March 2009.indd SQU MED J, APRIL 2009, VOL. 9, ISS. 1, PP. 32-36, EPUB 16TH MAR 2009 SUBMITTED - 28TH JULY 08 REVISION REQ. 21ST AUG 08, REVISION RECD. 26TH AUG 08 ACCEPTED - 28TH AUG 08 Quality of Diabetes Care: A cross-sectional observational study in Oman *Ahmed Al-Mandhari,1 Ibrahim Al-Zakwani,2 Omayma El-Shafie,3 Mohammed Al-Shafaee,4 Nicholas Woodhouse5 عمان في وصفية مقطعية دراسة : السكر لداء الرعاية جودة وودهاوس نيكوالس الشافعي، محمد الشفيع، أميمه الزكواني، ابراهيم املندري، أحمد عدد نصف اختيار فيها مت مقطعية ــة دراس الطريقة: هذه عمان. في ــكر الس داء املقدمة ملرضى الرعاية الصحية جودة ــة: الهــدف: تقييم اخلالص لتبيان ــتخدم اإلحصاء الوصفي اس . منهجية 2005 بصورة عام من ــو يوني ــهر ش خالل األولية الصحية للرعاية ــتة مراكز س راجعوا الذين ــى املرض عمر متوسط كان . (-61% 263 امرأة (منهم 430 مريضا الدراسة هذه شملتهم الذين السكر بداء املصابني املرضى عدد بلغ املعطيات. النتائج: 169) 39% مقابل الدم ، لسكر الفحص العشوائي مت (171 مريضا) 40% فقط في . 84 سنة 6 إلى املدى بني كان بينما 12 ± 52 سنة العينة أو عشوائيا ذلك سواء كان الدم السكر في فحص على حصلوا (339 مريضا) 79% أن يعني .وهذا عندهم على الريق فحص سكر الدم مت مريضا) ثافة بينما الكَ فيضُ خَ يُّ مِ حْ الشَّ والبروتنيُ السكري الهيموغلوبني مت فحص ( (317 مريضا كما يلي: 74% فكانت األخرى الفحوص أما . الريق على وشــملت: (249 مريضا) العينة %58 من في كاملة الفحوص كانت . (409 مريضا) %95 منهم في ــاطي االنقباضي واالنبس الدم ضغط قياس مت ثافَة الكَ عُ رْتَفِ مُ يُّ مِ حْ الشَّ البروتنيُ و ثافة فيضُ الكَ يُّ خَ مِ ــحْ الشَّ والبروتنيُ الكلي ــتيرول والكوليس الدم ضغط وقياس ــكري الس الهيموغلوبني فحص (7%>) ــكري الهيموغلوبني الس مقياس من الطبيعية احلدود ضمن نتائج 249 مريضا) ــوع (6 من مجم 2.4% فقط لدى كان . ــة الثالثي ــون والده ثافَة الكَ عُ رْتَفِ مُ يُّ مِ ــحْ الشَّ البروتنيُ و (>3.5مم/ل) ثافة الكَ ــضُ في خَ يُّ مِ ــحْ و البروتنيُ الشَّ (>5.2مم/ل) ــترول و الكوليس (80/130=<) الدم ــط وضغ ذلك من الرغم على اجلودة. لتقييم املستخدمة املؤشرات جيدا لقيم تدوينا كان هناك اخلالصة: (>1.8مم/ل). الدهون الثالثية و (<-1.1>1.68مم/ل) جدا. منخفضة عامليا الطبيعية املعروفة احلدود في يقعون الذين املرضى %2.4 من تعتبر نسبة . عمان ، املؤشرات ، السكر داء الكلمات: اجلودة ، مفتاح 1Department of Family Medicine & Public Health, Sultan Qaboos University Hospital, Muscat, Oman; 2Department of Pharmacy, Sultan Qaboos University Hospital, Muscat, Oman; 3Department of Medicine, Sultan Qaboos University Hospital; 4Department of Family Medicine & Public Health, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman; 5Department of Medicine, College of Medicine & Health Sciences, Sultan Qaboos University, Muscat, Oman; *To whom correspondence should be addressed. Email: manar96@yahoo.com ABSTRACT Objectives: The objective of this study was to evaluate the quality of diabetes care in Oman. Methods: This was a cross- sectional observational study. Fifty percent of all those attending six general health centres in June 2005 were systematically selected for the study. Descriptive statistics were used to describe the data. Results: A total of 430 diabetic subjects were included. Just over 6% percent of the subjects were female (n = 263). The overall mean age of the cohort was 52 ± 2 years ranging from 6 to 84 years. Only 40% (n = 7) and 39% (n = 69) of the diabetics had their random blood sugar (RBS) and fasting blood sugar (FBS) documented, respectively. However, 79% (n = 339) had either RBS or FBS done according to the records. Documentation for the other measure- ments ranged from 74% (n = 37) for HbAc and LDL (low density lipoproteins)-cholesterol to 95% (n = 409) for systolic and diastolic blood pressure (SBP/DBP) readings. A total of 58% (n = 249) of patients had non-missing values of HbAc, SBP/DBP, total cholesterol, LDL-cholesterol, HDL (high density lipoproteins)-cholesterol, and triglycerides. Only 2.4% (6 out of 249 diabetics) were simulta- neously within goal for HbAc (<7%), SBP/DBP (<=30/80mmHg), total cholesterol (<5.2mmol/L), LDL-cholesterol (<3.3mmol/L), HDL-cholesterol (>. - <.68mmol/L), and triglycerides (<.8mmol/L). Conclusion: There was good documentation of values for the indicators used in the assessment of quality. However, the proportion (2.4%) of those meeting internationally recognised goals for the three diabetes-related factors was extremely low. Key Words: Quality; Diabetes; Indicators; Oman. C L I N I C A L A N D B A S I C R E S E A R C H Q UA L I T Y O F D I A B E T E S C A R E : A C R O S S - S E C T I O N A L O B S E R VAT I O N A L S T U D Y I N O M A N 33 DIABETES MELLITUS IS A MAJOR HEALTH problem that is associated with significantmorbidity and mortality. The estimated number of diabetics world wide is greater than 240 million, with 1 of them dying every 10 seconds. The number of affected individuals is increasing rapidly from 94 million in 2003 to 246 million in 2007 rep- resenting 6.0% of the adult population. In 2025, the projected prevalence is estimated to be 308 million.1 These startling figures are due mainly to a massive in- crease in the worldwide prevalence of obesity. In the USA, 75% of adults will be overweight and 41% obese by 2025 if its citizens continue to gain weight at the current rate.2 Diabetes also imposes a huge cost bur- den on the patients, families and health care systems. In 2007, the cost of diabetes mellitus (DM) in the USA alone was estimated to be 232 billion USD.1 These problems are also reflected in the Middle East where the prevalence of obesity is also increasing along with that of diabetes mellitus 2 (DM2), which in 2007 varied between 3.4% in the Yemen to 19.5% in the UAE in patients between 20-79 years of age. In Oman, the 2007 figure was 14% and is expected, as in other countries, to increase sharply in the next 25 years.1 Given the high prevalence rates of diabetes and the di- rect link between its poor control and significant mor- bidities such as blindness, myocardial infarction and renal failure, it is essential to assure delivery of high quality care. Ultimately, this would help in reducing the cost of managing such complications and improve the quality of life of diabetic patients. Furthermore, primary health care centres play a major role in the management of chronic illnesses. Therefore, assess- ing the quality of care provided by these centres is es- sential for improving such care. The aim of this study was to assess the quality of diabetic care in the primary health care centres in Oman. M E T H O D S Out of 26 primary health care centres in Muscat, six centres were specifically selected for the study based on their distance from the University Hospital. These centres were representative of the Muscat region in terms of population covered and type of services provided.3 The target population was 860 patients who visited the six centres during the month of June 2005. Every second patient attending the clinics was selected for the study. This produced data on 50% of the total number of patients from each centre. A checklist of indicators was developed based on the Omani Ministry of Health guidelines for the man- agement of diabetes mellitus in primary health care centers.4 The variables assessed included recorded HbA1c, triglycerides, total cholesterol, low density li- poproteins-cholesterol (LDL), high density lipopro- teins-cholesterol (HDL), systolic and diastolic blood Advances in Knowledge • This is the first study to highlight the quality of diabetes care in a regions where diabetes is becoming an important factor in regional health problems. Applications to Patient Care Given the background of a less than desirable quality of care in Oman, more vigilance is required to improve the care of diabetes in Oman. The following are recommended: - Self-management support to patients. - Maintenance of disease registries. - Monitoring compliance at the point of care with active follow-up to