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Evaluating quality of overall care among older adults with diabetes with comorbidities in Ontario, Canada: a retrospective cohort study
  1. Yelena Petrosyan1,
  2. Kerry Kuluski2,3,
  3. Jan Barnsley2,
  4. Barbara Liu4,
  5. Walter P Wodchis2,3
  1. 1 Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
  2. 2 Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  3. 3 Institute for Better Health, Trillium Health Partners, Toronto, Ontario, Canada
  4. 4 Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  1. Correspondence to Dr Walter P Wodchis; walter.wodchis{at}


Objectives This study aimed to: (1) explore whether the quality of overall care for older people with diabetes is differentially affected by types and number of comorbid conditions and (2) examine the association between process of care measures and the likelihood of all-cause hospitalisations.

Design A population-based, retrospective cohort study.

Setting The province of Ontario, Canada.

Participants We identified 673 197 Ontarians aged 65 years and older who had diabetes comorbid with hypertension, chronic ischaemic heart disease, osteoarthritis or depression on 1 April 2010.

Main outcome measures The study outcome was the likelihood of having at least one hospital admission in each year, during the study period, from 1 April 2010 to 3 March 2014. Process of care measures specific to older adults with diabetes and these comorbidities, developed by means of a Delphi panel, were used to assess the quality of care. A generalised estimating equations approach was used to examine associations between the process of care measures and the likelihood of hospitalisations.

Results The study findings suggest that patients are at risk of suboptimal care with each additional comorbid condition, while the incidence of hospitalisations and number of prescribed drugs markedly increased in patients with 2 versus 1 selected comorbid condition, especially in those with discordant comorbidities. The median continuity of care score was higher among patients with diabetes-concordant conditions compared with those with diabetes-discordant conditions, and it declined with additional comorbid conditions in both groups. Greater continuity of care was associated with lower hospital utilisation for older diabetes patients with both concordant and discordant conditions.

Conclusions There is a need for focusing on improving continuity of care and prioritising treatment in older adults with diabetes with any multiple conditions but especially in those with diabetes-discordant conditions (eg, depression).

  • health & safety
  • quality in health care
  • multimorbidity clusters
  • diabetes
  • diabetes-concordant conditions
  • diabetes-discordant conditions

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  • Contributors All coauthors fulfill the criteria required for authorship. WPW was the lead for the creation of the cohort. YP and WPW substantially contributed to the conception, analysis and interpretation of the data for the work and to the drafting of the work. JB, KK and BL substantially contributed to the analysis and interpretation of the data for the work. YP drafted the manuscript. YP and WPW revised the drafting of the work critically for important intellectual content. All authors contributed to the final approval of the version to be published and are in agreement to be accountable for all aspects of the work and in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

  • Funding This study was supported by Institute of Clinical Evaluative Sciences(ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care. This study also received funding from a research grant from a Canadian Institute for Health Research Community Based Primary Health Care Team Grant (#495120).

  • Disclaimer The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. The data from this study are held securely in coded format ICES. While data sharing agreements prohibit ICES from making the data publicly available, access may be granted to those who meet prespecified criteria for confidential access, available at

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