Quality of care for migrant populations with type 2 diabetes mellitus in Italy: a retrospective analysis of data from the the Italian AMD (Associations of Medical Diabetologists) annals initiative

Abstract

Purpose

Italy is a major hub for migration routes. Disparities in health management across different geographic regions, particularly among individuals with type 2 diabetes mellitus (T2D), are well recognized, yet comprehensive data on the quality of T2D care in migrant populations remain limited.

Methods

Quality indicators of T2D care were analyzed for foreign patients compared with European patients using the 2022 AMD Annals database. The Italian National Institute of Statistics classification defined geographic origins.

Results

Data on country of origin were available for 179,536 T2D patients, with 19.3% being foreign, mainly from North Africa, Central and Eastern Europe, Central and South Asia, Central and South America.Foreign T2D patients were generally younger, resulting in shorter disease duration. While annual screening rates for risk factors and major complications were as European subjects, critical gaps were noted in microalbuminuria and retinopathy assessments. Treatment intensity was lower for patients from North and West Africa and Central and South Asia, though the use of innovative therapies like GLP-1RAs and SGLT2i was comparable to European patients. The overall quality of care, measured by the Q-score, was lowest in West African patients (26.4 ± 9.1 vs. 29.1 ± 8.0), while 51.6% of those from Central and South Asia had satisfactory care quality (Q-score > 25).

Conclusion

Study showed differences in age, disease duration, and treatment among patients from various geographic regions, while indicating equitable access to therapies and comparable overall quality of care. These findings may inform management strategies to improve T2D care for migrant populations.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1007/s00592-026-02675-8.

Introduction

Migration has increased substantially in Italy over the last two decades, reshaping the demographic structure of the population. According to data from the Italian National Institute of Statistics, more than five million foreign residents were living in Italy in 2022, accounting for approximately 8% of the total population, with even higher proportions in some regions [1]. These demographic changes pose important challenges for the Italian healthcare system. Since migrant populations may experience barriers to healthcare access, including linguistic, cultural, and socioeconomic factors, which may negatively affect the management of chronic diseases, such as type 2 diabetes (T2D).

Moreover, T2D, one of the most prevalent chronic conditions worldwide, disproportionately affects certain ethnic groups and migrant communities [2–6]. At this regard, previous studies have consistently reported ethnic- and migration-related differences in the quality of diabetes care and in the achievement of recommended targets for glycemic control and cardiovascular risk factors, even in healthcare systems with universal coverage [7, 8]. Such disparities vary according to sex, ethnicity, socioeconomic status, and geographic area of origin, highlighting the complex interplay between biological, social, and healthcare-related determinants [9–12].

In Italy, specialist diabetes care is delivered through a nationwide network of diabetes centres. Since 2006, the Italian Association of Diabetologists has promoted the Annals Initiative, a large quality-improvement program that collects standardized clinical data from approximately half of Italian diabetes centres [13, 14]. Although recent Annals data [14] indicate that nearly one in five individuals with diabetes attending these services is of foreign origin, it remains unclear whether geographic origin influences the quality of care provided. The present study aimed to describe the sociodemographic and clinical characteristics of migrant populations with T2D attending Italian diabetes centres and to assess the quality of specialist diabetes care across different geographic areas of origin.

Methods

This retrospective observational study was conducted using data from the Annals Initiative of the Italian Association of Diabetologists, a national program aimed at monitoring and improving the quality of diabetes care. The initiative collects anonymized clinical data extracted from electronic medical records (EMRs) of participating diabetes centres, as described in detail in a previous paper [13]. Overall, more than 550,000 patients with diabetes were included in the 2022 AMD Annals database [14]. Information on country of origin was available for 179,536 patients with T2D, who constituted the study population. Geographic areas of origin were defined according to the ISTAT 2022 classification [15].

The following data were analyzed:

• Sociodemographic data, glucometabolic indicators (including body mass index, HbA1c, lipid profile, estimated glomerular filtration rate, microalbuminuria, and blood pressure), and clinical information (pharmacological treatments classified according to Anatomical Therapeutic Chemical codes and chronic diabetes complications identified using ICD-9-CM codes).

