People with diabetes should receive medical care from a physician-coordinated team. these patients, American Diabetes Association (ADA) has suggested …
ASSESSMENT OF CARE FOR TYPE 2 DIABETIC PATIENTS AT THE PRIMARY CARE CLINICS
OF A REFERRAL HOSPITAL
Assim Alfadda, FRCPC, MSc, Khalid A Bin Abdulrahman, ABFM, MHScMEd
Department of Medical Biochemistry and Family Medicine, College of
Medicine, King Saud University, Riyadh, Saudi Arabia
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__
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Background: There is rapid increase in the incidence of Diabetes
Mellitus DM in the Kingdom of Saudi Arabia KSA, as in other
countries An optimal care of diabetic patients depends on the health
care providers as well as the type of health care setting Due to the
severity of chronic complications in Type 2 diabetic patients, it is
essential to assess both the practices of the providers and the patient
outcomes at any clinical setting
Objectives: To assess the screening patterns of diabetes associated
health care problems
in primary care clinics of King Khalid University
Hospital KKUH and while compare them to the current diabetes clinical
practice recommendations of American Diabetes Association ADA
____________________________________________________________________________
________
Correspondence to:
Dr Khalid B Abdulrahman, Associate Professor of Family Medicine, Vice
Dean, Postgraduate and CME, College of Medicine, King Saud University, PO
Box 2925, Riyadh 11461, Saudi Arabia - E-mail: khalidab@ksuedusa
Methods: The retrospective review of charts of 103 eligible patients who
attended the primary care clinics of KKUH over a 3 year-period 1/12001-
31/12/2003 had provided 99 type 2 diabetic patients The study variables
included demographic data, complications, treatment, the provider
screening practices measurements of HbA1c, BP, Lipid profile, number of
eye and foot examination From these data, the frequency of provider
screening tests, normalized by patient-year could be compared with the
ADA guidelines
Results: The mean age of 99 type 2 diabetic patients was 57 years, with
a mean BMI of 308 kg/m2 and with a mean duration of
diabetes of 118
years Many had comorbidites or complications: 25 had retinopathy, 172
had nephropathy, and 121 had neuropathy The HbA1c level of ? 70 was
maintained by only 247 of patients About 85 of patients had 1 lipid
profile, during their follow-up period During 2nd and 3rd year follow
up only 30 had 1 HbA1c measurement and 265 at 2nd year, 22at 3rd
year had 1 foot examination The proportion of patients, who had 1
eye examination was also reduced during their follow up The provider
practice screening results per patient-year was well below the specified
guidelines of ADA
Conclusion: Type 2 diabetic patients care at our primary care clinics
did not adhere to the guidelines of ADA The reasons for the deficiencies
were not evident from this study More detailed studies are needed to
find out the relevant causes for the lack of adequate diabetic care at
primary care clinics
Key Words: Diabetes, Primary health care, Saudi Arabia
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INTRODUCTION
Diabetes Mellitus DM is a group of metabolic diseases characterized
by
hyperglycemia resulting from defects in insulin secretion, insulin
action, or both The chronic hyperglycemia of diabetes is associated with
long-term damage, dysfunction, and failure of various organs, especially
the eyes, kidneys, nerves, heart and blood vessels Several pathogenic
processes are involved in the development of diabetes Long term
complications of diabetes include retinopathy with potential loss of
vision; nephropathy leading to renal failure; autonomic neuropathy causing
gastrointestinal, genitourinary and cardiovascular symptoms and sexual
dysfunction Patients with diabetes have an increased incidence of
atherosclerotic cardiovascular, peripheral arterial and cerebrovascular
disease The prevalence of diabetes varies throughout the world, but
increasing because of changes in lifestyle According to the estimates of
World Health Organization WHO, around 100 million people suffer from
diabetes1,2 The Kingdom of Saudi Arabia KSA, a country of over 16
million people, is a rapidly developing country During the past three
decades the potential surge in socioeconomic growth
has considerably
influenced the lifestyle of the people A recent community-based national
epidemiological health survey in KSA has found the overall prevalence of DM
as 2373 which is alarming for health care providers
People with diabetes should receive medical care from a
physician-coordinated team These teams may include physicians, nurse
practitioners, physicians assistants, nurses, dietitians, pharmacists, and
mental health professionals with the expertise and a special interest in
