Assessing diabetic control--reliability of methods available in resource poor settings

Process evaluation of integrated diabetes management at primary healthcare facilities in Pakistan: a mixed-methods study

Background

Integrated care for diabetes and associated conditions at primary level health facilities can make care available to a much larger population, especially in rural areas.

Aim

This process evaluation was to understand how the authors' integrated care was implemented and experienced by the care providers and patients, and to inform modifications prior to province-wide scale-up.

Design & setting

The mixed-method study was conducted as part of a cluster randomised trial on integrated diabetes care at 14 public health facilities.

Method

The care practices were assessed by analysing the routine clinical records of 495 registered patients with diabetes. Then semi-structured interviews with service providers and patients were used to understand their respective care experiences. A framework approach was applied to analyse and interpret the qualitative data.

Results

The intervention and the study were implemented as intended under routine conditions in rural health centres. Key service processes effectively delivered included: skill-based training; screening and diagnostic tests; treatment card records; and the additional case management as per desk guide, including monitoring progress in glucose and weight at follow-up consultations, and mobile phone calls to help adherence. However, social and cultural factors affected clients' ability to change lifestyles, especially for women. The intervention effect was limited by the short study follow-up of only 9 months.

Conclusion

Integrated diabetes care was feasible, both for providers and patients, and potentially scalable at primary care facilities under routine conditions in Pakistan. Additional operational interventions are required for sustained drug supplies, supervision, in-service training, and to address the social challenges to healthy activity and eating, especially for women.

Clinical management of concurrent diabetes and tuberculosis and the implications for patient services

Diabetes triples the risk for active tuberculosis, thus the increasing burden of type 2 diabetes will help to sustain the present tuberculosis epidemic. Recommendations have been made for bidirectional screening, but evidence is scarce about the performance of specific tuberculosis tests in individuals with diabetes, specific diabetes tests in patients with tuberculosis, and screening and preventive therapy for latent tuberculosis infections in individuals with diabetes. Clinical management of patients with both diseases can be difficult. Tuberculosis patients with diabetes have a lower concentration of tuberculosis drugs and a higher risk of drug toxicity than tuberculosis patients without diabetes. Good glycaemic control, which reduces long-term diabetes complications and could also improve tuberculosis treatment outcomes, is hampered by chronic inflammation, drug-drug interactions, suboptimum adherence to drug treatments, and other factors. Besides drug treatments for tuberculosis and diabetes, other interventions, such as education, intensive monitoring, and lifestyle interventions, might be needed, especially for patients with newly diagnosed diabetes or those who need insulin. From a health systems point of view, delivery of optimum care and integration of services for tuberculosis and diabetes is a huge challenge in many countries. Experience from the combined tuberculosis and HIV/AIDS epidemic could serve as an example, but more studies are needed that include economic assessments of recommended screening and systems to manage concurrent tuberculosis and diabetes.

An effective system of nurse-led diabetes care in rural Africa

AIMS

Delivering adequate diabetes care is difficult in rural Africa because of drug and equipment shortages; as well as lack of trained medical expertise. We aimed to set up and evaluate a nurse-led protocol and education-based system in rural Kwazulu Natal in South Africa.

METHODS

A treatment algorithm and education system adapted from previously validated methods was used; care was devolved to primary health clinics and was delivered by two nurses. Glycaemic control was assessed by glycated haemoglobin (HbA1c), assayed off site and not available for clinical use during the study. Results A total of 284 patients were enrolled, with 197 followed for 18 months (13 died and 26% lapsed during the period). HbA1c was 11.6 +/- 4.5% (sd) at baseline, 8.7 +/- 2.3% at 6 months and 7.7 +/- 2.0% at 18 months. There was a small associated increase in weight but no increase in hypoglycaemia. Subgroup analysis showed that education alone, without drug type or dose changes, also improved control (HbA1c 10.6 +/- 4.2% baseline and 7.6 +/- 2.3% at 18 months). The service was very popular with patients, families and other health workers.

CONCLUSIONS

We conclude that a simple protocol and education-based diabetes care system can be successfully introduced and run by nurses in rural Africa. Medium-term glycaemic improvements are excellent and the service has been very well received.

The influence of glucose self-monitoring on glycaemic control in patients with diabetes mellitus in Sudan

OBJECTIVE

To investigate the influence of self-monitoring of glucose on the glycaemic control in Sudanese diabetic subjects.

SUBJECTS AND METHODS

A group of 193 consecutive type 2 and type 1 diabetic subjects (95 men, 98 women) were studied. In 104 subjects with type 2 diabetes fasting blood glucose was measured using a glucose meter and blood was obtained for serum glucose measurement in the laboratory. In the remaining 89 diabetic subjects random blood glucose was measured using the same glucose meter and a whole blood sample was drawn for laboratory assessment of HbA1c. Data on self-monitoring and other clinical and personal characteristics were recorded.

