Diabetes as a Tracer Condition in International Benchmarking of Health Systems

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To assess the performance of health systems using diabetes as a tracer condition.


We generated a measure of “case-fatality” among young people with diabetes using the mortality-to-incidence ratio (M/I ratio) for 29 industrialized countries using published data on diabetes incidence and mortality. Standardized incidence rates for ages 0–14 years were extracted from the World Health Organization DiaMond study for the period 1990–1994; data on death from diabetes for ages 0–39 years were obtained from the World Health Organization mortality database and converted into age-standardized death rates for the period 1994–1998, using the European standard population.


The M/I ratio varied >10-fold. These relative differences appear similar to those observed in cohort studies of mortality among young people with type 1 diabetes in five countries. A sensitivity analysis showed that using plausible assumptions about potential overestimation of diabetes as a cause of death and underestimation of incidence rates in the U.S. yields an M/I ratio that would still be twice as high as in the U.K. or Canada.


The M/I ratio for diabetes provides a means of differentiating countries on quality of care for people with diabetes. It is solely an indicator of potential problems, a basis for stimulating more detailed assessments of whether such problems exist, and what can be done to address them.

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