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International Journal of Circumpolar Health logoLink to International Journal of Circumpolar Health
. 2023 Dec 6;82(1):2290305. doi: 10.1080/22423982.2023.2290305

High quality of diabetes care in Greenland since the launch of Steno Diabetes Center Greenland 2020 - geographical disparities need attention

Marie Balslev Backe a,b,c,✉, Marit Eika Jørgensen a,b,c,d, Michael Lynge Pedersen a,b
PMCID: PMC10997303  PMID: 38055761

ABSTRACT

The aim of this study was to estimate the prevalence of diagnosed diabetes in Greenland and evaluate quality of care according to sex, region and healthcare unit within regions. Data on all inhabitants registered with diabetes were extracted from the electronic medical record. We found a crude prevalence of diagnosed diabetes in the population aged ≥ 20 years to be 4.7%, and the prevalence of diabetes standardised to the WHO world population was 4.0%. Compared to males, a significantly higher proportion of females had mean glycated haemoglobin (HbA1c) level below 7% (68.9% vs. 57.5%) and blood pressure below 140/90 mmHg (83.4% vs. 73.5%). Regarding healthcare unit within regions, quality of care was higher in regional cities compared to smaller cities, concerning proportion of persons having blood pressure measured regularly (86.0% vs. 71.7%), urine tested for albuminuria (70.6% vs. 51.2%), receiving eye examination (86.9% vs. 79.5%) and foot examination (87.9% vs. 79.4%). In conclusion, the prevalence of diagnosed diabetes in Greenland is the highest reported yet. The overall quality of diabetes care was high and significantly improved compared to 2018. We observed geographical inequality in diabetes care and improvements in the quality of care in specific remote locations are necessary to minimise health care disparities.

KEYWORDS: Diabetes, prevalence, quality-of-care, regions, healthcare

Introduction

The prevalence of diabetes constitutes a major health problem worldwide. In addition to directly causing approximately 1.5 million deaths annually, diabetes is associated with severe complications potentially causing blindness, kidney failure, heart attacks, stroke, and lower limb amputation [1].

In Greenland, diabetes was virtually non-existent only half a century ago [2]. However, since the 1950s, living conditions in Greenland have changed rapidly from a traditional hunting society to a more Westernised society. Sedentary lifestyle and imported foods have replaced an active hunter-fisher lifestyle and traditional foods, respectively, resulting in metabolic disturbances and obesity [3]. This change has been accompanied by increased prevalence of lifestyle-related diseases such as type 2 diabetes [4,5]. The proportion of inhabitants with a BMI ≥ 30 has increased from 12% in 1993 to almost a third of the population in 2018, and more than half of the adult population smoke on daily basis [6]. Further contributing to the high prevalence of diabetes is increasing age. The life expectancy has thus increased dramatically since the 1950s (from 46 years in 1950 to 73 years in 2023) [7], and within the past two decades, the proportion of inhabitants ≥65 years has almost doubled from 5.4% in 2003 to 9.7% in 2023 [8].

In 2001, approximately 70% of the reported diabetes cases in a study conducted in Greenland were undiagnosed [4]. The awareness of diabetes subsequently increased resulting in a number of studies focusing on diabetes in Greenland [9–15], and a national diabetes programme was implemented in 2008 to improve diabetes care [11,16]. The diabetes programme was later replaced by a lifestyle initiative focusing on general prevention and quality of care among patients with hypertension, chronic obstructive lung disease and/or diabetes [17]. Most recently (in 2020), the Steno Diabetes Center Greenland was established with the overall goal of improving health and quality of life for all inhabitants suffering from diabetes and lifestyle-related diseases [18].

