Quality of Type II Diabetes Care in Primary Health Care Centers in Kuwait: Employment of a Diabetes Quality Indicator Set (DQIS)

Indirect effects of the COVID-19 pandemic on diagnosing, monitoring, and prescribing in people with diabetes and strategies for diabetes service recovery internationally

The COVID-19 pandemic has caused major disruptions in clinical services for people with chronic long-term conditions. In this narrative review, we assess the indirect impacts of the COVID-19 pandemic on diabetes services globally and the resulting adverse effects on rates of diagnosing, monitoring, and prescribing in people with type 2 diabetes. We summarise potential practical approaches that could address these issues and improve clinical services and outcomes for people living with diabetes during the recovery phase of the pandemic.

Assessment of Quality of Diabetic Care in Teaching Hospitals in Ethiopia: In Comparison to International Guidelines

Background

Comprehensive high quality of care is critical in preventing diabetic complications and improving quality of life. This needs compliance with guidelines and focused therapy. There is no data in Ethiopia evaluating the quality of diabetes care using standard guidelines (American diabetic association and international diabetic federation) as a reference.

Methods

A cross-sectional study was conducted at Yekatit 12 Hospital Medical College (YHMC) to assess the process and outcome quality indicators of diabetic patients. Data were collected from outpatient clinics between May and July 2022 over a period of 3 months. Diabetic patients with at least one year since diagnosis were selected using systematic random sampling. Both the process and outcome of diabetic quality care indicators were measured and compared with standard guidelines (ADA and IDF). Both descriptive statistics and logistic regression were used for data analysis. The P-value <0.05 was used as statistical significance.

Results

About 250 diabetic patients with a mean age of 53±15 were included. The majority were type 2 diabetes mellitus (83.2%). HbA1c was determined for 128 (51.2%) patients with the recent mean value of 8±1.6. Only 52 (40.6%) of patients achieved target HbA1c. Annual comprehensive feet examination, urine albuminuria test, and retinal examination were done for 54 (21.6%), 52 (20.8%), and 122 (48.8%), respectively. Single marital status (AOR = 5.76; 95% CI; 1.02-32.36) P = 0.047, determining HbA1c level at least twice a year (AOR = 6.27; 95% CI; 2.18-17.73) P = 0.001, and medication adherence (AOR = 7.1; 95% CI; 2.61-19.01)P = 0.001, were significantly associated with good glycemic control.

Conclusion

The overall quality of diabetic care was found suboptimal both in process and outcome quality indicators. Thus, awareness creation about quality indicators for caregivers, compliance with guidelines, wise resource utilization, and cooperation with different stakeholders like hospital management teams, and government officials is needed.

Development of indicators to assess quality and patient pathways in interdisciplinary care for patients with 14 ambulatory-care-sensitive conditions in Germany

BACKGROUND

In settings like the ambulatory care sector in Germany, where data on the outcomes of interdisciplinary health services provided by multiple office-based physicians are not always readily available, our study aims to develop a set of indicators of health care quality and utilization for 14 groups of ambulatory-care-sensitive conditions based on routine data. These may improve the provision of health care by informing discussions in quality circles and other meetings of networks of physicians who share the same patients.

METHODS

Our set of indicators was developed as part of the larger Accountable Care in Deutschland (ACD) project using a pragmatic consensus approach. The six stages of the approach drew upon a review of the literature; the expertise of physicians, health services researchers, and representatives of physician associations and statutory health insurers; and the results of a pilot study with six informal network meetings of office-based physicians who share the same patients.

RESULTS

The process resulted in a set of 248 general and disease specific indicators for 14 disease groups. The set provides information on the quality of care provided and on patient pathways, covering patient characteristics, physician visits, ambulatory care processes, pharmaceutical prescriptions and outcome indicators. The disease groups with the most indicators were ischemic heart diseases, diabetes and heart failure.

CONCLUSION

Our set of indicators provides useful information on patients' health care use, health care processes and health outcomes for 14 commonly treated groups of ambulatory-care-sensitive conditions. This information can inform discussions in interdisciplinary quality circles in the ambulatory sector and foster patient-centered care.

