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Carrillo-Larco RM, Guzman-Vilca WC, Varghese JS, Pasquel FJ, Caixeta R, Antini C, Bernabé-Ortiz A. Compliance with eye and foot preventive care in people with self-reported diabetes in Latin America and the Caribbean: Pooled, cross-sectional analysis of nine national surveys. Prim Care Diabetes 2024; 18:374-379. [PMID: 38503635 DOI: 10.1016/j.pcd.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 12/04/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024]
Abstract
AIMS To estimate the proportion of people with self-reported diabetes receiving eye and foot examinations in Latin America and the Caribbean (LAC). METHODS Cross-sectional analysis of national health surveys in nine countries. Adults aged 25-64 years with self-reported diabetes. We quantified the proportion who reported having an eye examination in the last two years or a foot examination in the last year. We fitted multilevel Poisson regressions to assess socio-demographic (age and sex) and clinical (oral hypoglycemic medication and insulin treatment) variables associated with having had examinations. RESULTS There were 7435 people with self-reported diabetes included in the analysis. In three countries (Chile [64%; 95% CI: 56%-71%], British Virgin Islands [58%; 95% CI: 51%-65%], and Brazil [54%; 95% CI: 50%-58%]), >50% of people with diabetes reported having had an eye examination in the last two years. Fewer participants (<50% across all countries) reported having had a foot examination in the last year, with Ecuador having the lowest proportion (12%; 95% CI: 8%-17%). Older people, and those taking oral medication or insulin, were more likely to have eye/foot examinations. CONCLUSIONS The proportion of eye and foot examinations in people with self-reported diabetes across nine countries in LAC is low.
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Affiliation(s)
- Rodrigo M Carrillo-Larco
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, US; Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA.
| | - Wilmer Cristobal Guzman-Vilca
- School of Medicine 'Alberto Hurtado', Universidad Peruana Cayetano Heredia, Lima, Peru; CRONICAS Centre of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jithin Sam Varghese
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, US; Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA
| | - Francisco J Pasquel
- Emory Global Diabetes Research Center, Emory University, Atlanta, GA, USA; Division of Endocrinology, Metabolism, and Lipids, Department of Medicine, School of Medicine, Emory University, Atlanta, GA, US
| | - Roberta Caixeta
- Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington DC, US
| | - Carmen Antini
- Department of Noncommunicable Diseases and Mental Health, Pan American Health Organization, Washington DC, US
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Chary AN, Nandi M, Flood D, Tschida S, Wilcox K, Kurschner S, Garcia P, Rohloff P. Qualitative study of pathways to care among adults with diabetes in rural Guatemala. BMJ Open 2023; 13:e056913. [PMID: 36609334 PMCID: PMC9827254 DOI: 10.1136/bmjopen-2021-056913] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE The burden of diabetes mellitus is increasing in low-income and middle-income countries (LMICs). Few studies have explored pathways to care among individuals with diabetes in LMICs. This study evaluates care trajectories among adults with diabetes in rural Guatemala. DESIGN A qualitative investigation was conducted as part of a population-based study assessing incidence and risk factors for chronic kidney disease in two rural sites in Guatemala. A random sample of 807 individuals had haemoglobin A1c (HbA1c) screening for diabetes in both sites. Based on results from the first 6 months of the population study, semistructured interviews were performed with 29 adults found to have an HbA1c≥6.5% and who reported a previous diagnosis of diabetes. Interviews explored pathways to and experiences of diabetes care. Detailed interview notes were coded using NVivo and used to construct diagrams depicting each participant's pathway to care and use of distinct healthcare sectors. RESULTS Participants experienced fragmented care across multiple health sectors (97%), including government, private and non-governmental sectors. The majority of participants sought care with multiple providers for diabetes (90%), at times simultaneously and at times sequentially, and did not have longitudinal continuity of care with a single provider. Many participants experienced financial burden from out-of-pocket costs associated with diabetes care (66%) despite availability of free government sector care. Participants perceived government diabetes care as low-quality due to resource limitations and poor communication with providers, leading some to seek care in other health sectors. CONCLUSIONS This study highlights the fragmented, discontinuous nature of diabetes care in Guatemala across public, private and non-governmental health sectors. Strategies to improve diabetes care access in Guatemala and other LMICs should be multisectorial and occur through strengthened government primary care and innovative private and non-governmental organisation care models.
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Affiliation(s)
- Anita Nandkumar Chary
- Medicine & Emergency Medicine, Baylor College of Medicine, Houston, Texas, USA
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
| | - Meghna Nandi
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Family Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - David Flood
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott Tschida
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
| | - Katharine Wilcox
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Family Medicine, University of Illinois Medical Center at Chicago, Chicago, Illinois, USA
| | - Sophie Kurschner
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Pablo Garcia
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Nephrology, Stanford University School of Medicine, Stanford, California, USA
| | - Peter Rohloff
- Center for Research on Indigenous Health, Maya Health Alliance Wuqu' Kawoq, Tecpan, Guatemala
- Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Flood D, Geldsetzer P, Agoudavi K, Aryal KK, Brant LCC, Brian G, Dorobantu M, Farzadfar F, Gheorghe-Fronea O, Gurung MS, Guwatudde D, Houehanou C, Jorgensen JMA, Kondal D, Labadarios D, Marcus ME, Mayige M, Moghimi M, Norov B, Perman G, Quesnel-Crooks S, Rashidi MM, Moghaddam SS, Seiglie JA, Bahendeka SK, Steinbrook E, Theilmann M, Ware LJ, Vollmer S, Atun R, Davies JI, Ali MK, Rohloff P, Manne-Goehler J. Rural-Urban Differences in Diabetes Care and Control in 42 Low- and Middle-Income Countries: A Cross-sectional Study of Nationally Representative Individual-Level Data. Diabetes Care 2022; 45:1961-1970. [PMID: 35771765 PMCID: PMC9472489 DOI: 10.2337/dc21-2342] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 05/18/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes prevalence is increasing rapidly in rural areas of low- and middle-income countries (LMICs), but there are limited data on the performance of health systems in delivering equitable and effective care to rural populations. We therefore assessed rural-urban differences in diabetes care and control in LMICs. RESEARCH DESIGN AND METHODS We pooled individual-level data from nationally representative health surveys in 42 countries. We used Poisson regression models to estimate age-adjusted differences in the proportion of individuals with diabetes in rural versus urban areas achieving performance measures for the diagnosis, treatment, and control of diabetes and associated cardiovascular risk factors. We examined differences across the pooled sample, by sex, and by country. RESULTS The pooled sample from 42 countries included 840,110 individuals (35,404 with diabetes). Compared with urban populations with diabetes, rural populations had ∼15-30% lower relative risk of achieving performance measures for diabetes diagnosis and treatment. Rural populations with diagnosed diabetes had a 14% (95% CI 5-22%) lower relative risk of glycemic control, 6% (95% CI -5 to 16%) lower relative risk of blood pressure control, and 23% (95% CI 2-39%) lower relative risk of cholesterol control. Rural women with diabetes had lower achievement of performance measures relating to control than urban women, whereas among men, differences were small. CONCLUSIONS Rural populations with diabetes experience substantial inequities in the achievement of diabetes performance measures in LMICs. Programs and policies aiming to strengthen global diabetes care must consider the unique challenges experienced by rural populations.