Greenland is the largest island in the world covering an area of 2,17 million km2. The majority of the area is covered by the ice cap, and the 56,000 inhabitants live widely spread along the coast. The healthcare in Greenland aspires to overcome the geographical challenges and provide equal healthcare to all inhabitants regardless of residence. In 2011, the healthcare in Greenland was reorganised, where 16 local medical districts managed by a chief district physician were assembled into larger geographical regions [19]. Management of the healthcare system was thus centralised to five regions, each encompassing towns and settlements, encompassing approximately more and less than 500 inhabitants, respectively. A regional hospital was placed in the largest city within each region (Nuuk (~19,600 inhabitants), Sisimiut (~5,400 inhabitants), Ilulissat (~4,800 inhabitants), Qaqortoq (3,000 inhabitants) and Aasiaat (~2,900 inhabitants), while local healthcare centres were placed in the remaining towns (Figure 1) [20]. While the division into five regions was a centralisation of medical functions, the central administrative management of the healthcare system outside Nuuk was disassembled and thus decentralised from the national to the regional level. It has not been investigated how the quality of diabetes care is managed at the intra- and interregional level.

Figure 1.

Figure 1.

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Five healthcare regions in Greenland and towns with local healthcare clinics [16].

The aim of this study was to estimate the age-specific prevalence of diabetes and furthermore to evaluate the quality of care by sex, region and level of healthcare unit within regions.

Materials and methods

The study was designed as an observational cross-sectional study based on data obtained from the electronic medical record (EMR) in Greenland in 2023. The Ethics Committee for Medical Research in Greenland approved the study (project number 2015–11).

Setting

The 56,000 inhabitants of Greenland are widely spread among 18 towns and 60 settlements. The five regional cities equipped with a regional hospital encompass approximately half the population. In the smaller towns, diabetes care is delivered through healthcare centres. In settlements, diabetes care is facilitated through minor healthcare stations staffed with one nurse or health aid in cooperation with the regional or local healthcare centre. Healthcare in Greenland, including medication, is provided free of charge. Persons diagnosed with diabetes are registered with a diagnose code within the EMR and offered lifestyle interventions, e.g. instruction in smoking cessation, free pedometers, dietary advice, and regular control measurements of blood pressure and parameters. Furthermore, persons with diabetes are offered screening for retinopathy with retinal photography, test for urinary albumin excretion, and neuropathy using biothesiometers. All tests are documented in an integrated lifestyle table within the EMR, allowing information to be extracted electronically.

Study population

All persons with a permanent address in Greenland, diagnosed with diabetes according to the International Classification of Primary Health Care (ICPC) 2 [21] or the International Classification of Diseases (ICD) 10 [22] system were identified electronically. Data were obtained from the EMR by January 11th 2023, from persons from all parts of Greenland except one town, Tasiilaq, where the EMR has not yet been fully implemented.

Definition of variables

Quality of diabetes care was described according to process-, and outcome indicators as proposed by the implementation plan by Steno Diabetes Center Greenland [18] in accordance with guidelines proposed by the National Diabetes Quality Alliance [23] and the American Diabetes Association [24] (Table 1).The process indicators applied include annual assessment of HbA1c, blood pressure, and smoking status, while urine albumin-to-creatinine ratio (U-ACR) should be measured every year. Furthermore, examination of eyes and feet should occur every fourth and second year, respectively. The goals should be attained for ≥ 85% of the persons with diabetes. To evaluate outcome indicators as well as describe basic characteristics of the study population, obtained information included age, weight, height, duration of diabetes, blood pressure, HbA1c, and estimated glomerular filtration rate (eGFR). Only most recent test results performed in a two-year period were included. Age was reported as age at date of extraction, and duration of diabetes was measured as date of extraction minus the date of diagnosis. BMI was calculated based on weight and height. Blood pressure was measured using the automatic blood pressure Easy Rapid device from PiC Solutions [25], and blood pressure measured at home was preferred over office blood pressure for the 1,152 persons having both. Venous HbA1c level was measured using IFCC-standardised HPLC analysis with ion-exchange. All analyses were performed at The Central Laboratory at Queen Ingrid’s Hospital, which is a member of the Danish Quality Control System for laboratories [11]. In addition, some patients were tested locally for level of HbA1c using point-of-care device (Afinion 2 from Alere®). Retinal imaging was performed using the Daytona Ultra-Widefield Optos® retinal camera. Medical treatment was classified based on active drug prescriptions. Antihypertensive drugs were defined as drugs with Anatomic Therapeutic Chemical (ATC) C02-C04 and C07-C09. Lipid-lowering drugs included ATC codes C10, while ATC codes A10 were defined as blood glucose-lowering drugs.

