Defining quality of care for children and adolescents with type 1 diabetes

Recent years have seen an increase in awareness of the need to improve the quality of diabetes care for children and adolescents, as detailed in the Declaration of Kos, for example. This paper addresses some quality-of-care principles and evaluates specific examples of current management. The meaning of the terms quality of care, evidence-based medicine and cost-containment are examined, and the features central to the development and evaluation of quality health care (structure, process and outcome) are explored. The practical aspects of diabetes care are reviewed in terms of the causes and prevention of early mortality, ambulatory vs inpatient care, the value of measuring HbA(1c), other metabolic control criteria (including the effect of patient selection, cultural, socioeconomic and biological differences) and clinical practice guidelines. It is concluded that a multidisciplinary team provides the optimum context for diabetes management and that care must be family centred and multidimensional (i.e. not focusing on HbA(1c) levels alone). The task of improving diabetes care is massive and operates at all levels (individual, family, health-care providers, national and international bodies), but offers significant improvements in quality and cost- effectiveness.