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Affiliation(s)
- David Flood
- Division of Hospital Medicine, Department of Medicine, University of Michigan, Ann Arbor, MI
- Center for Indigenous Health Research, Wuqu’ Kawoq, Tecpán, Guatemala
- Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Stanford University, Stanford, CA
- Chan Zuckerberg Biohub, San Francisco, CA
| | | | - Krishna K. Aryal
- Public Health Promotion and Development Organization, Kathmandu, Nepal
| | - Luisa Campos Caldeira Brant
- Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Departamento de Clínica Médica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Garry Brian
- The Fred Hollows Foundation New Zealand, Auckland, New Zealand
| | - Maria Dorobantu
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
| | - Farshad Farzadfar
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Oana Gheorghe-Fronea
- University of Medicine and Pharmacy Carol Davila, Bucharest, Romania
- Cardiology Department, Emergency Hospital Bucharest, Bucharest, Romania
| | | | - David Guwatudde
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Corine Houehanou
- Laboratory of Epidemiology of Chronic and Neurological Diseases, Faculty of Health Sciences, University of Abomey-Calavi, Cotonou, Benin
| | | | - Dimple Kondal
- Public Health Foundation of India, Gurugram, India
- Centre for Chronic Disease Control, New Delhi, India
| | - Demetre Labadarios
- Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
| | - Maja E. Marcus
- Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Mary Mayige
- National Institute for Medical Research, Dar es Salaam, Tanzania
| | - Mana Moghimi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bolormaa Norov
- Division of Nutrition, National Center for Public Health, Ulaanbaatar, Mongolia
| | - Gastón Perman
- Department of Public Health, Instituto Universitario Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sarah Quesnel-Crooks
- Non-Communicable Diseases, Caribbean Public Health Agency, Port of Spain, Trinidad and Tobago
| | - Mohammad-Mahdi Rashidi
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Sahar Saeedi Moghaddam
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Silver K. Bahendeka
- Saint Francis Hospital Nsambya, Kampala, Uganda
- Uganda Martyrs University, Kampala, Uganda
| | | | - Michaela Theilmann
- Heidelberg Institute of Global Health, Heidelberg University and University Hospital, Heidelberg, Germany
| | - Lisa J. Ware
- South African Medical Research Council–Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand, Johannesburg, South Africa
- Department of Science and Innovation–National Research Foundation Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Sebastian Vollmer
- Department of Economics and Centre for Modern Indian Studies, University of Göttingen, Göttingen, Germany
| | - Rifat Atun
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA
- Department of Global Health and Social Medicine, Harvard Medical School, Harvard University, Boston, MA
| | - Justine I. Davies
- Institute of Applied Health Research, University of Birmingham, Birmingham, U.K
- Centre for Global Surgery, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit, Faculty of Health Sciences, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
| | - Mohammed K. Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA
| | - Peter Rohloff
- Center for Indigenous Health Research, Wuqu’ Kawoq, Tecpán, Guatemala
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA
| | - Jennifer Manne-Goehler
- Division of Infectious Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Hassan S, Magny-Normilus C, Galusha D, Adams OP, Maharaj RG, Nazario CM, Nunez M, Nunez-Smith M. Glycemic control and management of cardiovascular risk factors among adults with diabetes in the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study. Prim Care Diabetes 2022; 16:107-115. [PMID: 34253484 PMCID: PMC8743302 DOI: 10.1016/j.pcd.2021.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 06/15/2021] [Accepted: 06/21/2021] [Indexed: 02/03/2023]
Abstract
AIMS To determine the level of glycemic control and cardiovascular (CVD) risk among adults with diabetes in the Eastern Caribbean. METHODS Baseline data from the Eastern Caribbean Health Outcomes Research Network (ECHORN) Cohort Study (ECS) were used for the analysis. ECS participants were 40 years of age and older, residing in the US Virgin Islands, Puerto Rico, Trinidad, or Barbados. Participants completed a survey, physical exam, and laboratory studies. CVD risk was calculated using the Atherosclerotic CVD risk equation. Bivariate analysis followed by multinomial logistic regression was used to assess social and biological factors (education, lifestyle, access to care, medical history) associated with level of glycemic control. RESULTS Twenty-three percent of participants with diabetes had an HbA1c ≥ 9% (>75 mmol/mol). Participants with diabetes had poorly controlled CVD risk factors: 70.2% had SBP ≥ 130 mmHg, 52.2% had LDL ≥ 100 mg/dl (2.59 mmol/L), and 73.2% had a 10-year CVD risk of more than 10%. Age and education level were significant, independent predictors of glycemic control. CONCLUSION There is a high prevalence of uncontrolled diabetes among adults in ECS. The high burden of elevated CVD risk explains the premature mortality we see in the region. Strategies are needed to improve glycemic control and CVD risk factor management among individuals with diabetes in the Caribbean.