Table 1.

Quality of care indicators.

Process indicators
Percentage of patients in whom HbA1c was measured within the previous yeara,b
Percentage of patients in whom blood pressure was measured within the previous yeara, c
Percentage of patients in whom urine was tested for albuminuria within the previous yeara, b
Percentage of patients receiving evaluation of retinal photography within the previous four yearsa
Percentage of patients who received a foot examination within the previous two yearsa, b, c
Proximal outcome indicators
Percentage of patients with HbA1c level < 7.0% (53 mmol/mol) within the previous yearc
Percentage of patients with blood pressure < 140/90 mmHg within the previous yearb
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aQuality indicator proposed by Steno Diabetes Center Greenland [18].

bQuality indicator proposed by The National Diabetes Quality Improvement Alliance [23].

cQuality indicator proposed by the American Diabetes Association [24].

Statistical analyses

Estimates were calculated with 95% confidence intervals (CI). Prevalence was calculated using the population of Greenland as of January 1st 2023, as background population. In addition, direct age-standardised prevalence was calculated using the WHO 2000–2005 population for adults ≥20 years as the standard [26]. Variables were described using means and standard deviation (SD). QQ-plots were used to check for normality. Chi-square tests were used to compare frequencies. Normally distributed variables were compared using two tailed t-tests. P-values below 0.05 were considered significant. Data were analysed in R version 4.2.2, and the graph was created using the Epi Package (Figure 2) [27].

Figure 2.

Figure 2.

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Estimated prevalence of diagnosed diabetes in Greenland, based on registered ICD-10 and ICPC-2 codes in the EMR. Shaded area shows 95% confidence interval.

Results

Study population

A total of 1,889 persons were registered with diabetes in the EMR as of NaN Invalid Date NaN, and of these, 1,878 were ≥20 years of age. Table 2 shows the basic characteristics of the study population according to sex.

Table 2.

Basic characteristics of diagnosed diabetes patients.

  Males
 Females
  
Characteristics Mean (SD) N Mean (SD) N p
Age (years) 63.1 (11.3) 991 62.1 (13.3) 898 0.095
Weight (kg) 92.8 (21.1) 969 78.7 (20.1) 884 <0.001
Height (cm) 171.5 (8.4) 965 157.0 (7.6) 875 <0.001
BMI (kg/m2) 31.5 (6.5) 964 31.9 (7.3) 875 0.286
Duration of diabetes (years) 7.8 (8.7) 590 7.3 (6.5) 490 0.290
HbA1c (mmol/mol) 55.4 (15.2) 977 52.6 (14.5) 889 <0.001
eGFR (ml/min) 76.5 (19.1) 956 71.3 (16.1) 859 <0.001
Blood pressure, systolic (mmHg)
Blood pressure, diastolic (mmHg)
 134.8 (15.7)
81.7 (10.3)
 956
955
 133.4 (16.1)
77.8 (10.0)
 870
870
 0.047
<0.001
 
 % (n)
 N
 % (n)
 N
 P
Daily smoking 35.8 (331) 958 45.1 (392) 865 <0.001
Glucose-lowering medicine 79.2 (797) 991 67.5 (629) 898 <0.001
Blood pressure-lowering medicine 76.5 (774) 991 70.0 (627) 898 <0.001
Lipid-lowering medicine 67.4 (663) 991 60.0 (528) 898 <0.001
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n/N, number of patients/population. P-values below 0.05 are in bold.

The study population with diagnosed diabetes consisted of 47.5% (898) females and 52.5% (991) males. The proportion of males was significantly higher than females (p < 0.01). Males were heavier and taller than females, had higher mean HbA1c, eGFR and blood pressure. A larger proportion of males received glucose-lowering-, antihypertensive, and lipid-lowering medicine, while a larger proportion of females were daily smokers. In total, 40.2% of the diabetes patients were daily smokers (data not shown).

