European Perioperative Diabetes Care: Significant Practice Variation Impacts 30-Day Recovery Outcomes

Highlights

• The MOPED study identified significant variation in perioperative diabetes management and 30-day outcomes across 21 European countries.
• Preoperative glycemic control is a key predictor of recovery, with HbA1c levels >69 mmol/mol associated with a significant reduction in Days at Home at 30 Days (DAH-30).
• Patients with Type 1 Diabetes (T1DM) were more likely to present with elevated HbA1c levels compared to those with Type 2 Diabetes (T2DM).
• The association between glycemic control and outcomes was particularly pronounced in patients undergoing surgeries with minimal blood loss.

Background: The Growing Challenge of Diabetes in Surgery

Diabetes mellitus (DM) has become an increasingly prevalent comorbidity among patients presenting for elective and emergency surgery. As global rates of obesity and metabolic syndrome rise, the surgical population reflects this shift, presenting clinicians with complex challenges in glycemic regulation and risk mitigation. The perioperative period is characterized by a significant stress response, involving the release of catabolic hormones such as cortisol and catecholamines, which induce insulin resistance and hyperglycemia even in patients without a history of diabetes.

For those with established DM, the risks are amplified. Poorly controlled perioperative blood glucose is traditionally linked to increased rates of surgical site infections, delayed wound healing, cardiovascular events, and prolonged hospital stays. Despite the clinical importance of this issue, current guidelines on perioperative diabetes management are largely based on expert consensus rather than high-level evidence from randomized controlled trials. This lack of robust data has led to substantial variability in clinical practice between institutions and across national borders. The Management and Outcomes of Perioperative Care of People with Diabetes across Europe (MOPED) study was designed to address this knowledge gap by documenting real-world management strategies and patient outcomes on a continental scale.

Study Design and Methodology

The MOPED study was a prospective, observational multicenter investigation involving 89 hospitals across 21 European countries. The participating centers ranged from small district general hospitals to large tertiary referral centers, providing a broad representation of European healthcare infrastructure.

Between January 2021 and February 2024, the study enrolled 6,126 adults with confirmed DM (excluding gestational diabetes) undergoing any type of surgery requiring anesthesia. Data collection was led by anesthesiology clinicians at self-selected sites. The primary endpoint was Days at Home at 30 Days (DAH-30), a validated, patient-centered outcome measure that integrates mortality, length of stay, and readmission rates. Secondary outcomes included descriptive analyses of perioperative management protocols, the incidence of dysglycemia (hypoglycemia and hyperglycemia), and the frequency of postoperative complications. The study achieved an impressive 97% completion rate for the 30-day follow-up, ensuring the reliability of the longitudinal data.

Key Findings: Glycemic Control and Practice Variation

Significant Variation in Outcomes

The study’s most striking finding was the wide variance in outcomes across different European regions. The median DAH-30 was 26 days, but the range across countries was significant (23 to 30 days; P = 0.0001). This variation suggests that the quality of perioperative care and the efficiency of recovery pathways for diabetic patients are highly dependent on local or national healthcare contexts rather than a unified European standard.

The Impact of Preoperative HbA1c

Preoperative glycemic control, measured by HbA1c, emerged as a critical determinant of recovery. The researchers observed a clear association between lower HbA1c levels (69 mmol/mol) had a median DAH-30 of only 25 days (difference 2.0 days; 95% CI 1.3-2.7; P < 0.0001). Interestingly, in multivariable analysis, this association remained significant primarily for patients who experienced minimal blood loss, suggesting that in major surgeries involving high physiological stress and significant blood loss, other factors may overshadow the impact of baseline glycemic control.

T1DM vs. T2DM Disparities

There were notable differences between diabetes phenotypes. A higher proportion of patients with T1DM presented with poorly controlled blood glucose (HbA1c >69 mmol/mol) compared to those with T2DM (18% vs. 7%; difference 11%, 95% CI 6-17; P = 0.002). This highlights a specific vulnerability in the T1DM population, who may require more intensive preoperative optimization and specialized perioperative management strategies.

Perioperative Dysglycemia

The study also documented high rates of perioperative dysglycemia. While specific protocols for glucose monitoring and insulin administration varied, the lack of uniformity contributed to inconsistent management of both hyper- and hypoglycemia. The findings emphasize that the current “expert opinion” based approach results in a fragmented landscape of care.

Expert Commentary: The Need for Harmonization

The results of the MOPED study serve as a wake-up call for the European perioperative community. The significant variance in DAH-30 indicates that a patient’s geographic location may be a major determinant of their surgical recovery trajectory. From a clinical perspective, the data reinforce the importance of preoperative HbA1c as a screening tool to identify high-risk patients who may benefit from delayed surgery and metabolic optimization.

However, the study also highlights the complexity of the “optimal” glucose target. While higher HbA1c is clearly detrimental, the multivariable analysis suggests that surgical factors—such as blood loss and the magnitude of the procedure—are powerful modifiers of the relationship between glycemic control and outcome. This suggests that a “one size fits all” approach to glucose targets may be inappropriate. Instead, management should be stratified based on both patient-specific metabolic health and the specific surgical insult.

One limitation of the study is its observational nature; while it reveals associations, it cannot definitively prove that specific management changes would improve DAH-30. Furthermore, the self-selection of centers may introduce a degree of reporting bias, potentially representing hospitals with a greater interest in diabetes care than the true European average. Nevertheless, the sheer scale and prospective design of MOPED provide the most comprehensive snapshot of perioperative diabetes care to date.

Conclusion

The MOPED study demonstrates that perioperative diabetes management in Europe is characterized by significant heterogeneity and varying patient outcomes. The correlation between preoperative HbA1c and the primary outcome of Days at Home at 30 Days provides a clear signal that better metabolic optimization is needed. To improve the quality and safety of surgical care for people with diabetes, there is an urgent need to move beyond expert opinion and develop evidence-based, harmonized international guidelines. Future research should focus on interventional trials that test specific glycemic management protocols across diverse surgical settings to determine the most effective strategies for reducing the burden of postoperative complications.

Funding and Clinical Trial Information

The European Society of Anaesthesiology and Intensive Care (ESA-IC) provided administrative funding for the study. Additional data collection support in Ireland and the UK was provided by the College of Anaesthesiologists of Ireland (CAI) and the British Journal of Anaesthesia (BJA).

References

1. Buggy DJ, Columb MO, Hermanides J, et al. Management and Outcomes of Perioperative Care of People with Diabetes across Europe (MOPED): a prospective, observational study. Lancet Reg Health Eur. 2025;61:101535. doi:10.1016/j.lanepe.2025.101535.
2. Levy N, Dhatariya K. Perioperative management of the patient with diabetes for elective surgery. Br J Anaesth. 2019;123(1):e9-e12.
3. Myles PS, Bellomo R, Corcoran T, et al. Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery. N Engl J Med. 2018;378(24):2263-2274. (Contextual reference for DAH-30 methodology).