• Quality-of-care indicators, including process measures (the proportion of patients with at least one annual assessment of HbA1c, blood pressure, lipid profile, renal function, foot examination, and eye examination), intermediate and final outcomes (achievement of guideline-recommended targets: HbA1c ≤ 7.0% [≤ 53 mmol/mol], blood pressure < 130/80 mmHg, and LDL cholesterol < 70 mg/dL), and indicators of treatment intensity and appropriateness. The latter included lack of insulin therapy despite HbA1c ≥ 9.0% (≥ 75 mmol/mol), lack of lipid-lowering therapy despite LDL cholesterol ≥ 100 mg/dL, lack of antihypertensive therapy despite blood pressure ≥ 140/90 mmHg, lack of ACE inhibitors or angiotensin receptor blockers despite micro- or macroalbuminuria, and inadequate control despite treatment (HbA1c ≥ 9.0%, LDL cholesterol ≥ 100 mg/dL, or blood pressure ≥ 130/80 mmHg).

• Finally, a summary measure of quality of care, the Q score, was calculated. The Q score, which was developed and validated in two previous studies [16, 17], has been incorporated into the AMD Annals Initiative since 2009 [14]. It combines both process and outcome indicators related to HbA1c, blood pressure, LDL cholesterol, and albuminuria. The Q score ranges from 0 to 40 and is associated with the three-year risk of cardiovascular events (80% excess risk for scores < 15 and 20% excess risk for scores between 15 and 25, compared with scores > 25).

Statistical methods

The study population included all individuals with a diagnosis of T2D documented in EMRs. When multiple entries were available for a given patient within the reference year, the most recent value was used to assess quality of care. The denominators for the various quality indicators differed according to data availability during the reference year, and no imputation was applied for missing values. Patient characteristics are reported as means with standard deviations or as frequencies, while quality indicators are presented as unadjusted percentages.

Results

Overall, 179,536 patients with T2D had a country of origin other than Italy (19.3%). Among migrant patients, the most frequent areas of origin were North Africa (4.5%), Central and Eastern Europe (3.9%), Central and South Asia (3.3%), and Central and South America (2.1%).

Characteristics of patients based on geographic area of origin

The main clinical characteristics of patients with T2D according to geographic area of origin are reported in Table 1. Overall, patients from the European Union were older (70.1 ± 10.8 years) than those from all other regions, whereas the youngest mean age was observed among patients from Central and South Asia (51.1 ± 10.8 years). In line with these data, the mean duration of T2D was longer among patients from the European Union (12.3 ± 9.8 years), while the shortest duration was observed among patients from West Africa (7.1 years). The proportion of men was higher than that of women across all geographic areas of origin, except for Central/South America and Eastern Europe.

Table 1.

Patient characteristics by geographic area of origin

General characteristics	European union	Central Eastern Europe	Other European Countries	North Africa	West Africa	East Africa	Central and South Africa	West Asia	Central and South Asia	East Asia	North America	Central and South America	Oceania
N. Group	147,050	6,991	1,045	8,165	2,242	650	205	541	5,978	2,502	187	3,858	122
Age (years)	70.1 ± 10.8	60.9 ± 10.3	59.8 ± 9.0	59.3 ± 11.8	52.4 ± 10.7	65.5 ± 12.2	58.5 ± 11.6	62.7 ± 11.0	51.1 ± 10.8	56.8 ± 10.8	63.0 ± 10.0	60.3 ± 11.2	60.1 ± 7.8
Male Gender (%)	59.0	43.4	57.5	56.6	60.4	52.0	53.7	62.5	62.0	48.6	65.8	38.1	61.5
Duration of diabetes (years)	12.3 ± 9.8	8.0 ± 7.1	9.3 ± 8.2	9.6 ± 8.1	7.1 ± 6.7	11.4 ± 9.5	7.8 ± 7.3	9.9 ± 8.5	7.4 ± 6.7	8.0 ± 7.4	9.3 ± 7.9	8.9 ± 7.9	9.9 ± 7.9
Smoking (%)	17.7	17.6	27.0	17.0	5.8	15.8	10.3	30.0	13.2	14.8	20.7	17.5	23.2

Indicators of volume of activity and process indicators according to geographic area of origin

Several indicators of quality of T2D care were analyzed according to geographic area of origin, including volume of activity and process indicators, which reflect access to diabetes centers and healthcare services. With regard to volume of activity, no substantial differences were observed in the average number of medical visits across ethnic groups (Table 2).