ensure the best outcome. General practitioners should be aggressive in controlling risk factors associated with diabetes • The nurse’s role in diabetes care should be enhanced. • Evidence-based guidelines should be integrated into care, and supported by provider education, links with specialty expertise, and reminder systems. • Interventions should focus on patient education, training of primary care physicians and other patient care providers in behavioural change and redesign of local systems of delivering care. • The Chronic Care Model (CCM) provides a blueprint for changing office systems to improve chronic pa- tient care. A H M E D A L - M A N D H A R I , I B R A H I M A L - Z A K WA N I , O M AY M A E L -S H A F I E , M O H A M M E D A L -S H A FA E E A N D N I C H O L A S WO O D H O U S E 34 Table 1: Demographic, diabetic, blood pressure and lipid profiles of the study cohort stratified by gender (n = 430) Characteristic Number (%) of documentation in file All Male Female p-value Gender, n (%) 430 (100%) 430 (100%) 167 (39%) 263 (61%) Age, mean ± SD, years 430 (100%) 52 ± 12 53 ± 12 51 ± 11 0.120 Random Blood Sugar (RBS),mmol/L 171 (40%) Mean ± SD 11.4 ± 4.2 11.0 ± 3.5 11.8 ± 4.7 0.186 Patients at goal, 4.4-< = 10, n (%) 72 (42%) 33 (44%) 39 (41%) 0.657 Fasting Blood Sugar (FBS),mmol/L 169 (39%) Mean ± SD 9.3 ± 3.1 8.9 ± 3.5 9.5 ± 2.9 0.184 Patients at goal, 4.4-< = 7, n (%) 40 (24%) 20 (34%) 20 (18%) 0.022 Presence of either RBS or FBS value, n (%) 339 (79%) 339 (79%) 134 (80%) 285 (78%) 0.571 HbA1c, % 317 (74%) Mean ± SD 8.7 ± 2.4 8.8 ± 2.4 8.7 ± 2.3 0.264 HbA1c, %, <8.0% 146 (46%) 59 (48%) 87 (45%) 0.515 HbA1c, %, <7.0% 77 (24%) 35 (29%) 42 (22%) 0.149 HbA1c, %, <6.5% 45 (14%) 23 (19%) 22 (11%) 0.060 HbA1c, %, <5.7% 13 (4%) 9 (7%) 4 (2%) 0.020 Systolic Blood Pressure (SBP), mmHg 409 (95%) Mean±SD 133 ± 17 133 ± 17 133 ± 17 0.945 Patients at goal, < = 135, n (%) 236 (58%) 92 (58%) 144 (57%) 0.947 Patients at goal, < = 130, n (%) 235 (57%) 91 (57%) 144 (58%) 0.849 Patients at goal, < = 125, n (%) 138 (34%) 51 (32%) 87 (35%) 0.522 Patients at goal, < = 120, n (%) 138 (34%) 51 (32%) 87 (35%) 0.522 Diastolic Blood Pressure (DBP), mmHg 410 (95%) Mean±SD 82 ± 9 82 ± 9 82 ± 9 0.704 Patients at goal, < = 80, n (%) 273 (67%) 110 (69%) 163 (65%) 0.457 Patients at goal, n (%) SBP/DBP, mmHg, < = 135/< = 80 409 (95%) 199 (49%) 77 (48%) 122 (49%) 0.863 SBP/DBP, mmHg, < = 130/< = 80 409 (95%) 198 (48%) 76 (48%) 122 (49%) 0.768 SBP/DBP, mmHg, < = 125/< = 80 409 (95%) 131 (32%) 48 (30%) 83 (33%) 0.481 SBP/DBP, mmHg, < = 120/< = 80 409 (95%) 131 (32%) 48 (30%) 83 (33%) 0.481 Total Cholesterol,mmol/L 386 (90%) Mean ± SD 5.41 ± 1.16 5.47 ± 1.38 5.37 ± 1.01 0.412 Patients at goal, <6.5, n (%) 326 (84%) 125 (84%) 201 (85%) 0.809 Patients at goal, <5.2, n (%) 153 (40%) 58 (39%) 95 (40%) 0.821 LDL-Cholesterol,mmol/L 317 (74%) Mean ± SD 3.56 ± 0.95 3.55 ± 1.01 3.57 ± 0.92 0.860 Patients at goal, <4.13, n (%) 233 (74%) 85 (71%) 148 (75%) 0.401 Patients at goal, <3.3, n (%) 119 (38%) 44 (37%) 75 (38%) 0.802 Patients at goal, <2.59, n (%) 46 (15%) 21 (17%) 25 (13%) 0.238 HDL-Cholesterol,mmol/L 324 (75%) Mean ± SD 1.12 ± 0.68 1.05 ± 0.46 1.16 ± 0.78 0.136 Patients at goal, >0.9 - <1.2, n (%) 132 (41%) 50 (40%) 82 (41%) 0.830 Patients at goal, >1.1 - <1.68, n (%) 105 (32%) 31 (25%) 74 (37%) 0.020 Triglycerides,mmol/L 346 (80%) Mean ± SD 1.68 ± 1.40 1.76 ± 1.35 1.60 ± 1.43 0.309 Patients at goal, <4.44, n (%) 333 (96%) 129 (94%) 204 (98%) 0.099 Patients at goal, <1.80, n (%) 234 (68%) 89 (65%) 145 (69%) 0.391 Total no. of non-missing values of HbA1c, SBP/DBP, Total cholesterol, LDL-cholesterol, HDL-cholesterol, and Triglycerides 249 (58%) 6 (2.4%) *** SD = Standard deviation; ***Only 6 (out of 249 diabetic patients = 2.4%) were within goal of HbA1c (<7.0%), SBP/DBP (< = 130/< = 80 mmHg), total cholesterol (<5.2mmol/L), LDL-cholesterol (<3.3mmol/L), HDL-cholesterol (>1.1 to <1.68mmol/L), and triglycerides (<1.8mmol/L). Q UA L I T Y O F D I A B E T E S C A R E : A C R O S S - S E C T I O N A L O B S E R VAT I O N A L S T U D Y I N O M A N 35 pressure as well as fasting and/or random blood sugar measurement during the most recent visit. This retro- spective research was done by third and fourth year medical students. In order to secure quality data col- lection, the students were supervised by the first au- thor after a three day training course on how to extract data from patient records. Descriptive statistics were used for the data. For categorical variables, frequencies and percentages were reported. Differences between groups were ana- lysed using Pearson’s χ2 tests (or Fisher’s exact test for cells less than 5). For continuous variables, means and standard deviations (±SD) were presented and analy- ses were conducted using the Student’s t-test. An a priori two-tailed level of significance was set at 0.05. R E S U L T S A total of 430 diabetic subjects were included in the study from six health centres in various sections of the capital city, Muscat. The demographic, diabetic, blood pressure and lipid profiles of the study cohort, strati- fied by gender, are shown in Table 1. Just over 61% per- cent of the subjects were females (n = 263). The overall mean age of the cohort was 52 ± 12 years ranging from 6 to 84 years. Only 40% (n = 171) and 39% (n = 169) of the diabetics had their random blood sugar (RBS) and fasting blood sugar (FBS) documented, respectively. However, 79% (n = 339) had either RBS or FBS done according to the records. Documentation for the other measurements ranged from 74% (n = 317) for HbA1c and LDL-cholesterol to 95% (n = 409) for blood pres- sure readings. A total of 58% (n = 249) of the patients had non- missing values of HbA1c, SBP/DBP, total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglycerides. Overall, there were only 2.4% (6 out of 249 diabetic pa- tients) that were simultaneously within goal for HbA1c (<7%), systolic and diastolic blood pressure (SBP/DBP) (< = 130/80mmHg), total cholesterol (<5.2mmol/L), LDL-cholesterol (<3.3mmol/L), HDL-cholesterol (>1.1 - <1.68mmol/L), and triglycerides (<1.8mmol/L). D I S C U S S I O N More than 70% of the patients had their blood pressure, fasting or random blood sugar and HbA1C levels meas- ured regularly; however, the proportion of those meet- ing the expected goals of risk factor control was much lower. More disappointing was the very low number of those (6 out of 249 = 2.4 %) who achieved internation- ally recognised goals for all 6 diabetes related factors, namely a HbA1C <7.0%, BP ≤130/80, total cholesterol <5.2mmol/L, LDL <3.3mmol/L, HDL-cholesterol >1.1 - <1.68mmol/L and triglycerides <1.8mmol/L. 5-11 Our disappointment is, however, tempered by a recent report form the USA concerning 36 academic, university, non-general practice clinics who reported a success rate of only 10% in achieving these goals.12 The challenge for diabetes care is that treatment of this complex disease requires multiple key processes and resources involving both provider and patient.13 In- terventions should focus on patient education, train- ing of primary care physicians and other patient care providers in behavioural change and redesign of local systems of delivering care. The Chronic Care Model (CCM) provides a blueprinting for changing office sys- tems to improve chronic care.14 In a study that exam- ined the effect of the Chronic Care Model in a small independent practice, often without major structural change in the practice, Nutting et al. showed an as- sociation with higher levels of process measures and intermediate outcomes for diabetes care.15 C O N C L U S I O N In conclusion, poor control of high blood sugar lev- els is linked with micro- and macrovascular compli- cations such as blindness, renal failure, myocardial infarction and