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Affiliation(s)
- Saria Hassan
- Yale School of Medicine, Department of Medicine, 100 Church Street South, New Haven, CT 06510, United States; Emory University School of Medicine, Atlanta, GA 30322.
| | - Cherlie Magny-Normilus
- Yale School of Medicine, Department of Medicine, 100 Church Street South, New Haven, CT 06510, United States
| | - Deron Galusha
- Yale School of Medicine, Department of Medicine, 100 Church Street South, New Haven, CT 06510, United States
| | - Oswald P Adams
- University of the West Indies, Cave Hill Campus, Bridgetown, Barbados
| | - Rohan G Maharaj
- University of the West Indies, St. Augustine Campus, St. Augustine, Trinidad, Trinidad and Tobago
| | - Cruz M Nazario
- University of Puert Rico, Medical Sciences Campus, Graduate School of Public Health, San Juan, Puerto Rico 00921
| | - Maxine Nunez
- University of the Virgin Islands, School of Nursing, St. Thomas, US Virgin Islands
| | - Marcella Nunez-Smith
- Yale School of Medicine, Department of Medicine, 100 Church Street South, New Haven, CT 06510, United States
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5
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Antonio-Villa NE, García-Tuomola A, Almeda-Valdes P, Vidrio-Velázquez M, Islas-Ortega L, Madrigal-Sanromán JR, Zaballa-Lasso C, Martínez-Ramos-Méndez A, De la Garza-Hernández NE, Bustamante-Martínez JF, González-Galvez G, Valadez-Capetillo M, Sanchez-Ruiz KL, Castillo-Galindo C, Yepez-Rodríguez AE, Polanco-Preza MA, Ceballos-Macías JJ, Valenzuela-Montoya JC, Escobedo-Ortiz AR, Ferreira-Hermosillo A, Rodríguez-Sanchez E, Romero-Zazueta A, Miracle-López S, Figueroa-Andrade MH, Faradji RN. Glycemic control, treatment and complications in patients with type 1 diabetes amongst healthcare settings in Mexico. Diabetes Res Clin Pract 2021; 180:109038. [PMID: 34487758 DOI: 10.1016/j.diabres.2021.109038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 08/11/2021] [Accepted: 08/31/2021] [Indexed: 11/30/2022]
Abstract
AIMS Type 1 diabetes (T1D) is a growing chronic disease. Evidence of whether the healthcare setting affects management and glycemic control is scarce. We evaluate outcomes in patients with T1D in private and public healthcare settings in Mexico, registered in the National T1D Registry in Mexico (RENACED-DT1). METHODS Biochemical parameters, diabetes education, and treatment were analyzed considering the data registered in the last visit. Development of chronic complications was determined during follow-up. RESULTS We included 1,603 patients; 71.5% (n = 1,146) registered in the public system, and 28.5% (n = 457) in a private institution. Patients in the public setting had higher HbA1c (8.6%, IQR: 7.3%-10.5% vs 7.7%, IQR: 7.0%-8.8%; p < 0.001). Indicators of diabetes education, glucose monitoring, and use of insulin-pumps were lower in the public setting. Patients in the public setting were at higher risk of diabetic chronic kidney disease, retinopathy, and neuropathy. Diabetes knowledge was a mediator between type of healthcare setting and the likelihood of achieving glycemic control. CONCLUSIONS Patients registered in public healthcare settings have an adverse metabolic profile and higher risk of complications. Social factors need to be addressed in order to implement multidisciplinary measures focused on diabetes education for patients with T1D in Mexico.
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Affiliation(s)
- Neftali Eduardo Antonio-Villa
- MD/PhD (PECEM), Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico; Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Aili García-Tuomola
- Departamento de Endocrinología y Metabolismo. Instituto Nacional de Ciencias Médicas y Nutrición"Salvador Zubirán, Mexico City, Mexico; Endocrinology, Centro Medico ABC, Mexico City, Mexico
| | - Paloma Almeda-Valdes
- Unidad de Investigación de Enfermedades Metabólicas, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Departamento de Endocrinología y Metabolismo. Instituto Nacional de Ciencias Médicas y Nutrición"Salvador Zubirán, Mexico City, Mexico
| | | | - Laura Islas-Ortega
- Pediatric Endocrinology, Hospital del Niño DIF Hidalgo, Pachuca, Hidalgo, Mexico
| | | | | | | | | | - Jorge F Bustamante-Martínez
- Internal Medicine Department, Servicios de Salud de Nayarit, Hospital General de Tepic, Tepic, Nayarit, Mexico
| | - Guillermo González-Galvez
- Endocrinology, Instituto Jalisciense de Investigación en Diabetes y Obesidad S. C, Guadalajara, Jalisco, Mexico
| | | | - Karla L Sanchez-Ruiz
- Clínica de Diabetes, Secretaría de Salud del Estado de Durango, Durango, Durango, Mexico
| | | | | | - Miguel A Polanco-Preza
- Endocrinology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Jalisco, Mexico
| | | | - Julio C Valenzuela-Montoya
- Pediatric Endocrinology, Hospital De Gineco-Pediatría No. 31 IMSS, Mexicali, Baja California Norte, Mexico
| | - Ana R Escobedo-Ortiz
- Endocrinology, Hospital General Dr. Miguel Silva, Secretaria de Salud, Morelia, Michoacán, Mexico
| | - Aldo Ferreira-Hermosillo
- Endocrinology, Unidad de Investigación Médica en Enfermedades Endocrinas. Centro Médico Nacional Siglo XXI, IMSS, Mexico
| | | | | | - Sigfrido Miracle-López
- Endocrinology, Hospital Angeles Lomas, Huixquilucan, México; Associate Investigator, Centro de Investigación en Ciencias de la Salud (CICSA) Universidad, Anáhuac, Mexico
| | | | - Raquel N Faradji
- Endocrinology and Diabetes, Clinica EnDi, Mexico City, Mexico; Endocrinology, Centro Medico ABC, Mexico City, Mexico.