RESULTS

More than 75% of either type 1 and type 2 diabetic patients never self-monitored blood or urine glucose. In type 2 diabetic subjects self-monitoring of blood or urine glucose was not related to glycaemic control. In type 1 diabetic subjects, however, self-monitoring of blood glucose was significantly associated with better glycaemic control, as assessed by HbA1c (P=0.02) and blood glucose at clinic visits (P< or =0.0001), and similar associations were found for urine glucose self-monitoring (P=0.04 and 0.02) respectively. Neither glycaemic control nor glucose self-monitoring was associated with education level.

CONCLUSIONS

Self-monitoring of blood glucose was not found to be associated to better glycaemic control in Sudanese subjects with type 2 diabetes. In contrast, self-monitoring of both blood and urine glucose was significantly associated with glycaemic control in subjects with type 1 diabetes. Self-monitoring of urine glucose could be useful where measurement of blood glucose is not available or affordable.

Predictive factors for nocturia in elderly men: a cross-sectional study in 21 general practices

OBJECTIVE

To measure the prevalence of nocturia in general practice and to determine which factors are associated with nocturia.

SUBJECTS AND METHODS

Data were collected from 3048 elderly men, who completed a questionnaire that was sent to every man aged 55-75 years in 21 general practices in Maastricht (the Netherlands). The symptom of nocturia was defined as two or more nocturnal voids. We investigated the prevalence of nocturia and the predictive relationships with the following factors: cerebrovascular disease, diabetes mellitus/insipidus (DMI), Parkinson's diseases, cardiovascular disease, hypertension, bladder/prostate cancer, kidney diseases, urinary bladder inflammation, congenital diseases (kidneys or prostate), using medical treatment for lower urinary tract symptoms, other treatment, psychological depression, symptoms suggestive of benign prostatic hyperplasia (BPH), and alcohol intake.

RESULTS

Data from 2934 respondents were analysed; the prevalence of nocturia (two or more nocturnal voids) was 32.9% (965 men). The frequency of the number of nocturnal voids was: zero in 588 (20.0%), one in 1344 (45.8%), two in 611 (20.8%), three in 208 (7.1%), four in 70 (2.4%), and five or more in 76 (2.6%), with 37 values missing. A multivariate logistic regression analysis showed that nocturia in elderly men was significantly related to bladder/prostate cancer, cerebrovascular disease, treatment of voiding disorders, and moderate alcohol consumption. Next to these, BPH had a significant relationship with nocturia, especially in respondents with DMI and hypertension. Cardiovascular disease or hypertension was significantly related to nocturia, mutually replacing each other as a risk factor.

CONCLUSION

Nocturia in elderly men is be related to many sources of potential risk factors: earlier urological diseases, cardiovascular and cerebrovascular diseases, BPH, DMI and behavioural habits. Some of these sources may interact and generate especially high risk in some groups for nocturia.

An accurate and portable system for glycated haemoglobin measurement in the tropics

Measurement of glycated haemoglobin (HbA1c) is vital to provide meaningful diabetic care, but the assay is difficult and expensive, making its availability limited in resource-poor countries. We have field-tested a novel near-patient HbA1c meter (Glycosal; Provalis Diagnostics Ltd, UK) in northern Ethiopia. The machine was easy to use and gave results which correlated well (r = -0.96) with standard laboratory methods. The meter also performed well and retained accuracy at high ambient temperature (34.0 degrees C). Though still relatively expensive (pound 4 per test), this meter does give the opportunity for practical and appropriate HbA1c testing in tropical climes, and should be considered for at least intermittent use in diabetic patients.

Variations in care of diabetes in primary care centres in Tunis

The aim of this study was to investigate the care of diabetes in primary care in the public sector in Greater Tunis and in particular, to assess variations in care across centres with the intention of seeking explanations for any differences identified. We undertook a retrospective medical review of patients with diabetes from four primary care health centres. Data were collected concerning patient characteristics, process of care criteria, outcome of care criteria, attendance rates, treatment and health centre characteristics. The total sample size was 235 patients. Outcome of care criteria were found to be similar across each of the centres. Process of care criteria were found to be significantly varied between the centres for all measurements used. Variations were also found in treatment and attendance rates across the health centres. In conclusion, there is a significant variation in the management of diabetes in primary care across centres within Greater Tunis, despite the use of standardised, national guidelines. A number of factors related to the centres may have given rise to these variations.