Prevalence

The crude prevalence of diagnosed diabetes among adults aged ≥20 years was 4.7%. The prevalence of diagnosed diabetes among adults ≥20 years standardised to the WHO world population was estimated to be 4.0%. There was no sex-specific difference in the estimated prevalence (Figure 2).

Quality indicators

In total, 94.1% had HbA1c measured within the previous year, of whom 62.9% had HbA1c-levels below 7% (53 mmol/mol) (Table 3). Blood pressure was measured in 81.7% of the persons with diabetes within the previous year, and of these, 78.2% had blood pressure below 140/90 mmHg. The proportion of persons with diabetes in whom urine was tested for albuminuria during the previous year was 64.7%, while 84.7% had received eye examination within the previous four years. Foot examination was performed for 85.3% of the persons with diabetes within the previous two years. There was no sex-specific difference in process indicators, but the outcome indicators were significantly better among females compared to males (p < 0.001).

Table 3.

Quality of diabetes care according to sex.

Process indicators, % (n) Males
N = 991 		Females
N = 898 		p Total
N = 1,889
Patients in whom HbA1c was measured within previous year. 93.7 (929) 94.5 (849) 0.460 94.1 (1,778)
Patients in whom blood pressure* was measured within previous year 82.5 (818) 80.7 (725) 0.310 81.7 (1,543)
Patients tested for albuminuria within previous year. 65.9 (653) 63.5 (570) 0.272 64.7 (1,223)
Patients receiving evaluation of retinal photography within previous four years. 84.9 (841) 84.5 (759) 0.836 84.7 (1,600)
Patients receiving foot examination within previous two years. 85.2 (844) 85.5 (768) 0.827 85.3 (1,612)
Outcome indicators, % (n)
Patients with HbA1c <53 mmol/mol (7%) 57.5 (534) 68.9 (585) <0.001 62.9 (1,119)
Patients with blood pressure < 140/90 mmHg 73.5 (601) 83.4 (605) <0.001 78.2 (1,206)
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P-values below 0.05 are in bold..

* Blood pressure is home blood pressure if available, and otherwise office blood pressure.

The quality of care varied across the five regions, although in a non-systematic manner (Table 4). As each region contains cities of varying levels of healthcare units, we wished to investigate the quality of care according to healthcare unit (Figure 3). When comparing the five cities with a regional hospital to the remaining cities with a healthcare centre or smaller unit, we found that the quality of care was significantly higher for four out of five process indicators in cities with a regional hospital. In accordance, there was a significant difference in the proportion of persons with diabetes having blood pressure measured or urine tested for albuminuria within the previous year (blood pressure: 86.0% vs. 71.7%; urine test: 70.6% vs. 51.2%, p < 0.001), and a significantly larger proportion of persons with diabetes having received eye examination within the previous four years (86.9% vs. 79.5%, p < 0.001) and foot examination within the previous two years (87.9% vs. 79.4, p < 0.001). There were no significant differences in the remaining quality of care indicators according to level of healthcare unit.

Table 4.

Quality of diabetes care according to region.

Process indicators, % (n) Disko
N = 249 		Avannaa N = 355 Qeqqa N = 277 Kujataa
N = 259 		Sermersooq N = 749 p Nuuk
N = 629
Patients in whom HbA1c was measured within previous year 92.0 (229) 91.5 (325) 94.2 (261) 96.5 (250) 95.2 (713) 0.031 95.4 (600)
Patients in whom blood pressure* was measured within previous year 87.6 (218) 78.6 (279) 74.7 (207) 73.7 (191) 86.5 (648) <0.001 88.1 (554)
Patients tested for albuminuria in urine within previous year 58.2 (145) 58.3 (207) 49.5 (137) 53.7 (139) 79.4 (595) <0.001 81.1 (510)
Patients receiving evaluation of retinal photography within previous four years 79.1 (197) 83.9 (298) 84.8 (235) 86.9 (225) 86.1 (645) 0.016 89.5 (563)
Patients receiving foot examination within previous two years 85.9 (214) 80.0 (284) 81.9 (227) 80.3 (208) 90.7 (679) <0.001 92.8 (584)
Outcome indicators, % (n)          
Patients with HbA1c level <53 mmol/mol (7%) 65.1 (149) 58.8 (191) 58.2 (152) 64.8 (162) 65.2 (465) 0.121 65.5 (393)
Patients with blood pressure < 140/90 mmHg 70.2 (153) 84.6 (236) 85.0 (176) 82.7 (158) 74.5 (483) <0.001 75.8 (420)
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P-values below 0.05 are in bold..