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Calderon-Ticona JR, Taype-Rondan A, Villamonte G, Labán-Seminario LM, Helguero-Santín LM, Miranda JJ, Lazo-Porras M. Diabetes care quality according to facility setting: A cross-sectional analysis in six Peruvian regions. Prim Care Diabetes 2021; 15:488-494. [PMID: 33358034 DOI: 10.1016/j.pcd.2020.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 11/19/2020] [Accepted: 11/29/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To characterize diabetes care across healthcare facilities in six Peruvian regions. METHODS Cross-sectional study of patients with type 2 diabetes mellitus (T2DM), ranging from primary care facilities to hospital-based facilities, in six Peruvian regions. Data was collected by health staff trained between 2012 and 2016. We studied six diabetes care outcomes and four adequate diabetes care outcomes considering the healthcare facility as the exposure of interest. We estimated prevalence ratios (PR) and their 95% confidence intervals (95% CI) using Poisson regression with robust variance. RESULTS Data from 8879 patients with T2DM, mean age 59.1 years (SD ± 12.2), 53.6% males, was analyzed. Of these, 8096 (91.2%) were treated at primary care facilities. The proportions of patients who had HbA1c, LDL-c, and creatinine/microalbumin test performed increased with the setting of the healthcare facility. Overall, 39%-56% of patients had an adequate HbA1c control, being higher in hospital-based facilities with specialists in comparison to primary care facilities. CONCLUSIONS We observed that the higher the setting of the facility, the higher the rate of the assessed diabetes care outcomes and adequate diabetes care for four of the six targets (fasting glucose, HbA1c, LDL-c and creatinine or microalbumin) and for three of the four targets (glucose≤130 mg/dL, HbA1c ≤7%(53 mmol/mol) and LDL-c <100 mg/dL), respectively. Substantial gaps were observed at the primary care facilities, calling for the strengthening of diabetes care.
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Affiliation(s)
- Jorge R Calderon-Ticona
- Endocrinology Service, Hospital Nacional Arzobispo Loayza, Ministerio de Salud, Lima, Peru; School of Medicine, Universidad Nacional Mayor de San Marcos, Lima Peru.
| | - Alvaro Taype-Rondan
- CRONICAS Center of Excellence in Chronic Disease, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - L Max Labán-Seminario
- CRONICAS Center of Excellence in Chronic Disease, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Disease, Universidad Peruana Cayetano Heredia, Lima, Peru; School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Maria Lazo-Porras
- CRONICAS Center of Excellence in Chronic Disease, Universidad Peruana Cayetano Heredia, Lima, Peru; Division of Tropical and Humanitarian Medicine, Geneva University Hospitals & University of Geneva, Switzerland.
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Duncan JP, Tulloch-Reid MK, Reid-Jones H, Figueroa JP. Use of a simplified clinical audit tool to evaluate hypertension and diabetes management in primary care clinics in Jamaica. J Clin Hypertens (Greenwich) 2020; 22:1275-1281. [PMID: 32516505 DOI: 10.1111/jch.13901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 04/27/2020] [Accepted: 04/30/2020] [Indexed: 11/27/2022]
Abstract
This study evaluates a simple clinical audit tool for assessing quality of care and blood pressure control among persons with hypertension in primary care clinics. A systematic random sampling of persons with diabetes mellitus (DM) and hypertension (HTN) attending five health centers in Kingston, Jamaica, was conducted. A modified Ministry of Health paper-based audit tool captured quality of care and outcome indicators (blood pressure and glycemic control). Additional chart audits were conducted by a physician and nurse to assess reliability. One hundred and forty-nine charts were audited between January and September 2017. One hundred and thirty-eight persons (92.6%) had hypertension (27 men and 111 women); 77 persons (51.7%) had DM (14 men and 63 women). The median age was 64 years old. Approximately two-thirds of persons with HTN and DM had electrolytes, lipid profile, and ECG done within the last year. One-fifth of persons with hypertension (18.5% men and 19.8% women, P = 1.000) had adequate blood pressure control with greater control among persons with HTN only compared to persons with both DM and HTN. Poor glycemic control was recorded for 69% of persons with DM (57% men and 71% women, P = .297). Moderate to substantial inter-rater agreement was observed for quality of care indicators. Our findings confirmed that hypertension and glycemic control are inadequate among persons attending primary care clinics in Jamaica's capital city. Simplified clinical audits can provide important quality of care and outcome indicators without losing the meaningfulness of the data collected.
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Affiliation(s)
- Jacqueline P Duncan
- Department of Community Health & Psychiatry, University of the West Indies, Mona, Jamaica
| | | | | | - J Peter Figueroa
- Department of Community Health & Psychiatry, University of the West Indies, Mona, Jamaica
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Abstract
Type 2 diabetes is a major and accelerating public health challenge. Between 1980 and 2014, a period of just 35 years, the number of adults with diabetes globally is estimated to have increased from 108 to 422 million, due not only to sharply rising obesity rates, but also to increasing population size, longer life expectancy, and rising prevalence of diabetes worldwide. Overall, worldwide age-standardized adult diabetes prevalence doubled from 4.3% to 9.0% in men and from 5.0% to 7.9% in women. The largest increases in diabetes type 2 have been demonstrated in low- and middle-income countries, whilst rises in high-income countries have been less marked, or even flat. Diabetes type 2 rates in low- and middle-income countries now in many instances surpass those in high-income countries, in response to changes in lifestyle. One factor of particular concern are the large relative increases in type 2 diabetes amongst young individuals observed in many countries, their higher overall risk factor burden, long exposure to hyperglycaemia and greater risk of complications over the life course. Type 2 diabetes is increasingly found to be a heterogeneous condition, where risk of cardiovascular disease that traditionally has been estimated at 2-4 times that of the nondiabetic population varies substantially with diabetes phenotype and accordingly diabetes does not confer the same increase in relative or absolute risk in all people. New research shows that excess risk varies substantially with type of outcome, age, glycaemic control, the presence of renal complications and other factors. Heart failure, previously less recognized that other cardiovascular conditions, is increasingly coming into focus, because of strong links with poor glycaemic control and obesity. The knowledge about risk of cardiovascular disease in diabetes is almost entirely derived from high-income countries, whereas there is comparatively very little data from low- and middle income countries, where the majority of persons with type 2 diabetes live, and where management in many cases is far from optimal. The reductions in cardiovascular disease incidence and mortality now observed in high-income countries are encouraging, because this reinforces the fact that improvement is possible and that a near-normal, or even normal life-expectancy can be achieved in subtypes of type 2 diabetes.