Impact of COVID-19 restrictions on diabetes health checks and prescribing for people with type 2 diabetes: a UK-wide cohort study involving 618 161 people in primary care

Objective

To compare rates of performing National Institute for Health and Care Excellence-recommended health checks and prescribing in people with type 2 diabetes (T2D), before and after the first COVID-19 peak in March 2020, and to assess whether trends varied by age, sex, ethnicity and deprivation.

Methods

We studied 618 161 people with T2D followed between March and December 2020 from 1744 UK general practices registered with the Clinical Practice Research Datalink. We focused on six health checks: haemoglobin A1c, serum creatinine, cholesterol, urinary albumin excretion, blood pressure and body mass index assessment. Regression models compared observed rates in April 2020 and between March and December 2020 with trend-adjusted expected rates derived from 10-year historical data.

Results

In April 2020, in English practices, rates of performing health checks were reduced by 76%–88% when compared with 10-year historical trends, with older people from deprived areas experiencing the greatest reductions. Between May and December 2020, the reduced rates recovered gradually but overall remained 28%–47% lower, with similar findings in other UK nations. Extrapolated to the UK population, there were ~7.4 million fewer care processes undertaken March–December 2020. In England, rates for new medication fell during April with reductions varying from 10% (95% CI: 4% to 16%) for antiplatelet agents to 60% (95% CI: 58% to 62%) for antidiabetic medications. Overall, between March and December 2020, the rate of prescribing new diabetes medications fell by 19% (95% CI: 15% to 22%) and new antihypertensive medication prescribing fell by 22% (95% CI: 18% to 26%), but prescribing of new lipid-lowering or antiplatelet therapy was unchanged. Similar trends were observed across the UK, except for a reduction in new lipid-lowering therapy prescribing in the other UK nations (reduction: 16% (95% CI: 10% to 21%)). Extrapolated to the UK population, between March and December 2020, there were ~31 800 fewer people with T2D prescribed a new type of diabetes medication and ~14 600 fewer prescribed a new type of antihypertensive medication.

Conclusions

Over the coming months, healthcare services will need to manage this backlog of testing and prescribing. We recommend effective communications to ensure patient engagement with diabetes services, monitoring and opportunities for prescribing, and when appropriate use of home monitoring, remote consultations and other innovations in care.

OUTCOME INDICATORS OF MULTI-PROFESSIONAL DIABETES CARE IN A REFERENCE SERVICE

ABSTRACT Objective to identify outcome indicators of the multi-professional Diabetes Mellitus care of a reference outpatient service. Method a descriptive study of evaluative nature, according to the health evaluation framework, carried out by documentary analysis of 173 medical charts, from August to October 2018. The variables were analyzed in the Statistical Package for the Social Science (SPSS), version 22.0, by descriptive statistics, as well as the association of variables, with the Chi-square, Mann-Whitney, and Wilcoxon tests being used, considering p-values ≤ 0.05 as statistically significant. Results predominance of older adult women, with a mean diagnosis time of 11.9 years. The tracking of complications due to Diabetes Mellitus occurred in 90.2% of the users, with a prevalence of 68.2%, of which 34.7% were diagnosed in the service. Absenteeism was 21.4%. The systolic and diastolic arterial pressure and total cholesterol parameters were in line with the proposed goals, while glycated hemoglobin (A1c), fasting glycaemia, HDL-c, LDL-c, triglyceride fractions, and BMI did not reach the target range. There was a significant reduction in final A1c, comparing to initial A1c, as well as an increase in the proportions of users who reached the goals in glycemic control. Conclusion a significant improvement in glycemic control, despite the fact that the parameters did not fully meet the goals, ratifying the importance of an effective assistance model for successful care strategies of Diabetes Mellitus.

Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries:a scoping review

BACKGROUND

Hypertension (HTN) and diabetes mellitus (DM) are highly prevalent in low- and middle-income countries (LMIC) and a leading cause of morbidity and mortality. Recent evidence on effectiveness of primary care interventions has attracted renewed calls for their implementation. This review aims to synthesize evidence pertaining to primary care interventions on these two diseases, evaluated and tested in LMICs.

