process measures include percentages of patients monitored at least once during the previous 12 months for the following parameters : a1c , blood pressure , lipid profile , microalbuminuria , and foot examination . intermediate outcome measures include the proportion of patients with a1c levels 7.0% or 8% , blood pressure values 130/85 or 140/90 mmhg , and ldl cholesterol levels < 100 or 130 mg / dl . a software program was developed to enable the extraction of the information needed from electronic medical record systems used for the everyday management of outpatients . all indicators were compared with reference values , or  gold standard ,  established by identifying the best performers . the gold standard for every indicator was represented by the 75th percentile of the ordered distribution of the results obtained in the centers . results were publicized through a specific publication ( amd annals ) and on a dedicated page of the amd web site ( 10 ) and discussed with participants in an annual meeting . each individual center could also measure its performance directly from the electronic record system , using specific queries . the project was conducted without allocation of extra resources or financial incentives but through a physician - led effort made possible by the commitment of the specialists involved . we report here the results relative to the year 2004 and concerning type 2 diabetes . to account for the hierarchical nature of the data and to control for the possible confounding effects of the different variables , we used multilevel regression models to investigate intercenter variability expressed as the 10th to 90th percentile range , adjusted for sex , age , and clustering effect . overall , 114,249 patients were seen by 86 diabetes outpatient clinics during 2004 . of the patients , 53% were male , 56% were aged > 65 years , 11.1% were on diet alone , and 63.3% were treated with oral agents and 25.3% with insulin  oral agents . results relative to process indicators , reported in table 1 , show the gap between the gold standard and the whole sample of diabetes outpatient clinics . as for intercenter variability in the process measures , a moderate variation for a1c monitoring was documented , whereas a wide heterogeneity in between - center performance was present for blood pressure , lipid profile , microalbuminuria , and foot monitoring . . a small minority of the patients had achieved all the favorable outcomes ( 5.5% ) , whereas in 8.8% , none of the goals were reached . the comparison with the gold standard showed a 1020% lower rate of patients at target in the whole population compared with individuals cared for by the best performers . a wide variation was also documented for the outcome measures ; it was associated with a parallel intercenter variation in the use of specific drug classes . for example , prescription rates for statins and ace inhibitors ranged between 13.2% and 35.5% and between 14.2% and 29.4% , respectively . our study documents the feasibility of conducting practice - based quality - of - care studies across large numbers of outpatient practices after having reached a consensus on how to measure quality in priority areas . this was a preliminary fundamental step to promote continuous critical evaluation of current practice , develop process improvements , and reduce practice variation . the  best performers  approach represented a key feature of the continuous quality - improvement effort implemented . in fact , clinicians were not faced with theoretical standards often perceived as unrealistic in their setting , but rather with the performance of centers operating in the same health care system under similar conditions . by comparing their own performance with that of centers reaching better results , specialists could easily realize the real margin of improvement made possible by increasing the level of attention to disease monitoring and treatment . the analysis of process indicators shows that the level of performance is consistently higher for some parameters , such as a1c , blood pressure , and lipid monitoring , than for others such as microalbuminuria monitoring or foot examination . the evaluation of between - center variability further documents heterogeneity in the rate of performance of some process measures , such as lipids , microalbuminuria , and foot monitoring . as for the outcomes considered , the comparison with the gold standard emphasizes the gap existing between the results achieved in the whole sample and those attained by the best performers . we also documented a wide variation in the ability to reach the targets recommended by existing guidelines , although part of this variation could be related to factors not taken into consideration ( e.g. , diabetes duration and complications ) . nevertheless , such variability was paralleled by strikingly different rates of prescriptions of specific drugs , thus suggesting a strong need for treatment intensification . in conclusion , our study describes the first step of a nationwide quality - improvement effort and documents that it is possible to obtain standardized information to be used for initiatives of diabetes care profiling and benchmarking . the yearly evaluation of patterns of care , the dissemination of results , and their discussion with the participants is expected to improve the performance of diabetes clinics and reduce variability ( 9 ) .
objective  to describe patterns of diabetes care and implement benchmarking activities at the national level.research design and methods  a total of 86 clinics participated , all using electronic medical records . 
 quality indicators were identified , and software was developed , enabling the extraction of the information needed for quality - of - care profiling.resultsoverall , 114,249 patients with type 2 diabetes were seen during 2004 . 
 a1c was measured at least once in 88.0% of the patients , lipid profile in 64.6% , blood pressure in 77.2% , and microalbuminuria in 48.1% . 
 overall , 43.1% of individuals had a1c 7.0% , 36.6% had blood pressure 130/85 mmhg , and 29.8% had ldl cholesterol < 100 mg / dl . 
 only 5.5% of the patients had achieved all the favorable outcomes . 
 wide between - center variation was documented for all indicators.conclusionsthis study is the first step of a nationwide quality - improvement effort and documents the possibility of obtaining standardized information to be used for diabetes care profiling and benchmarking activities .