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Affiliation(s)
- A Rosengren
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
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Barcelo A, Arredondo A, Gordillo-Tobar A, Segovia J, Qiang A. The cost of diabetes in Latin America and the Caribbean in 2015: Evidence for decision and policy makers. J Glob Health 2018; 7:020410. [PMID: 29163935 PMCID: PMC5681710 DOI: 10.7189/jogh.07.020410] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The financial implications of the increase in the prevalence of diabetes in middle–income countries represents one of the main challenges to health system financing and to the society as a whole. The objective of this study was to estimate the economic cost of diabetes in Latin America and the Caribbean (LAC) in 2015. METHODS The study used a prevalence–based approach to estimate the direct and indirect costs related to diabetes in 29 LAC countries in 2015. Direct costs included health care expenditures such as medications (insulin and oral hypoglycemic agents), tests, consultations, hospitalizations, emergency visits and treating complications. Two different scenarios (S1 and S2) were used to analyze direct cost. S1 assumed conservative estimates while S2 assumed broader coverage of medication and services. Indirect costs included lost resources due to premature mortality, temporary and permanent disabilities. RESULTS In 2015 over 41 million adults (20 years of age and more) were estimated to have Diabetes Mellitus in LAC. The total indirect cost attributed to Diabetes was US$ 57.1 billion, of which US$ 27.5 billion was due to premature mortality, US$16.2 billion to permanent disability, and US$ 13.3 billion to temporary disability. The total direct cost was estimated between US$ 45 and US$ 66 billion, of which the highest estimated cost was due to treatment of complications (US$ 1 616 to US$ 26 billion). Other estimates indicated the cost of insulin between US$ 6 and US$ 11 billion; oral medication US$ 4 to US$ 6 billion; consultations between US$ 5 and US$ 6 billion; hospitalization US$ 10 billion; emergency visits US$ 1 billion; test and laboratory exams between US$ 1 and US$ 3 million. The total cost of diabetes in 2015 in LAC was estimated to be between US$ 102 and US$ 123 billion. On average, the annual cost of treating one case of diabetes mellitus (DM) in LAC was estimated between US$ 1088 and US$ 1818. Per capita National Health Expenditures averaged US$ 1061 in LAC. CONCLUSIONS Diabetes represented a major economic burden to the countries of Latin America and the Caribbean in 2015. The estimates presented here are key information for decision–making that can be used in the formulation of policies and programs to achieve greater efficiency and effectiveness in the use of resources for diabetes prevention in the 29 countries of LAC.
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Affiliation(s)
- Alberto Barcelo
- University of Miami, Miller School of Medicine, Miami, Florida, USA
| | | | | | - Johanna Segovia
- University of Miami, Miller School of Medicine, Miami, Florida, USA
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Machado-Duque ME, Ramírez-Riveros AC, Machado-Alba JE. Effectiveness and clinical inertia in patients with antidiabetic therapy. Int J Clin Pract 2017; 71. [PMID: 28524340 DOI: 10.1111/ijcp.12954] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
AIMS To establish the effectiveness of antidiabetic therapy and the frequency of clinical inertia in the management of type 2 diabetes mellitus in Colombia. METHODS A cross-sectional study with follow-up of patients who had been treated for at least 1 year and were receiving medical consultation for antidiabetic treatment. Effectiveness was established when haemoglobin-A1c levels were <7% and when clinical inertia was reached, which was defined as no therapeutic modifications despite not achieving management controls. Sociodemographic, clinical and pharmacological variables were evaluated, and multivariate analyses were performed. RESULTS In total, 363 patients with type 2 diabetes mellitus were evaluated, with a mean age of 62.0±12.2 years. A total of 1,016 consultations were evaluated, and the therapy was effective at the end of the follow-up in 57.9% of cases. Clinical inertia was found in 56.8% of patients who did not have metabolic control. The most frequently prescribed medications were metformin (84.0%), glibenclamide (23.4%) and insulin glargine (20.7%). Moreover, 57.6% of the patients were treated with two or more antidiabetic medications. Having metabolic control in the first consult of the follow-up was a protective factor against clinical inertia in the subsequent consultations (OR: 0.08; 95%CI: 0.04-0.15; P<.001). CONCLUSIONS The effectiveness of treatment for patients with type 2 diabetes mellitus has increased in Colombia, and for the first time, clinical inertia was identifiable and quantifiable and found in similar proportions to other countries. Clinical inertia is a relevant condition given that it interferes with the possibility of controlling this pathology.
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Affiliation(s)
- Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Facultad Ciencias de la Salud, Universidad Tecnológica de Pereira, Colombia
| | | | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A., Pereira, Colombia
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Moreira AM, Marobin R, Rados DV, de Farias CB, Coelli S, Bernardi BL, Faller LDA, Dos Santos LF, Matzenbacher AM, Katz N, Harzheim E, Silveiro SP. Effects of nurse telesupport on transition between specialized and primary care in diabetic patients: study protocol for a randomized controlled trial. Trials 2017; 18:222. [PMID: 28521796 PMCID: PMC5437415 DOI: 10.1186/s13063-017-1954-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 04/27/2017] [Indexed: 11/24/2022] Open
Abstract
Background According to the Global Diabetes Plan, a unified health system with preventive and educational strategies is essential to proper diabetes care and primary settings should be the main site of care. In Brazil, there is limited access to outpatient hospital diabetes services, while primary-care diabetes support is underutilized. Telemedicine can be a useful adjunct to support discharge of stable patients with type 2 diabetes to the primary care setting. In this paper, we present a randomized controlled trial (RCT) protocol designed to evaluate the effects of telehealth support for stable type 2 diabetes patients discharged from hospital outpatient diabetes clinics. Methods We designed a RCT. Patients with stable type 2 diabetes (glycated hemoglobin < 8%) considered eligible for discharge from specialized to primary care will be included. Those with uncontrolled ischemic heart disease, severe neuropathy, and stage IV/V nephropathy will be excluded. Enrolled patients will be randomized into two groups: follow-up supported by periodic phone calls by a nurse (intervention group) plus primary care or routine primary care only (control group). The intervention group will receive regular telephone calls (every three months for one year) and will have a toll-free number to call in case of questions about disease management. The main outcome measure is a comparison of glycemic control between groups (assessed by glycated hemoglobin) at one-year follow-up. Discussion We plan to evaluate the effectiveness of a telephone-based intervention on glycemic control in patients with type 2 diabetes followed by primary care teams. Telemedicine can be an important adjunct in type 2 diabetes management, improving patient education and knowledge about the disease. Furthermore, it can help the healthcare system by alleviating overload in specialized care settings and supporting the stewardship role of primary care. Trial registration Clinical Trials, NCT02768480. Registered on 29 April 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1954-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ana Marina Moreira
- Post Graduate Program in Medical Sciences - Division of Endocrinology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil. .,Serviço de Endocrinologia do Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos, 2350, 4 andar, Porto Alegre, RS, CEP 90035-903, Brazil.
