A performance score of the quality of inpatient diabetes care is a marker of clinical outcomes and suggests a cause-effect relationship between hypoglycemia and the risk of in-hospital mortality.

AIMS: to build a tool to assess the management of inpatients with diabetes mellitus and to investigate its relationship, if any, with clinical outcomes. MATERIALS AND METHODS: 678 patients from different settings, Internal Medicine (IMU, n = 255), General Surgery (GSU, n = 230) and Intensive Care (ICU, n = 193) Units, were enrolled. A work-flow of clinical care of diabetes was created according to guidelines. The workflow was divided in 5 different domains: 1) initial assessment, 2) glucose monitoring, 3) medical therapy, 4) consultancies, 5) discharge. Each domain was assessed by a performance score (PS), computed as the sum of the scores achieved in a set of indicators of clinical appropriateness, management and patient empowerment. Appropriate glucose goals were included as intermediate phenotypes. Clinical outcomes included: hypoglycemia, survival rate and clinical conditions at discharge. RESULTS: the total PS and those of initial assessment and glucose monitoring were significantly lower in GSU respect to IMU and ICU (P < 0.0001). The glucose monitoring PS was associated with lower risk of hypoglycemia (OR 0.55; P < 0.0001), whereas both the PSs of glucose monitoring and medical therapy resulted associated with higher in-hospital survival only in IMU ward (OR = 6.67 P = 0.001 and OR = 2.38 P = 0.03, respectively). Instrumental variable analysis with the aid of PS of glucose monitoring showed that hypoglycemia may play a causal role in in-hospital mortality (P = 0.04). CONCLUSIONS: the quality of in-hospital care of diabetes may affect patient outcomes, including glucose control and the risk of hypoglycaemia, and through the latter it may influence the risk of in-hospital mortality. This article is protected by copyright. All rights reserved.