* Blood pressure is home blood pressure if available, and otherwise office blood pressure.

Figure 3.

Figure 3.

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Quality of diabetes care according to level of healthcare unit within regions.

Discussion

In this study, we report an age-standardised prevalence of diagnosed diabetes of 4.0% among adults ≥20 years. The crude prevalence among adults ≥20 years was estimated to be 4.7%. Process indicators were not affected by sex, while outcome indicators were significantly better among females. In general, quality of diabetes care was high in all of Greenland. Yet, quality of care was better in regional cities compared to smaller cities.

Prevalence

The prevalence of diabetes in Greenland continues to increase, as we here report the age-standardised prevalence of diagnosed diabetes to be 4.0%, as compared to studies from 2018 (2.2%) and 2014 (1.7%) [14,28]. Besides being in line with a global increase in diabetes prevalence [29]. The main driver of the observed increase may be high diagnostic activity including active case finding with testing patients with risk factors of diabetes. Other drivers may include the increasing proportion of elder citizens and increasing prevalence of obesity. Since the introduction of national diabetes initiatives in 2008, the proportion of undiagnosed diabetes has decreased from approximately 80% in 2010 [30] to around 24% in 2018 [6]. This is important since timely diagnosis and early intervention and treatment is crucial in preventing complications to diabetes [31]. Meanwhile, the prevalence of diagnosed diabetes among adults ≥40 years has increased from 2.2% in 2008 [9] compared to 7.7% in 2023, as found in this study (1,794/23,227, data not shown). Further adding to the increased prevalence is a shift in the age distribution towards older age, so that the proportion of elderly citizens ≥65 years have increased from 6.3% in 2008 (3,564/56,462) to 9.7% in 2023 (5,493/56,609) [8]. In addition to the increasing age of the population, increasing prevalence of overweight and obesity in Greenland has been observed during the past three decades [32,33], and is, together with decreased physical activity [34,35], believed to be a key driver of the increasing diabetes prevalence. The high prevalence of overweight and obesity is especially pronounced among females in Greenland, which might explain why the observed prevalence of diabetes in Greenland is not higher among males, as seen in other countries [36,37].

Quality of care

Overall, we found the quality of diabetes care to be significantly better compared to in 2018 [28]. In accordance, more persons with diabetes had HbA1c and U-ACR levels measured within the previous year in 2023 compared to 2018 (HbA1c: 94.1% vs. 87.8%, U-ACR: 64.7% vs. 49.3%, p < 0.001). The proportion of persons with diabetes receiving foot examination within the previous two years had also significantly increased in 2023 compared to 2018 (85.3% vs. 44.5%, p < 0.001). Furthermore, the proportion of persons with diabetes having eye examination performed within the previous four years was 84.7% in 2023 compared to the standard of ≥ 85% set by Steno Diabetes Center Greenland and compared to 79.8% in 2018 within the previous two years. Regarding outcome indicators, more persons with diabetes in 2023 had well-controlled glycaemic level compared to 2018 (62.9% vs. 52.8%, p < 0.001) and similarly for the proportion of persons with diabetes without hypertension (78.2% vs. 59.8%, p < 0.001).