| | - Roberta Marobin
- Post Graduate Program in Medical Sciences - Division of Endocrinology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Dimitris Varvaki Rados
- Post Graduate Program in Medical Sciences - Division of Endocrinology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.,Division of Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Camila Bergonsi de Farias
- Post Graduate Program in Medical Sciences - Division of Endocrinology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Sabrina Coelli
- Post Graduate Program in Medical Sciences - Division of Endocrinology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Bárbara Luiza Bernardi
- Post Graduate Program in Medical Sciences - Division of Endocrinology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | | | | | | | - Natan Katz
- Division of Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Erno Harzheim
- Division of Epidemiology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Sandra Pinho Silveiro
- Post Graduate Program in Medical Sciences - Division of Endocrinology, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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Ali MK, Singh K, Kondal D, Devarajan R, Patel SA, Shivashankar R, Ajay VS, Unnikrishnan AG, Menon VU, Varthakavi PK, Viswanathan V, Dharmalingam M, Bantwal G, Sahay RK, Masood MQ, Khadgawat R, Desai A, Sethi B, Prabhakaran D, Narayan KMV, Tandon N. Effectiveness of a Multicomponent Quality Improvement Strategy to Improve Achievement of Diabetes Care Goals: A Randomized, Controlled Trial. Ann Intern Med 2016; 165:399-408. [PMID: 27398874 PMCID: PMC6561084 DOI: 10.7326/m15-2807] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Achievement of diabetes care goals is suboptimal globally. Diabetes-focused quality improvement (QI) is effective but remains untested in South Asia. OBJECTIVE To compare the effect of a multicomponent QI strategy versus usual care on cardiometabolic profiles in patients with poorly controlled diabetes. DESIGN Parallel, open-label, pragmatic randomized, controlled trial. (ClinicalTrials.gov: NCT01212328). SETTING Diabetes clinics in India and Pakistan. PATIENTS 1146 patients (575 in the intervention group and 571 in the usual care group) with type 2 diabetes and poor cardiometabolic profiles (glycated hemoglobin [HbA1c] level ≥8% plus systolic blood pressure [BP] ≥140 mm Hg and/or low-density lipoprotein cholesterol [LDLc] level ≥130 mg/dL). INTERVENTION Multicomponent QI strategy comprising nonphysician care coordinators and decision-support electronic health records. MEASUREMENTS Proportions achieving HbA1c level less than 7% plus BP less than 130/80 mm Hg and/or LDLc level less than 100 mg/dL (primary outcome); mean risk factor reductions, health-related quality of life (HRQL), and treatment satisfaction (secondary outcomes). RESULTS Baseline characteristics were similar between groups. Median diabetes duration was 7.0 years; 6.8% and 39.4% of participants had preexisting cardiovascular and microvascular disease, respectively; mean HbA1c level was 9.9%; mean BP was 143.3/81.7 mm Hg; and mean LDLc level was 122.4 mg/dL. Over a median of 28 months, a greater percentage of intervention participants achieved the primary outcome (18.2% vs. 8.1%; relative risk, 2.24 [95% CI, 1.71 to 2.92]). Compared with usual care, intervention participants achieved larger reductions in HbA1c level (-0.50% [CI, -0.69% to -0.32%]), systolic BP (-4.04 mm Hg [CI, -5.85 to -2.22 mm Hg]), diastolic BP (-2.03 mm Hg [CI, -3.00 to -1.05 mm Hg]), and LDLc level (-7.86 mg/dL [CI, -10.90 to -4.81 mg/dL]) and reported higher HRQL and treatment satisfaction. LIMITATION Findings were confined to urban specialist diabetes clinics. CONCLUSION Multicomponent QI improves achievement of diabetes care goals, even in resource-challenged clinics. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute and UnitedHealth Group.
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Affiliation(s)
- Mohammed K Ali
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Kavita Singh
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Dimple Kondal
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Raji Devarajan
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Shivani A Patel
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Roopa Shivashankar
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Vamadevan S Ajay
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - A G Unnikrishnan
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - V Usha Menon
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Premlata K Varthakavi
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Vijay Viswanathan
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Mala Dharmalingam
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Ganapati Bantwal
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Rakesh Kumar Sahay
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Muhammad Qamar Masood
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Rajesh Khadgawat
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Ankush Desai
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Bipin Sethi
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Dorairaj Prabhakaran
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - K M Venkat Narayan
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
| | - Nikhil Tandon
- From the Rollins School of Public Health, Emory University, Atlanta, Georgia; All India Institute of Medical Sciences, New Delhi, India; Public Health Foundation of India, Gurgaon, India; Chellaram Diabetes Institute, Pune, India; Amrita Institute of Medical Sciences, Kochi, India; Topiwala National Medical College & BYL Nair Charity Hospital, Mumbai, India; M.V. Hospital for Diabetes and Diabetes Research Centre, Chennai, India; Bangalore Endocrinology & Diabetes Research Centre and St. John's Medical College and Hospital, Bangalore, India; Osmania General Hospital and CARE Hospital, Hyderabad, India; Aga Khan University, Karachi, Pakistan; and Goa Medical College, Bambolim, India
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Fantinati MS, Mendonça DEO, Fantinati AMM, Santos BFD, Reis JCO, Afonso CL, Vinaud MC, Lino Júnior RDS. Low intensity ultrasound therapy induces angiogenesis and persistent inflammation in the chronic phase of the healing process of third degree burn wounds experimentally induced in diabetic and non-diabetic rats. Acta Cir Bras 2016; 31:463-71. [DOI: 10.1590/s0102-865020160070000006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/22/2016] [Indexed: 12/25/2022] Open
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Gregg EW, Sattar N, Ali MK. The changing face of diabetes complications. Lancet Diabetes Endocrinol 2016; 4:537-47. [PMID: 27156051 DOI: 10.1016/s2213-8587(16)30010-9] [Citation(s) in RCA: 336] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/22/2016] [Accepted: 03/23/2016] [Indexed: 12/16/2022]
Abstract
The global increase in type 2 diabetes prevalence is well documented, but international trends in complications of type 2 diabetes are less clear. The available data suggest large reductions in classic complications of type 2 diabetes in high-income countries over the past 20 years, predominantly reductions in myocardial infarction, stroke, amputations, and mortality. These trends might be accompanied by less obvious, but still important, changes in the character of morbidity in people with diabetes. In the USA, for example, substantial reductions in macrovascular complications in adults aged 65 years or older mean that a large proportion of total complications now occur among adults aged 45-64 years instead, rates of renal disease could persist more than other complications, and obesity-related type 2 diabetes could have increasing effect in youth and adults under 45 years of age. Additionally, the combination of decreasing mortality and increasing diabetes prevalence has increased the overall mean years lived with diabetes and could lead to a diversification of diabetes morbidity, including continued high rates of renal disease, ageing-related disability, and cancers. Unfortunately, data on trends in diabetes-related complications are limited to only about a dozen countries, most of which are high income, leaving the changing character for countries of low and middle income ambiguous.