Table 2.

Quality of care process indicators (percentage of patients with at least one assessment in the index year)

Quality of care process indicators	European Union	Central Eastern Europe	Other European Countries	North Africa	West Africa	East Africa	Central and South Africa	West Asia	Central and South Asia	East Asia	North America	Central and South America	Oceania
N. visits/year in patient treated with oral agents	1.5 ± 0.8	1.5 ± 0.7	1.6 ± 0.9	1.5 ± 0.9	1.6 ± 1.0	1.5 ± 0.7	1.6 ± 0.9	1.6 ± 0.9	1.5 ± 0.8	1.5 ± 0.8	1.6 ± 0.8	1.5 ± 0.8	1.4 ± 0.5
n° visits/year in patient treated with insulin	2.1 ± 1.2	2.0 ± 1.1	2.2 ± 1.5	1.9 ± 1.2	2.2 ± 1.5	2.2 ± 1.2	1.9 ± 1.1	1.8 ± 1.1	2.2 ± 1.4	2.0 ± 1.1	2.2 ± 1.3	2.0 ± 1.1	1.8 ± 0.9
n° visits/year in patient treated with oral agents + insulin	2.1 ± 1.4	2.2 ± 2.1	2.2 ± 1.8	2.3 ± 2.1	3.3 ± 3.5	2.3 ± 1.6	3.0 ± 2.8	2.2 ± 1.2	3.0 ± 2.9	2.3 ± 1.6	2.1 ± 2.2	2.2 ± 2.0	1.6 ± 1.1
Blood pressure (%)	87.9	87.5	86.8	88.2	90.4	83.2	85.9	86.3	86.8	85.6	80.2	85.7	75.4
Albuminuria (%)	67.4	65.7	66.2	64.3	64.9	59.7	59.5	69.3	68.1	64.3	64.7	60.8	69.7
Serum creatinine (%)	92.9	90.7	90.6	88.5	88.2	91.7	87.3	90.9	88.5	88.7	87.7	89.6	91.8
Foot examination (%)	16.3	17.9	17.4	13.3	15.5	11.7	14.1	17.9	17.6	10.2	19.3	17.2	16.4
Eye examination (%)	31.6	23.2	29.5	22.5	23.1	25.7	26.3	26.4	21.1	22.8	23.5	25.4	32.0

Regarding process indicators, more than 90% of patients in all groups received at least one annual assessment of HbA1c and serum creatinine. Annual lipid profile assessment ranged from 81.5% in patients from the European Union to 71.7% in those from Central and South Africa. Blood pressure was recorded in more than 75% of patients in all subgroups. The lowest proportion of patients monitored for albuminuria was observed among those from Central/South Africa (59.5%). Ophthalmological examination was performed in fewer than 30% of patients in all groups, except for those from the European Union. Foot examination rates were low across all groups, ranging from 19.3% in patients from North America to 10.2% in those from East Asia (Table 2).

Achievement of targets for risk factors according to the country of origin

Mean HbA1c values were higher among patients from North Africa (7.7%) and Central and South Asia (8.0%) than among those from European countries (7.1%) (Supplementary Table 1). Table 3 reports the proportion of patients achieving the HbA1c target (< 7.0%) by geographic area of origin; the lowest proportions were observed among patients from North Africa and Central and Eastern Europe.

Table 3.