The process indicators set by Steno Diabetes Center Greenland resemble those of the Danish Steno Diabetes centres, except for a higher established standard in Denmark. In accordance, the goal in Denmark is that process indicators concerning measurement of blood pressure, eye and foot examination should be conducted for ≥ 95% of the persons with diabetes within one, four, and two years, respectively [38]. Despite the standard being higher in Denmark, the performance is better for some indicators in Greenland. In accordance, while annual measurement of blood pressure was conducted for 81.7% of the Greenlandic persons with diabetes, the number was found to be 83% and 75% for the Danish persons with diabetes in 2022 within primary and secondary care, respectively. Furthermore, while 85.3% of Greenlandic persons with diabetes had foot examinations conducted within the two previous years, 71% and 30% of the Danish persons with diabetes had annual foot examinations within primary and secondary care, respectively. In contrast, more Danish persons with diabetes had eye screening conducted within the previous four years compared to Greenlandic persons with diabetes (98% vs. 84.7%) [39]. In Denmark, the process indicator concerning screening for diabetic retinopathy has been expanded with an indicator called “the proportion of persons with diabetes screened within an individual interval”. Thus, in Denmark, an eye doctor performs screenings with an individually determined interval inversely proportional to the severity of retinopathy/maculopathy. The reasoning behind this seems valid, as an eye screening conducted within four years does not necessarily equal high quality, if the person with diabetes has an individual screening interval set, e.g. for three months. Making similar adjustments of the quality indicators in Greenland might be considered for future evaluations.

The overall quality of diabetes care has improved significantly since the establishment of Steno Diabetes Center Greenland in 2020 compared to the quality of care reported in 2018. Yet, room for improvement is still an issue since only measurement of HbA1c and regular foot examinations meet the goal of ≥ 85% as set by Steno Diabetes Center Greenland.

When looking at healthcare unit across regions, four out of five process indicators were significantly better in regional towns compared to the smaller cities (p < 0.001). Furthermore, in the regional towns, four out of five quality of care indicators met the standard of Steno Diabetes Center Greenland compared to only one indicator in the smaller cities. It is possible that reorganisation of the Greenlandic healthcare might have had undesired consequences. Centralisation is a well-known strategy to maintain safety and quality of care as costs associated with healthcare are growing. The strategy has been chosen by several countries, e.g. France and Denmark [40,41]. The benefit of centralisation is expressed mainly as reduced mortality rates and healthcare costs, while information on other outcomes such as patient and family satisfaction and quality of life is lacking. Centralisation of limited resources is, however, believed to bring about certain negative effects, overall associated with the geographical distance between centres, transportation, the effects on staff in smaller non-specialised centres, and the psychological impact on the person with diabetes and their relatives [42,43]. Telemedicine is believed to be a promising tool to integrate specialist expertise in local environments, thereby promoting training of medical staff, dissemination of knowledge, quality of service and local governance. It has been shown that telemedicine is associated with better quality of care for persons with diabetes living in remote areas [44], as also shown during COVID-19, where telemedical interventions allowed for continuous patient care [45,46].

Strengths and limitations

A great strength of this study is the electronic identification of persons diagnosed with diabetes, encompassing 95% of the entire Greenlandic population. However, as patients were only included based on presence of diagnosis, there might be persons with diabetes not included due to lack of proper registration. It is therefore possible that the estimated diabetes prevalence is underestimated.

The selected quality of care-indicators used in this study were internationally accepted. However, like for registration of diagnostic codes, there is a risk of incorrect registration of clinical parameters such as blood pressure. Incorrect registration is most likely associated with lack of knowledge concerning national guidelines, possibly related to the high turnover in healthcare professionals. However, despite possible registration flaws and underestimation, the reported quality of care must be considered the best measurement available.

Valid information on U-ACR values was unfortunately not available for the study, wherefore it was only included to evaluate process indicators of quality of care, and not outcome indicators nor basic characteristics.

This study is the first to compare quality of care across regions and different levels of healthcare units since reorganisation of healthcare in 2011.

Conclusion

In conclusion, the prevalence of diagnosed diabetes in Greenland is the highest reported yet. The overall quality of diabetes care was high and significantly improved compared to 2018. We observed geographical inequality in diabetes care and improvements in the quality of care in specific remote locations is necessary to minimise health care disparities.

Funding Statement

Steno Diabetes Centre Greenland is partly funded by the Novo Nordisk Foundation (NNF20SA0064190).

Disclosure statement

No potential conflict of interest was reported by the authors.

Author contributions

MLP was responsible for design of the study. MBB, MEJ and MLP all contributed to data analysis, description, and interpretation, and further reviewed drafts of the manuscript and approved prior to submission.

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