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Affiliation(s)
- Edward W Gregg
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mohammed K Ali
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA, USA; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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15
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Hennink MM, Kaiser BN, Sekar S, Griswold EP, Ali MK. How are qualitative methods used in diabetes research? A 30-year systematic review. Glob Public Health 2016; 12:200-219. [DOI: 10.1080/17441692.2015.1120337] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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16
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Haw JS, Venkat Narayan KM, Ali MK. Quality improvement in diabetes-successful in achieving better care with hopes for prevention. Ann N Y Acad Sci 2015; 1353:138-51. [DOI: 10.1111/nyas.12950] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
| | - K. M. Venkat Narayan
- School of Medicine
- Rollins School of Public Health; Emory University; Atlanta Georgia
| | - Mohammed K. Ali
- Rollins School of Public Health; Emory University; Atlanta Georgia
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Anjana RM, Shanthirani CS, Unnikrishnan R, Mugilan P, Amutha A, Nair HD, Subhashini S, Venkatesan U, Ali MK, Ranjani H, Mohan V. Regularity of follow-up, glycemic burden, and risk of microvascular complications in patients with type 2 diabetes: a 9-year follow-up study. Acta Diabetol 2015; 52:601-9. [PMID: 25539883 DOI: 10.1007/s00592-014-0701-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 12/09/2014] [Indexed: 12/01/2022]
Abstract
AIMS To assess the relationship between regularity of follow-up and risk of complications in patients with type 2 diabetes (T2DM) followed up for 9 years at a tertiary diabetes center in India. METHODS We compared glycemic burden [cumulative time spent above a HbA1c of 53 mmol/mol (7 %)] and incidence of diabetes complications (retinopathy, neuropathy, nephropathy, peripheral arterial disease, coronary heart disease) between 1,783 T2DM patients with "regular follow-up" (minimum of three visits and two HbA1c tests every year from 2003 to 2012), and 1,798 patients with "irregular follow-up" (two visits or less and one HbA1c or less per year during the same time period), retrospectively identified from medical records. Cox proportional hazards models were used to estimate risk associated with diabetes complications. RESULTS Compared to those with regular follow-up, the irregular follow-up group had significantly higher mean fasting and postprandial plasma glucose, HbA1c, glycemic burden, total and LDL cholesterol, and triglycerides at every time point during the 9 years of follow-up. Those with irregular follow-up had double the total and mean monthly glycemic burden and 1.98 times higher risk of retinopathy (95 % CI 1.62, 2.42) and 2.11 times higher risk of nephropathy (95 % CI 1.73, 2.58) compared to those with regular follow-up, even after adjusting for time-varying confounding variables. Complications tended to develop significantly earlier and were more severe in those with irregular follow-up. CONCLUSION Among patients with type 2 diabetes, regular follow-up was associated with significantly lower glycemic burden and lower incidence of retinopathy and nephropathy over a 9-year period.
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Affiliation(s)
- Ranjit Mohan Anjana
- Madras Diabetes Research Foundation and Dr. Mohan's Diabetes Specialities Centre, WHO Collaborating Centre for Non-Communicable Diseases Prevention and Control & IDF Centre of Education, 4, Conran Smith Road, Gopalapuram, Chennai, 600086, India,
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Escalante M, Gagliardino JJ, Guzmán JR, Tschiedel B. Call-to-action: timely and appropriate treatment for people with type 2 diabetes in Latin America. Diabetes Res Clin Pract 2014; 104:343-52. [PMID: 24835577 DOI: 10.1016/j.diabres.2014.01.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 08/27/2013] [Accepted: 01/01/2014] [Indexed: 01/27/2023]
Abstract
Latin America faces a unique set of challenges in the treatment of type 2 diabetes mellitus (T2DM). This report identifies these challenges and provides a framework for implementation of the strategies, policies and education programs which are needed to optimize the management of this condition. In order to improve future diabetes care, it will be necessary to address existing problems such as limitation of resources, inadequate management of hyperglycemia, and inappropriate education of healthcare team members and people with diabetes. Achieving these goals will require collaborative efforts by many individuals, groups and organizations. These include policymakers, international organizations, healthcare providers, those responsible for setting medical school curricula, patients and society as a whole. It is anticipated that improved/continuing education of healthcare professionals, diabetes self-management education and development of a team approach for T2DM care will lead to optimization of patient-centered care. Implementation of multicentric demonstration studies and rational use of antidiabetic treatments will be necessary to demonstrate the long-term favorable impact of these strategies upon quality of care, prevention of chronic complications, mortality, healthcare costs and patient quality of life.
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Affiliation(s)
- Miguel Escalante
- Hospital de Especialidades, Centro Medico Nacional de Occidente, Mexican Institute of Social Security, Guadalajara, Mexico.