diabetes It is essential in this collaborative and integrated team
approach that individuals with diabetes assume an active role in their
care There is strong evidence to suggest that a close correlation exists
between good glucose control and improved clinical outcomes in hospitalized
diabetic patients and in the outpatient setting4-6 Also, the target levels
of good glucose could not be achieved in the diabetic outpatients who
attend both at private and government hospitals7 Patients cared for by
physicians in the diabetes clinic receive better quality of diabetes care
than patients cared for by physicians in the general
medical clinic8
However, another component of care is a community care A meta-analysis of
randomized controlled trials found that the unstructured care in the
community is associated with poorer follow up, worse glycaemic control, and
greater mortality than in hospital care9 In fact, most of the diabetic
patients are not optimally managed despite the availability and efficacy of
interventions for the control of glycemia, blood pressure, and
hyperlipidemia10,11 The gap between optimal and actual care constitutes a
wide quality chasm, and underscores the need for innovative approaches to
change the current practice of diabetes care There are barriers to
effective care in the medical system, physician, and patient levels12 All
three elements of medical care, viz, the medical system, the actions or
inactions of physicians and other providers, as well as the behavior of
patients and their families and communities, play a critical role in
achieving the overall goal of optimal diabetes control13 Treatment and
preventive care in persons with diabetes, particularly towards the care of
vascular complications of Type 2
diabetes which causes high morbidity,
hospitalization and mortality, is the cornerstone of management of these
patients To monitor these patients, American Diabetes Association ADA
has suggested the guidelines for classification, diagnosis and screening of
diabetes14 Even though the ADA guidelines for desired HbA1c values, lipid
and BP values, and screening procedures have been widely distributed, these
goals often are not met in the primary care setting where most diabetic
patients receive their diabetes care15,16 This study was carried out to
assess the screening patterns of diabetes associated health care problems
in primary care clinicsPCCs of King Khalid University Hospital KKUH
and compare them to current diabetes clinical practice recommendations of
ADA The specific objectives of this study were to quantify 1 the
provider practice measures for the care of both macro and microvascular
level complications of type 2 diabetic patients 2 the patient outcome
measures and 3 to compare these results with ADA guidelines
METHODS
A retrospective review of charts of the last three years from 1/1/2001 to
31/12/2003 was performed
in 2004, for all patients with Type 2 DM who
attended the outpatient clinics of KKUH, Riyadh, KSA The inclusion
criterion for this study was that the patient should have done HbA1c at
least once during the period from 1/1/2001 to 1/7/2001 and been followed
subsequently for at least one year at the PCC Patients who were
subsequently seen at the endocrine clinic and those without regular follow-
up at PCC were excluded for assessment Out of 407 patients, a sample 99
eligible patients constituted the study subjects This study was approved
by the ethical committee of KKUH Its outcome after reviewing each chart
was to assess the quality of management of diabetes in terms of controlling
blood glucose, blood pressure, serum lipids, and check for other
complications, and compare them to standards of medical care in diabetes
published by ADA The indicators assessed in this study were as follows:
percentage of patients with a blood pressure measurement recorded at each
visit, percentage of patients receiving 1 glycohemoglobin HbA1c
test/year, distribution of mean HbA1c values, assessment for nephropathy in
the
last year, at least one lipid profile in the last year, percentage of
patients receiving a dilated eye examination or retinal imaging at least
once per year, percentage of patients with foot examination per year The
HbA1c tests which were ordered by PCC physicians were only included in the
assessment
A 24-hour urine collection is the only method available for the
detection of microalbuminuria and quantification of proteinuria at this
institution
Statistical Analysis
The data were entered in MS Excel and analyzed using the SPSS version 120
statistical software Descriptive statistics mean, standard deviation,
proportions, and patient years, was used to summarize the outcome
variables And students t-test for independent samples with 95 confidence
intervals for difference of means, and a one-way analysis of variance was
