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 61% percent of the subjects were female (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 (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 HbA1c, SBP/DBP, total cholesterol, LDL-cholesterol, HDL (high density lipoproteins)-cholesterol, and triglycerides. Only 2.4% (6 out of 249 diabetics) were simultaneously within goal for HbA1c (<7%), 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).
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.
Keywords: Quality, Diabetes, Indicators, Oman
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 patient care.
Diabetes mellitus is a major health problem that is associated with significant morbidity 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 representing 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 increase 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 burden 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 direct link between its poor control and significant morbidities 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, assessing the quality of care provided by these centres is essential 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.
METHODS
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 management of diabetes mellitus in primary health care centers.4 The variables assessed included recorded HbA1c, triglycerides, total cholesterol, low density lipoproteins-cholesterol (LDL), high density lipoproteins-cholesterol (HDL), systolic and diastolic blood pressure as well as fasting and/or random blood sugar measurement during the most recent visit. This retrospective research was done by third and fourth year medical students. In order to secure quality data collection, the students were supervised by the first author 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 analysed 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 analyses were conducted using the Student’s t-test. An a priori two-tailed level of significance was set at 0.05.
RESULTS
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, stratified by gender, are shown in Table 1. Just over 61% percent 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 pressure readings.
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).
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 patients) 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).
DISCUSSION
More than 70% of the patients had their blood pressure, fasting or random blood sugar and HbA1C levels measured regularly; however, the proportion of those meeting 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 internationally 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 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 blueprinting for changing office systems to improve chronic care.14 In a study that examined 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 association with higher levels of process measures and intermediate outcomes for diabetes care.15
CONCLUSION
In conclusion, poor control of high blood sugar levels is linked with micro- and macrovascular complications such as blindness, renal failure, myocardial infarction and cerebrovascular accidents. Ultimately, these have direct impact on the economic state of patients 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 monitoring 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 institution levels are recommended. This would help in identifying opportunities for improvements thus reducing the social and economic burden of the disease on the society.
Acknowledgments
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-Khanbashi, Iman Al-Lawati, third year medical students at Sultan Qaboos University, who were involved in the data collection.
Footnotes
CONFLICT OF INTEREST: None
SOURCE OF FUNDING: Sultan Qaboos University
REFERENCES
- 1.International Diabetes Federation (IDF) Diabetes Atlas. From http://www.eatlas.idf.org/ Accessed January 2008.
- 2.Wang Y, Baydoun M. The obesity epidemic in the United States - Gender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6–28. doi: 10.1093/epirev/mxm007. [DOI] [PubMed] [Google Scholar]
- 3.Ministry of Health Oman. Annual Health Report. Muscat: Ministry of Health; 2005. [Google Scholar]
- 4.Ministry of Health Oman Diabetes Mellitus: Management guidelines for primary health care. 2nd edition. Muscat: Ministry of Health; 2003. [Google Scholar]
- 5.Saydah S, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335–42. doi: 10.1001/jama.291.3.335. [DOI] [PubMed] [Google Scholar]
- 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. doi: 10.1111/j.1464-5491.2004.01095.x. [DOI] [PubMed] [Google Scholar]
- 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. doi: 10.1001/archinte.164.10.1134. [DOI] [PubMed] [Google Scholar]
- 8.Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the US. JAMA. 2003;290:1884–90. doi: 10.1001/jama.290.14.1884. [DOI] [PubMed] [Google Scholar]
- 9.Gaede P, Vedel P, Larsen N. Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. New Engl J Med. 2003;348:383–93. doi: 10.1056/NEJMoa021778. [DOI] [PubMed] [Google Scholar]
- 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. doi: 10.1093/fampra/19.4.344. [DOI] [PubMed] [Google Scholar]
- 11.UK Prospective Diabetes Study (UKPDS) Group Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33) Lancet. 1998;352:837–53. [PubMed] [Google Scholar]
- 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. doi: 10.2337/diacare.28.2.337. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.American Diabetes Association. Clinical practice recommendations 2000. Diabetes care. 2000;23:S1–116. [PubMed] [Google Scholar]
- 14.Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manag Care Q. 1996;4:12–25. [PubMed] [Google Scholar]
- 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 diabetes. Ann Fam Med. 2007;5:14–20. doi: 10.1370/afm.610. [DOI] [PMC free article] [PubMed] [Google Scholar]