cerebrovascular accidents. Ultimately, these have direct impact on the economic state of pa- tients and families as well as being a burden on health care systems. Therefore, given the high prevalence of diabetes and its complications with the increasing cost of health care services, assuring high quality care to diabetic patients becomes imperative. This should be achieved through offering self-management support to patients, maintaining disease registries, and monitor- ing compliance at the point of care with active follow- up to ensure the best outcome. Moreover, the role of nurses in diabetes care should be enhanced. Evidence- based guidelines should be integrated into care, and supported by provider education, links with specialty expertise, and reminder systems. Furthermore, larger scale studies to assess the quality of diabetes care at the primary, secondary and tertiary health care insti- tution levels are recommended. This would help in identifying opportunities for improvements thus re- ducing the social and economic burden of the disease on the society. A H M E D A L - M A N D H A R I , I B R A H I M A L - Z A K WA N I , O M AY M A E L -S H A F I E , M O H A M M E D A L -S H A FA E E A N D N I C H O L A S WO O D H O U S E 36 A C K N OW L E D GE M E N T S The authors would like to thank the staff at all the health centres who participated in the study as well as Ibtisam Al-Shaili, Amal Al-Nabhani, Khalsa Al-Khan- bashi, Iman Al-Lawati, third year medical students at Sultan Qaboos University, who were involved in the data collection. C O N FL I C T O F I N T E R E ST : None S O U R C E O F F U N D I N G : Sultan Qaboos University R E F E R E N C E S 1. International Diabetes Federation (IDF). Diabetes At- las. From http://www.eatlas.idf.org/ Accessed January 2008. 2. Wang Y, Baydoun M. The obesity epidemic in the Unit- ed States - Gender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review and meta-regression analysis. Epidemiol Rev 2007; 29:6-28. 3. Ministry of Health Oman. Annual Health Report. Mus- cat: Ministry of Health, 2005. 4. Ministry of Health Oman. Diabetes Mellitus: Manage- ment guidelines for primary health care. 2nd edition. Muscat: Ministry of Health, 2003. 5. Saydah S, Fradkin J, Cowie CC. Poor control of risk fac- tors for vascular disease among adults with previously diagnosed diabetes. JAMA 2004; 291:335-42. 6. Grant RW, Cagliero E, Dubey AK, Gildesgame C, Chueh HC, Barry MJ, et al. Clinical inertia in the management of type 2 diabetes metabolic risk factors. Diabet Med 2004; 21:150-5. 7. Grant RW, Pirraglia PA, Meigs JB, Singer DE. Trends in complexity of care from 1991 to 2000 for patients with diabetes. Arch Intern Med 2004; 164:1134-9. 8. Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the US. JAMA 2003; 290:1884-90. 9. Gaede P, Vedel P, Larsen N. Multifactorial intervention and cardiovascular disease in patients with type 2 dia- betes. New Engl J Med 2003; 348:383-93. 10. Brown JB, Harris SB, Webster-Bogaert S, Wetmore S, Faulds C, Stewart M. The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus. Fam Pract 2002; 19:344-9. 11. UK Prospective Diabetes Study (UKPDS) Group. Inten- sive blood-glucose control with sulphonylureas or insu- lin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352:837-53. 12. Grant RW, Buse JB, Meigs JB. Quality of diabetes care in the US academic medical centers; low rates of medical regimen change. Diabetes Care 2005; 28:337-442. 13. American Diabetes Association. Clinical practice rec- ommendations 2000. Diabetes care 2000; 23:S1-116. 14. Wagner EH, Austin BT, Von Korff M. Improving out- comes in chronic illness. Manag Care Q 1996; 4:12-25. 15. Nutting PA, Dickinson WP, Dickinson LM, Nelson CC, King DK, Crabtree BF, et al. Use of chronic care model elements is associated with higher quality care for dia- betes. 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