lluı
´s Gracia; Imma Grau;
Neus Gregori; Montserrat Grive
´; Teresa
Gros; Elisenda Guarne
´; Asuncio
´n Guar-
ner; Faustino Guerri; Jesu
´s Domingo
Guevara; Mª Anto
`nia Gutı
´errez; Marı
´a
Cruz Guzma
´n; Anna Rosa Hernandez; Mª
Merce
`Hernandez; Enric Herna
´ndez;
Anna Herna
´ndez; Juan Herreros; Beatriz
Hortangas; Monica Iban
˜ez; Carme Igle-
sias; Pedro Iglesias; Pascual Jaime;
Ricardo Jara; Rosa Juanola; Joan Juvante-
ny; Eduard Kronfly; Cristina Laserna;
Carmen Lecumberri; Xavier Lecumberri;
Montserrat Ledesma; M. Jose
´Ledo
´;Mª
Antonia Llauger; Josep Lluı
´s Llor; Judit
Llussa
`; Flora Lopez; Regina Lopez; Angels
Lo
´pez; Anna Lo
´pez; M.Jose
´Lorente; Gus-
tavo Losada; Joan Lozano; Marissa
Madrid; Carme Mallorqui; Sara Marcelo;
Yolanda Marcos; M. Victoria Marina;
Carmen Marquilles; Jordi Marti; Laia
Martı
´; Raquel Martı
´n; Jose
´Antonio Mar-
tin; Ana Martinez; Daniel Martinez; Do-
lores Martinez; Dolors Martinez; Ignacio
Martinez; Miguel Martinez; Carmen Mar-
tinez; Rafael Martinez; Valenti Martinez;
Sara Martinez de Arenzana, Raquel Mar-
tos; Rosa Mª Masdeu; Anna Masseda; Jo-
sep Massons; Manel Mata; Enriqueta
Matheu, Anna Mayoral; Laura Mayordo-
mo; Pilar Medina; Salvador Medina, Ce
`lia
Mele
`ndez; Ana Menal; Mª Angeles Me
´n-
dez; Miquel A. Mercade
`; Josep Mercader;
Xavier Mestre; Concepcio
´n Mestres; Rosa
Mar Miguel; Anna Miralbe
´s; Merce
`Mir-
anda; So
`nia Miravet; Magda Mitjavila;
A
`ngels Mollo
´i Josep Felip Monclus; Sus-
anna Montesinos; Javier Monteverde; San-
dra Moraleda; Carlos Moreno; Maria de la
Sierra Moreno; Miguel Moreno; Rocı
´o
Moreno; Xavier Mundet; Pere Munt; Aser
Mun
˜oz; Roser Mun
˜oz; Marife Mun
˜oz;
Rosa Blanca Mun
˜oz; Josep Murria; Josep
Mussoll; Carme Nabau; Carmel Nadal;
Antonia Navarro; Juan Navarro; Maria del
Mar Navarro; Pilar Navarro; Cristina
Nieto; Vicente Nieto; Pere Noe; Ana
M.Nogales; Concepcion Nogue
´s; Marisol
Oliva; Irene Oliva; Mercedes Oliver;Mª
Angels Oliveras; Miquel Oller; Montserrat
Ortigas; Jacinto Ortiz; Jose Osvet; Isabel
Otzet; Antonio Padilla; Jesu
´s Pages; Elisen-
da Palet; Merce Pallare
´s; M. Pilar Pallare
´s;
Mª Teresa Pallerols; Nuria Palou; Clara
Pareja; Rosa Pascual; Maria Pastoret; M.
Florencia Patittucci; David Pedrico; Magda
Pedrosa, Margarida Pelegri; Francisca Pe-
n
˜as; Josep Maria Pepio
´; Consol Peracaula;
Julio Perez; Elena Pe
´rez; Miguel Peso;Jordi
Pi; Magda Pi; Antoni Plana; Isabel Plaza;
Montserrat Policarpio; Isabel Porta; Mon-
tserrat Portas; Joan Prat; Paloma Prats; Pi-
lar Prellezo; Neus Profito
´s; Francesc Puig;
Josep Puig; Marta Puig; Xavier Puigdengo-
las; Montserrat Pujiiula; Ramon Pujol;
Dolors Pujol; Francisca Puntes; Nu
´ria Rab-
ento
´s; Joana Ramon; Ana Maria Ramos;
Estibaliz Redondo; David Riba; Fidel Riba
Barre
´s; Enriqueta Ribas; Ricart Ribas; Ter-
esa Ribe
´; Trinitat Ribes; Carme Riera;
Nata
`lia Riera; Jose
´Luı
´s Rivero; Rosabel
Roca; Antonio Rodriguez; Francisco
Rodriguez; Javier Rodriguez; Mo
`nica Rod-
rı
´guez; Olivia Roig; Montserrat Romagu-
era; Xavier Romani; Eva Romero; Mª
Dolors Romero; Esther Ros; Pilar Roura;
Montserrat Roures; Aurora Rovira; Carles
Rubio; Laura Rubio; Montserrat Rubio;
Irene Ruiz; M.Paz Ruiz; Miriam Ruiz; Jo-
ana Ruiz; Teresa Sabartes; Primitivo
Sabate
´; Maria A.Sagarra; Josep M Sagrera;
Isabel Sales; Anneliese Salzer; Angela San-
chez; Rosalia Sanchez; Yolanda Sanchez;
Carme Sa
´nchez; Josep M.Sa
´nchez; Consol
Sa
´nchez; Enric Sanchis; Teresa Sangra;
Laura Sanguesa; Maria Sanmartin; Neus
Saun; Meritxell Saura; Montserrat Saus;
Carme Sebastia
`; Eva Segura; Amparo Segu-
ra; Gemma Sellas; Beatriz Sena; Mª Jose
´
Sender; Dolores Serra; Marta Serra; Imma
Serrabasa; Lido
´n Serrano; Vanesa Serrano;
Maria Serratosa; Angels Sieria; Silvia
Sierra; Josep Mª Sierra; Josefina Sirvent;
Jose
´Francisco Sobrino; Silvia Sola
`; Pascual
Solans; Mª Carmen Soldado; Ju
´lia Sole
´;
Montserrat Sole
´; Magda Sole
´; Merce Soler;
Luı
´s Solsona; Mª Teresa Sopena; Marta
Sorribes; Edith Steiner; Ana Mª Suarez;
Esperanza Suros; Robert Surriba; Pau
Surribes; M. Luz Talavera; Sol Taramon;
Maria Victoria Tarin; Salvador Tarradas;
Eduard Tarrago; Luisa Tarrida; Joan
Tobias Pedro Toma
´s; Marta Torne; Anabel
Torras; Emma Torres; Natividad Torres;
Josep Ubach; Antonio Ubieto; Sara Una-
nue; Luı
´s Carlos Valladares; Marı
´a Jose
´.
Vendrell; Cristina Verdera; Maria Vernet;
Raquel Vicente; Roser Vicente; Antonieta
Vidal; Mª Antonia Vila; Carme Vila; Marga
Vilageliu; Luisa Vilaginer; Josep Vilalta;
Pere Vilalta; Eula
`lia Vilaplana; Esther
Viler; Lidia Villagrasa; Merce Villaro; Jordi
Villegas; Antoni Vives; Rosa Vives; Nuria
Xifro; Rosa Elena Yan
˜ez; Montserrat
Zamora
Paper received September 2011, accepted November 2011
298 Primary care interventions for diabetes mellitus
ª2012 Blackwell Publishing Ltd
Int J Clin Pract, March 2012, 66, 3, 289–298