Quality of care intermediate outcomes indicators (data are percentages)

Intermediate outcome indicators	European Union	Central Eastern Europe	Other European Countries	North Africa	West Africa	East Africa	Central and South Africa	West Asia	Central and South Asia	East Asia	North America	Central and South America	Oceania
HbA1c ≤ 7.0%	55.8	44.1	55.6	42.1	48.8	52.7	54.0	50.1	34.5	50.3	46.6	52.5	58.1
HbA1c > 8.0%	16.8	27.5	20.0	31.0	29.3	20.1	18.5	20.6	38.8	24.1	24.7	23.8	19.7
BMI ≥ 30 Kg/m²	37.9	47.7	47.1	33.8	31.2	22.4	41.0	38.7	19.6	9.7	48.9	39.3	50.4
Blood pressure < 130/80 mmHg	23.5	22.5	20.2	28.7	23.3	25.7	20.5	29.1	31.9	30.7	20.0	28.6	23.9
Blood pressure ≥ 140/90 mmHg	46.6	45.5	46.3	38.9	45.1	40.5	44.3	39.4	34.8	35.5	49.3	39.1	39.1
LDL cholesterol < 70 mg/dl	35.7	24.7	28.0	22.0	17.0	25.5	19.7	33.6	23.5	27.0	29.9	23.4	24.2
LDL cholesterol ≥ 100 mg/dl	29.4	44.5	38.3	44.7	52.1	40.5	50.3	36.0	45.6	40.1	36.8	45.4	33.7
Normoalbuminuria	73.6	83.3	80.0	78.4	80.6	75.6	83.3	77.5	79.2	74.6	75.2	80.4	65.9
Microalbuminuria	18.9	12.5	13.4	16	14.4	17.1	12.5	18.2	15.5	17.6	15.7	14.3	22.4
Macroalbuminuria	7.5	4.2	6.7	5.5	5.0	7.3	4.2	4.3	5.3	7.9	9.1	5.2	11.7
eGFR < 60 ml/min/1.73 m²	31.0	14.9	15.5	15.0	14.5	25.8	22.3	17.7	8.7	16.6	22.6	14.5	12.5
KDIGO risk class
Low risk	54.0	72.6	69.0	68.5	70.2	57.9	67.5	64.8	73.5	65.2	60.0	70.3	60.2
Moderate risk	21.5	14.6	16.2	16.2	16.5	21.1	16.7	19.2	15.8	17.9	19.1	16.0	21.7
High risk	11.8	6.1	7.3	6.5	5.0	9.6	4.4	5.8	5.2	7.2	13.9	6.9	9.6
Very high risk	12.7	6.7	7.5	8.8	8.3	11.5	11.4	10.2	5.5	9.7	7.0	6.8	8.4

Mean body mass index exceeded 30 kg/m² in patients from Central and Eastern Europe, other European countries, and North America, whereas it ranged between 25 and 29 kg/m² among patients from Africa, Asia, and Central and South America (Supplementary Table 1). It should be noted, however, that BMI cut-offs for obesity vary by ethnicity and that a BMI > 25 kg/m² is already considered indicative of obesity in Asian populations [18].

Low-density lipoprotein cholesterol values above the target of 100 mg/dL were observed more frequently among patients of African origin (Table 3). Mean systolic blood pressure values exceeded target levels in almost all groups, except for patients from Central and South Asia and East Asia (128–129 mmHg) (Supplementary Table 1).

According to the KDIGO classification of renal risk [19], the highest proportion of individuals at high or very high risk was observed among patients from the European Union (24.5%), East Africa (21.1%), and North America (20.9%), whereas the lowest prevalence was recorded among patients from Central and South Asia (10.7%) and Central and Eastern Europe (Table 3).

T2D treatment according to the country of origin

With regard to glucose-lowering therapy (Supplementary Table 2), metformin was prescribed in all groups, with proportions ranging from 72.7% in patients from the European Union to 84.5% in those from Central/South Asia. Secretagogues (sulfonylureas or glinides), pioglitazone, and acarbose were prescribed to a small proportion of patients across all groups. Dipeptidyl peptidase-4 inhibitors were prescribed more frequently to patients from the European Union (21.0%), whereas the lowest prescription rate was observed among patients from Oceania (11.5%).