| | - Juan José Gagliardino
- CENEXA. Centro de Endocrinología Experimental y Aplicada (UNLP-CONICET La Plata), PAHO/WHO Collaborating Centre for Diabetes, Facultad de Ciencias Médicas UNLP, La Plata, Argentina
| | - Juan Rosas Guzmán
- Centro de Especialidades Medicas de Celaya, Latin University of Mexico in Celaya, Guanajuato, Mexico
| | - Balduino Tschiedel
- Institute for Children with Diabetes in Porto Alegre and the Brazilian Diabetes Society, Porto Alegre, Brazil
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Davidson JA, Lajara R, Aguilar RB, Mattheus M, Woerle HJ, von Eynatten M. Efficacy and safety of linagliptin in Hispanic/Latino patients with type 2 diabetes mellitus: a pooled analysis from six randomized placebo-controlled phase 3 trials. BMJ Open Diabetes Res Care 2014; 2:e000020. [PMID: 25452864 PMCID: PMC4212575 DOI: 10.1136/bmjdrc-2014-000020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 03/04/2014] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE The number of individuals diagnosed with type 2 diabetes mellitus is expected to rise disproportionately in Hispanic/Latino populations. We therefore aimed to assess the efficacy and safety of the dipeptidyl peptidase-4 inhibitor linagliptin specifically in Hispanic/Latino patients with type 2 diabetes mellitus. RESEARCH DESIGN AND METHODS Data from 745 patients who self-identified their ethnicity as Hispanic or Latino were pooled from six randomized, placebo-controlled phase 3 trials. Participants received linagliptin (5 mg/day) or placebo as monotherapy, or in combination with other oral antidiabetes drugs for 18 or 24 weeks. RESULTS The placebo-adjusted mean change (95% CI) in glycated hemoglobin from baseline (mean 8.2%) was -0.63% (-0.77 to -0.48; p<0.0001) at week 18, and -0.58% (-0.74 to -0.42; p<0.0001) at week 24. The placebo-adjusted mean change (95% CI) in fasting plasma glucose from baseline was -11.7 mg/dL (-19.3 to -4.0; p=0.0028) at week 18 and -14.1 mg/dL (-22.0 to -6.3; p=0.0004) at week 24. Hypoglycemia incidence was 17.4% with linagliptin and 21% with placebo. In patients not receiving concomitant sulfonylurea, the hypoglycemia incidence was 10.1% with linagliptin and 19.4% with placebo. The overall incidence of adverse events (AEs), drug-related AEs, and serious AEs with linagliptin was similar to placebo (AEs 67.6% vs 68.9%; drug-related AEs 15.1% vs 18.7%; serious AEs 3.6% vs 3.0%). The mean body weight remained unchanged in both groups. CONCLUSIONS In Hispanic/Latino patients with inadequately controlled type 2 diabetes mellitus, linagliptin provided clinically meaningful improvements in glycemic control without weight gain or increased risk of hypoglycemia.
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Affiliation(s)
- Jaime A Davidson
- The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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de Vries ST, Voorham J, Haaijer-Ruskamp FM, Denig P. Potential overtreatment and undertreatment of diabetes in different patient age groups in primary care after the introduction of performance measures. Diabetes Care 2014; 37:1312-20. [PMID: 24595634 DOI: 10.2337/dc13-1861] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess whether after the introduction of diabetes performance measures decreases in undertreatment correspond with increases in overtreatment for blood pressure (BP) and glycemic control in different patient age groups. RESEARCH DESIGN AND METHODS We conducted a cohort study using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database. General practices were included when data were available from 1 year before to at least 1 year after the introduction of diabetes performance measures. Included patients had a confirmed diagnosis of type 2 diabetes. Potential overtreatment was defined as prescribing maximum treatment or a treatment intensification to patients with a sustained low-risk factor level. Potential undertreatment was defined as a lack of treatment intensification in patients with a sustained high-risk factor level. Percentages of over- and undertreated patients at baseline were compared with those in subsequent years, and stratified analyses were performed for different patient age groups. RESULTS For BP, undertreatment significantly decreased from 61 to 57% in the first year after the introduction of performance measures. In patients >75 years of age, undertreatment decreased from 65 to ∼61%. Overtreatment was relatively stable (∼16%). For glycemic control, undertreatment significantly increased from 49 to 53%, and overtreatment remained relatively stable (∼7%). CONCLUSIONS The improvement of BP undertreatment after introduction of the performance measures did not correspond with an increase in overtreatment. The performance measures appeared to have little impact on improving glucose-regulating treatment. The trends did not differ among patient age groups.
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Ricci-Cabello I, Ruiz-Perez I, Rojas-García A, Pastor G, Gonçalves DC. Improving diabetes care in rural areas: a systematic review and meta-analysis of quality improvement interventions in OECD countries. PLoS One 2013; 8:e84464. [PMID: 24367662 PMCID: PMC3868600 DOI: 10.1371/journal.pone.0084464] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 11/21/2013] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND AIMS Despite well documented disparities in health and healthcare in rural communities, evidence in relation to quality improvement (QI) interventions in those settings is still lacking. The main goals of this work were to assess the effectiveness of QI strategies designed to improve diabetes care in rural areas, and identify characteristics associated with greater success. METHODS We conducted a systematic review and meta-analysis. Systematic electronic searches were conducted in MEDLINE, EMBASE, CINAHL, and 12 additional bibliographic sources. Experimental studies carried out in the OECD member countries assessing the effectiveness of QI interventions aiming to improve diabetes care in rural areas were included. The effect of the interventions and their impact on glycated hemoglobin was pooled using a random-effects meta-analysis. RESULTS Twenty-six studies assessing the effectiveness of twenty QI interventions were included. Interventions targeted patients (45%), clinicians (5%), the health system (15%), or several targets (35%), and consisted of the implementation of one or multiple QI strategies. Most of the interventions produced a positive impact on processes of care or diabetes self-management, but a lower effect on health outcomes was observed. Interventions with multiple strategies and targeting the health system and/or clinicians were more likely to be effective. Six QI interventions were included in the meta-analysis (1,496 patients), which showed a significant reduction in overall glycated hemoglobin of 0.41 points from baseline in those patients receiving the interventions (95% CI -0.75% to -0.07%). CONCLUSIONS This work identified several characteristics associated with successful interventions to improve the quality of diabetes care in rural areas. Efforts to improve diabetes care in rural communities should focus on interventions with multiple strategies targeted at clinicians and/or the health system, rather than on traditional patient-oriented interventions.
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Affiliation(s)
- Ignacio Ricci-Cabello
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- CIBER en Epidemiologia y Salud Pública (CIBERESP), Barcelona, Spain
| | - Isabel Ruiz-Perez
- CIBER en Epidemiologia y Salud Pública (CIBERESP), Barcelona, Spain
- Andalusian School of Public Health, Granada, Spain
| | - Antonio Rojas-García
- CIBER en Epidemiologia y Salud Pública (CIBERESP), Barcelona, Spain
- Andalusian School of Public Health, Granada, Spain
| | | | - Daniela C. Gonçalves
- Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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