used to compare the mean values of quantitative variables Age in years
was categorized into 2 groups 65 65 years , so as to facilitate the
comparison of two age strata non geriatric and geriatric
RESULTS
The study sample of 99 type 2 diabetic patients, and their characteristics
are given in Table 1 The total
number of patient-year follow-up of these
99 patients was 256 About 69 of these type 2 diabetic patients were using
Oral hypoglycemic agents OHA only, 5 were on diet only, 5 were on
insulin only and 21 were on OHA and Insulin
The distribution of macro and micro vascular complications of
these patients are shown in Table 2 Retinopathy and Nephropathy were in
higher proportion, followed by Neuropathy and Coronary artery disease The
distribution of the number of patients n93 for different levels of HbA1c
is shown in Figure 1 These 93 HbA1c values were the most recent or last
values of patients during
Table 1: Characteristics of Type 2 DM patients n99
| | |
|Variables |Mean SD |
| | |
|Age in years |566 120|
|range:17-87 | |
|Duration of diabetes | 118 |
|years n86 |77 |
|Weight kg |774 144|
|Height mts |16 02 |
|BMI kg/m2 | 308 |
| |58 |
|Male |53 554 |
| | |
Table 2: Distribution of MACRO
and MICRO vascular complications of Type 2
DM patients N74
| | |
|Complications |No |
| | |
|Coronary artery disease |11 111 |
|Vascular disease |3 30 |
|Stroke |4 40 |
|Amputation |2 20 |
|Retinopathy |25 253 |
|Neuropathy |12 121 |
|Nephropathy |17 172 |
| | |
Figure 1: Distribution of Hba1c values for Type 2 diabetic patients n93
the follow-up period Only 247 of the patients had HbA1c values less ?
70, while the remaining 753 had HbA1c values which were more than the
standard guideline value The mean standard deviation of HbA1c of these
patients was 897 22 There was a statistically significant difference
in the mean values of HbA1c of male 85 213 and female 95 02
patients [p 0027, 95 confidence intervals CIs: -192,-012] There
was no significant difference in the mean values of HbA1c of patients in
relation to their age groups 65 years: 89 22; 65 years: 91 24;
p080; 95 CIs: -124, 096 The mean values of HbA1c were
not
statistically different across the three levels of duration of diabetes
5years:8622; 5-10years:8221; 10 years:9422; F008 p 01
The proportion of patients receiving the provider practice measures for
HbA1c, BP, Lipid profile, detailed eye examination and detailed foot
examination in each of three-year period and at all three years of follow-
up is shown in Table 3 The total number of patient-year ie, 256 was
arrived by quantifying the number of patients seen 2 times during each
year of the 3-year follow-up period The number of each of the screening
tests carried out on the patients, in terms of per patient-year and its
relative values to the total number of patient-year was calculated These
values were then compared with current clinical practice guidelines Table
4 From these two tables 3 4 it can be observed that the proportion of
patients receiving the provider practice measures towards eye and foot
examination was lower and the number of screening procedures for these
patients were well below the ADA recommended clinical practice guidelines
For example, the screening for diabetic nephropathy, and a detailed
foot
examination done per patient-year were less than half 011 009 per
patient year of the one per year recommended by the ADA
DISCUSSION
The retrospective study of records of Type 2 diabetic patients has brought
out the provider screening practices in primary care clinics at KKUH, where
most of the patients studied did not meet the current clinical practice
guidelines as recommended by ADA About 687 of our patients were on OHA
and 212 were on OHA and insulin, which shows that complex treatment
regimens were essential In spite of the high prevalence of micro vascular
level complications in our cohort, only about 25 of study subjects did
achieve the recommended glycemic control These findings agree with
previous studies based mostly on patients in primary care settings which
have often shown poor glycemic control Martin et al15 studied 378
ethnically different patients with Type 2 diabetes in 1992-1993 and found
that mean HbA1c values ranged from 86 in whites to 94 in blacks and
98 in Hispanics In 1994, Weatherspoon et al 17 reported that nearly
40 of patients with type 2 diabetes had HbA1c values of 8 In
contrasts
to these findings, Christopher DMiller and Sandy DRossman,18 who studied
the Type 2 diabetic patients at an Endocrinologist practice reported only
13 of their patients had HbA1c levels 8 They attributed the glycemic
control to the use of complex therapeutic regimens by their patients
Hellman et al19 achieved a median HbA1c level of 73 in patients who had
received long-term care
Table 3: Number of patients receiving provider process parameters during