Overall, more than 30% of patients were treated with SGLT2 inhibitors, with the highest use observed among Asian populations (Western Asia 35.7% and Central/South Asia 33.6%), compared with patients of European origin (28.6%).

Basal insulin was more frequently prescribed to patients from North Africa (38.5%), West Africa (38.3%), and Central/South Asia (38.1%). Rapid-acting insulin was also more commonly prescribed in these groups, particularly among patients from North Africa (21.1%), West Africa (20.7%), and Central/South Africa (20.5%).

The intensity of cardiovascular risk management varied substantially across geographic areas of origin (Table 4). Overall, patients from Africa and from Central and South Asia were less intensively treated with respect to blood pressure and lipid management. Among patients with albuminuria, marked variability was observed in the use of ACE inhibitors or angiotensin receptor blockers, with lower treatment rates among patients from West Africa (62.4%) and Central/South Asia (59.5%). The proportion of patients with cardiovascular disease treated with antiplatelet agents exceeded 70% in all groups (Table 4).

Table 4.

Indicators of treatment intensity, expressed as percentages of patients, according to geographic area of origin

Indicators of treatment intensity/appropriateness	European Union	Central Eastern Europe	Other European Countries	North Africa	West Africa	East Africa	Central and South Africa	West Asia	Central and South Asia	East Asia	North America	Central and South America	Oceania
No insulin despite HbA1c ≥ 9.0%	30.2	33.6	40.8	28.2	24.5	26.2	31.8	36.4	28.9	34.6	40.0	34.5	38.5
No antihypertensive treatment despite BP ≥ 140/90 mmHg**	27.0	42.0	37.9	53.8	55.7	37.9	47.4	42.4	58.4	44.2	40.5	48.2	36.1
No lipid-lowering agents despite LDL-cholesterol ≥ 100 mg/dl***	43.1	43.9	51.9	53.0	57.9	50.0	54.1	42.8	54.7	49.3	52.8	50.0	46.9
No ACE-I and/or ARBs despite albuminuria£	37.7	47.6	36.2	55.7	62.4	46.8	40.0	41.7	59.5	47.4	33.3	53.0	55.2
HbA1c ≥ 9.0% in spite of insulin treatment	15.3	28.6	21.8	30.5	36.5	23.0	21.1	17.3	41.1	26.3	24.0	29.3	23.5
BP ≥ 130/80 mmHg in spite of antihypertensive treatment¤	23.6	21.4	17.6	24.2	16.7	23.2	15.3	27.3	27.4	27.4	23.2	24.3	21.4
LDL-cholesterol ≥ 100 mg/dl in spite of lipid lowering treatmentƚ	23.5	38.6	30.0	38.2	48.5	33.7	47.9	29.9	38.0	32.9	27.5	37.9	28.8
Antihypertensive treatment	71.7	54.5	57.9	39.4	36.0	52.8	48.3	54.3	33.5	47.0	63.1	45.7	60.7
Lipid-lowering treatment	69.0	60.6	60.2	50.7	39.7	57.2	45.4	63.8	50.6	58.4	58.8	56.2	56.6
Anti-platelets therapy in patients with CV disease	80.4	76.7	76.0	77.7	73.0	75.4	72.7	78.9	79.8	70.8	83.3	81.0	90.9

Indicators represent the percentage of patients who did not receive the specified treatment despite meeting guideline-based clinical criteria. Specifically: no insulin despite HbA1c ≥ 9.0% indicates patients with poor glycemic control not treated with insulin; no antihypertensive treatment despite BP ≥ 140/90 mmHg indicates untreated hypertension; no lipid-lowering agents despite LDL-cholesterol ≥ 100 mg/dl indicates untreated dyslipidemia; no ACE inhibitors and/or ARBs despite albuminuria indicates absence of renin–angiotensin system blockade in patients with albuminuria

*The denominator is represented by all patients with HbA1c ≥ 9%

**The denominator is represented by all patients with blood pressure ≥ 140/90 mmHg

***The denominator is represented by all patients with LDL-cholesterol ≥ 100 mg/dl

£The denominator is represented by all patients with albuminuria

¤The denominator is represented by all patients on antihypertensive treatment

ƚThe denominator is represented by all patients on lipid-lowering treatment

Prevalence of micro- and macrovascular complications according to geographic area of origin

The highest prevalence of retinopathy was observed among patients from East Asia (18.2%), who also showed poorer metabolic control. Cardiovascular disease was most prevalent among patients from the European Union (15.4%), followed by those from Western Asia (14.0%) and North America (12.8%), whereas the lowest prevalence was observed among patients from West Africa (3.3%). Regarding foot complications, the highest prevalence was reported among patients from North America (1.6%) and Western Asia (1.1%). In addition, the prevalence of patients requiring dialysis was higher among those from East Asia (0.8%), East Africa (0.6%), and West Africa (0.5%). Even for diabetes-related complications, genetic factors cannot be excluded (Supplementary Table 3).

Overall quality of care indicators

Mean Q score values were highest among patients from the European Union (29.1 ± 8.0). A satisfactory level of quality of care (Q score > 25) was observed in 51.6% of patients from Central and South Asia, 50.1% of those from West Africa, and 53.1% of those from Eastern Europe, compared with 62.8% of patients from the European Union (Table 5).

Table 5.

Overall quality of care: the Q score

Overall quality of care	European Union	Central Eastern Europe	Other European Countries	North Africa	West Africa	East Africa	Central and South Africa	West Asia	Central and South Asia	East Asia	North America	Central and South America	Oceania
Q score	29.1 ± 8.0	27.3 ± 8.7	28.5 ± 8.4	27.3 ± 8.8	26.4 ± 9.1	28.3 ± 8.2	27.8 ± 8.6	28.9 ± 8.4	26.8 ± 9.1	28.4 ± 8.7	27.7 ± 8.7	28.0 ± 8.5	28.7 ± 7.6
Q score < 15	2.9	5.3	3.9	5.7	7.7	3.9	4.9	4.3	7.2	4.9	4.9	4.7	1.7
Q score > 25	62.8	53.1	59.2	53.4	50.1	57.9	58.5	59.9	51.6	58.4	55.1	57.0	61.7

Discussion

The aim of this nationwide analysis based on data from the AMD Annals Initiative was to provide an updated evaluation of the quality of specialist care delivered to migrant patients with type 2 diabetes mellitus (T2D) attending diabetes centres in Italy. Our findings indicate that, despite substantial differences in demographic characteristics, age, and disease duration across different geographic areas of origin, overall access to diabetes services, use of glucose-lowering therapies, and global quality-of-care indicators were largely comparable between migrant and European patients.

As for the demographic distribution of migrant patients with T2D attending specialistic centres observed in our study, it is consistent with recent migration trends in Italy. Thus, migration patterns in Italy have evolved over time, with a reduction in work-related migration, stable rates of family reunification, and a marked increase in humanitarian migration, including refugees and asylum seekers. As a result, migrant populations in Italy are increasingly younger, heterogeneous, and geographically widespread [20].

Our results indicate that patients from Asian and African regions had access to diabetes services comparable to that of patients from the European Union, as reflected by a similar number of visits per year. This finding likely reflects the universal structure of the Italian healthcare system, which provides free access to care through a nationwide network of general practitioners and approximately 600 specialist diabetes centers. The present analysis includes updated data from nearly half of these facilities.

Our findings partly differ from those reported in a recent study by Marchesini et al. [21], which documented lower adherence to biomarker monitoring and follow-up visits among immigrants compared with Italian patients in the metropolitan area of Bologna. In contrast, our national data revealed no substantial differences in the management of T2D. This discrepancy may be explained by differences in the study populations: while the analysis by Marchesini et al. included the entire population with diabetes managed both in primary and secondary care within the National Health System in area of a town in Northen Italy, our current data specifically refer to migrant patients followed by specialist diabetes clinics, who are likely to be more engaged in disease management.