their three-year follow-up period
| | | | | |
|Provider parameters |No of patients during follow-up period |
| |1st year |2nd year |3rd year |All 3 |
| |n97 |n98 |n90 |years |
| | | | |n99 |
| | | | | |
|BP measurement at each visit |40 412 |51 520 |50 556 |12 121 |
| 1 HbA1c |89 917 |29 296 |28 311 |7 71 |
| 1 Lipid profile |83 856 |79 806 |77 856 |58 586 |
| 1 Detailed eye examination |78 804 |67 684 |65
722 |56 566 |
| 1 Well documented foot |33 340 |26 265 |20 222 |10 101 |
|examination | | | | |
|Assessment for nephropathy |11 113 |1 1 |15 167 |0 0 |
Table 4: Comparison of number of times screening tests of Type 2 DM
patients done by primary care physicians per patient-year with current
diabetes clinical practice guidelines
| | | | |
|Variables |No |Per patient-year |Current clinical |
| | | |practice |
| | | |guidelines per |
| | | |year |
| | | | |
|Patient - year |256 | |- |
| | |10 | |
|HbA1c |174 |068 | 2 times |
|Retinopathy |192 |075 |1 time |
|Foot exam
| 77 |030 | 4 times |
|Detailed foot exam |24 |009 |1 time |
|Lipid profile |222 |087 |1 time |
|Blood pressure |250 |098 | 4 times |
|Nephropathy | 27 |011 |1 time |
| | | | |
means visual inspection of patients feet
includes the assessment of protective sensation, foot structure, vascular
status, and skin integrity
in their specialty practice Hence the care of Type 2 diabetes patients is
better at the specialized clinics than at the primary care clinics in
relation to the control of HbA1c values
Along with the metabolic outcomes, screening process measures
for micro vascular complications are also important for treating Type 2
diabetic patients Our data reveals that a low proportion of patients
received provider process parameters each year for all three years Table
3 These findings are close to those of two studies of Medicare patients,
40-46 of whom had ophthalmologic
examinations, and 55-56 of whom had
lipid measurements during a one-year period16,21 Martin et al found that
53-66 of patients had annual opthamological examinations, 52-62 had at
least one total cholesterol and one HDL cholesterol measurement during a
two-year period, and 56-63 had at least two urine dipstick tests during a
two- year period15 Another study reported that 48 of 353 patients with
diabetes had urine protein screenings, but 94 had no documented foot
examinations during a one-year period22 Reported studies of the care of
Type 2 diabetic patients15,16,21,22 were at non-specialty clinics which are
similar to our primary care setting However, some studies have reported
that specialists may be able to meet ADA guidelines for both macro and
micro vascular level complications, better than primary care practice
physicians Ho et al8 showed that process measures are addressed better by
specialists The reason behind the difference in addressing the issues of
care, between the primary care setting and a specialty clinic may be due to
the type of treating physician and the attitude of coordinate team A
questionnaire
survey of primary care physicians to assess their attitudes
and behavior toward keeping tight control of blood glucose in patients with
type 1 diabetes found that HbA1c testing was severely underused20
Attention should be focused on the attitudes and practice behavior of
primary care physicians in their provision of care to diabetic patients
Jacques et al noted that a physician-reported rate of obtaining HbA1c
levels as 18 per year for patients with type 1 diabetes and 14 per year
for patients with Type 2 diabetes23 Our results shows low per patient-year
figures for all screening variables Table 4, which clearly demonstrates a
deficiency in the screening of the development of diabetes related micro
and macro vascular complications From the available data, it is difficult
to address reasons for the existence of this deficiency It may be the
result of a lack of awareness and /or education of primary care physicians
of the standards of medical care in diabetic care as given in the ADA
guidelines Secondly, it could be the result of the lack of patients
adherence to medical advice during their follow-up
In
conclusion, the results of this study indicate that suitable
measures must be introduced in order to improve and provide adequate care
of our diabetic patients This could be done through i better physician
education about standards of care, ii acquisition of patients full
support for regular visits, and iii the maintenance of consistent quality
care from the other staff members of primary care setting, by continuous
monitoring
ACKNOWLEDGMENT
The authors would like to thank Dr Shaik Shaffi Ahmed for his kind
statistical assistance This work was supported in part by College of
Medicine Research Centre, King Saud University, Riyadh, Saudi Arabia
Grant: 04-480
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