Migrant populations in our study were generally younger than European patients and exhibited a shorter duration of diabetes. However, when the marked age difference—often exceeding 10 years between Asian and European patients—is contrasted with the smaller gap in disease duration (approximately 3–5 years), an earlier onset of T2D can be inferred for several migrant groups. This observation is consistent with previous epidemiological evidence and suggests that, in the coming years, healthcare systems may face an increasing number of migrant patients with long-standing diabetes and a growing burden of cardiovascular risk [22].

Despite comparable access to care, relevant differences emerged in metabolic control. Patients from South Asia exhibited the poorest glycemic control, with mean HbA1c values around 8%. These findings are consistent with previous reports. In a retrospective analysis by Mukhopadhyay et al., South Asian patients with T2D showed a significantly greater deterioration in HbA1c over nearly five years of follow-up compared with European patients attending a diabetes clinic in Glasgow [23].

The higher degree of insulin resistance observed in South Asian populations may be attributable to multiple mechanisms, including increased triglyceride accumulation in skeletal muscle [24], greater central adiposity reflected by higher waist-to-hip ratios [25], increased systemic inflammation [26], and alterations in adipokine synthesis or secretion [27]. These mechanisms may contribute to the more rapid deterioration of insulin sensitivity observed in South Asian patients with diabetes, who may therefore particularly benefit from more potent insulin-sensitizing agents, such as PPARγ agonists. This interpretation is supported by our findings, which showed a higher use of pioglitazone among Asian patients compared with those from the European Union (5.9% vs. 3.8%).

Disparities in LDL-cholesterol management according to race and/or ethnicity have been reported in several large cohort studies. In a recent retrospective analysis using electronic medical record data from five healthcare systems participating in the Cardio Health Alliance, Black individuals with established atherosclerotic cardiovascular disease were more likely to have uncontrolled LDL-cholesterol levels and to fail to achieve guideline-recommended targets, highlighting the need for targeted implementation strategies [28]. Similarly, in a study conducted in a large private healthcare setting in South Africa, most patients with T2D showed poor achievement of LDL-cholesterol targets recommended by national guidelines, regardless of the presence of major depressive disorder [29].

Age-related differences may also influence the management of cardiovascular risk factors. In our study, migrant populations were generally younger than European patients but showed a relatively smaller difference in disease duration, again suggesting an earlier onset of T2D in several migrant groups [24, 26, 30]. This demographic profile may inadvertently lead to less aggressive treatment of dyslipidemia and hypertension, despite their established role in preventing long-term complications. Evidence from the UK Prospective Diabetes Study demonstrated that Indian Asian patients had lower baseline blood pressure levels and consequently received antihypertensive therapy less frequently than European patients; however, given their higher susceptibility to progressive diabetic nephropathy, these patients required more intensive blood pressure and glycemic control [31, 32].

As for treatments, metformin was widely prescribed across all groups, while sulfonylureas accounted for a relatively small proportion of treatments. Moreover, the use of glucose-lowering agents with established cardio-renal benefits was comparable to, or in some cases higher than, that observed among European patients. Approximately one-quarter to one-third of patients were treated with SGLT2 inhibitors, with the highest use observed among Asian populations. These findings are encouraging, as they suggest equitable access to newer and more costly glucose-lowering therapies among migrant patients, in contrast with previous nationwide registry-based cross-sectional studies [33].

It should be noted, however, that our analysis was restricted to patients actively followed by specialist diabetes clinics and does not include the entire population with diabetes. Nevertheless, the Bologna Survey reported similarly high use of innovative therapies among foreign patients [21]. Compared with earlier reports from the ARNO study [32], which documented undertreatment and preferential use of less costly therapies among migrants, our findings suggest that increasing attention has been paid over time to achieving equity in T2D care in Italy.

Overall, the quality of care, assessed using the Q score, was broadly comparable between migrant and European patients, despite some differences across geographic areas of origin. However, certain migrant populations, particularly those from West Africa, exhibited lower mean Q scores than patients from the European Union, whereas more than half of patients from Central and South Asia achieved a satisfactory level of care (Q score > 25). These findings indicate that, although access to specialist services is largely equitable, relevant gaps persist in the integrated management of cardiovascular risk factors, including lipid levels, blood pressure, and renal risk markers. Given the established association between lower Q scores and increased cardiovascular risk, targeted strategies are needed to strengthen comprehensive risk factor management in specific migrant populations.

Study limitation

This study has several limitations that should be acknowledged. First, its retrospective design based on routinely collected data limits the assessment of temporal trends and causal relationships. Second, information on socioeconomic status, educational level, language proficiency, and duration of residence in Italy was not available, although these factors may substantially influence health behaviours and treatment outcomes. Finally, ethnicity was inferred from country of origin, which may not fully capture the heterogeneity within migrant populations.

Conclusions

In this large nationwide analysis of patients with type 2 diabetes mellitus (T2D) attending Italian diabetes centres, we observed meaningful differences in age, sex distribution, disease duration, metabolic control, and treatment intensity across populations originating from different geographic areas. Despite these differences, access to specialist diabetes care, use of glucose-lowering therapies—including agents with proven cardiovascular and renal benefits—and overall quality of care were largely comparable between migrant and European patients.

Notably, migrant populations were younger and often exhibited an earlier onset of T2D, particularly among individuals from Asian regions, who also showed poorer glycaemic control and suboptimal management of cardiovascular risk factors such as dyslipidaemia and blood pressure. These findings suggest that, although equity in access to specialist diabetes care has largely been achieved, further efforts are needed to optimize the intensity and appropriateness of treatment for specific high-risk groups.

Research agenda

Our findings highlight several priorities for future research. Longitudinal studies are needed to evaluate long-term cardiovascular and microvascular outcomes among migrant populations with T2D and to determine whether observed differences in risk factor control translate into disparities in clinical endpoints. In addition, interventional studies should assess the effectiveness of culturally tailored strategies—such as multilingual educational materials, dietitian-led interventions, and community-based programs—in improving treatment adherence, metabolic control, and cardiovascular risk management.

Integrating social, cultural, and socioeconomic determinants into routine diabetes care and research frameworks may further help identify modifiable barriers and support the development of more personalized and equitable models of care. In this context, culturally sensitive approaches to diabetes management are essential. Previous studies conducted in Italy have documented disparities in cardiovascular risk and access to care among migrant populations [30, 34]. Moreover, lifestyle-tailored and culturally adapted interventions have been shown to improve metabolic control and adherence among South Asian populations living in high-income countries [35]. Ongoing Italian initiatives are also evaluating complex, co-created, culture-sensitive interventions aimed at improving lifestyle behaviors and treatment adherence among migrants with T2D [36].

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Material 1 ^{(460.2KB, pdf)}

Supplementary Material 2 ^{(23.6KB, docx)}

Supplementary Material 3 ^{(419.9KB, pdf)}

Author contributions

Margherita Occhipinti, Ivana Ragusa, Valeria Manicardi, Federica Bellone, Maria Calabrese, Laura Esposito, Elisa Manicardi: Conceptualisation, Investigation, Writing – original draft, Writing – review & editing.

Antonio Nicolucci, Alberto Rocca, Maria Chiara Rossi, Giuseppina Russo: Formal analysis, Methodology.

Antonio Ceriello, Riccardo Candido, Graziano di Cianni: Supervision, Project administration, Writing – review & editing. All authors have directly accessed and verified the underlying data reported in the manuscript. All authors have read and approved the final version of the manuscript.

Funding

Associazione Medici Diabetologi (AMD), Rome, Italy.

Data availability

The datasets generated during and/or analyzed during the current study are available from the Sponsor on reasonable request.

Declarations

Conflict of interest

None.

Ethics approval

The study protocol was approved by the local Ethics Committes of the participating centers.

Consent to participate

Informed consent was not applicable.