METHODS

Two reviewers conducted an electronic search of three databases (Pubmed, EMBASE and Web of Science) and screened for eligible articles. Interventions covering health promotion, prevention, treatment, or rehabilitation activities at the PHC or community level were included. Studies published in English, French, Portuguese and Spanish, from January 2007 to January 2017, were included. Key extraction variables included the 12 criteria identified by the Template for Intervention Description and Replication (TIDieR) checklist and guide. The Innovative Care for Chronic Conditions Framework (ICCCF) was used to guide analysis and reporting of results.

RESULTS

198 articles were analyzed. The strategies focused on healthcare service organization (76.5%), community level (9.7 %), creating a positive policy environment (3.6%) and strategies covering multiple domains (10.2%). Studies included related to the following topics: description or testing of interventions (n=81; 41.3%), implementation or evaluation projects (n=42; 21.4%), quality improvement initiatives (n=15; 7.7%), screening and prevention efforts (n=26; 13.2%), management of HTN or DM (n=13; 6.6%), integrated health services (n=10; 5.1%), knowledge and attitude surveys (n=5; 2.5%), cost-effective lab tests (n=2; 1%) and policy making efforts (n=2; 1%). Most studies reported interventions by non-specialists (n=86; 43.4%) and multidisciplinary teams (n=49; 25.5%).

CONCLUSION

Only 198 articles were found over a 10 year period which demonstrates the limited published research on highly prevalent diseases in LMIC. This review shows the variety and complexity of approaches that have been tested to address HTN and DM in LMICs and highlights the elements of interventions needed to be addressed in order to strengthen delivery of care. Most studies reported little information regarding implementation processes to allow replication. Given the need for multi-component complex interventions, study designs and evaluation techniques will need to be adapted by including process evaluations versus simply effectiveness or outcome evaluations.

Assessment of steroid use as a key performance indicator in inflammatory bowel disease-analysis of data from 2385 UK patients

BACKGROUND

Patients with IBD are at risk of excess corticosteroids.

AIMS

To assess steroid excess in a large IBD cohort and test associations with quality improvement and prescribing.

METHODS

Steroid exposure was recorded for outpatients attending 19 centres and associated factors analysed. Measures taken to avoid excess were assessed.

RESULTS

Of 2385 patients, 28% received steroids in the preceding 12 months. 14.8% had steroid excess or dependency. Steroid use was significantly lower at 'intervention centres' which participated in a quality improvement programme (exposure: 23.8% vs 31.0%, P < .001; excess 11.5% vs 17.1%, P < .001). At intervention centres, steroid use fell from 2015 to 2017 (steroid exposure 30.0%-23.8%, P = .003; steroid excess 13.8%-11.5%, P = .17). Steroid excess was judged avoidable in 50.7%. Factors independently associated with reduced steroid excess in Crohn's disease included maintenance with anti-TNF agents (OR 0.61 [95% CI 0.24-0.95]), treatment in a centre with a multi-disciplinary team (OR 0.54 [95% CI 0.20-0.86]) and treatment at an intervention centre (OR 0.72 [95% CI 0.46-0.97]). Treatment with 5-ASA in CD was associated with higher rates of steroid excess (OR 1.72 [95% CI 1.24-2.09]). In ulcerative colitis (UC), thiopurine monotherapy was associated with steroid excess (OR 1.97 [95% CI 1.19-3.01]) and treatment at an intervention centre with less steroid excess (OR 0.72 [95% CI 0.45-0.95]).

CONCLUSIONS

This study validates steroid assessment as a meaningful quality measure and provides a benchmark for this performance indicator in a large cohort. A programme of quality improvement was associated with lower steroid use.

Metabolic health in the Middle East and north Africa

The Middle East and north Africa are home to different populations with widely varying cultures, histories, and socioeconomic settings. Hence, their health status, health management, and access to appropriate health care differ accordingly. In this Review, we examine data on the historical and prospective status of metabolic diseases in this region including obesity, diabetes, hypertension, dyslipidaemia, and non-alcoholic fatty liver disease. Women in the Middle East and north Africa have the highest risk of metabolic diseases of all women globally, whereas men rank second of all men in this respect. Metabolic risk factors are responsible for more than 300 deaths per 100 000 individuals in this region, compared with a global mean of fewer than 250. Physical inactivity, especially in women, and an unhealthy diet (ie, low consumption of whole grains, nuts, and seafoods) stand out. More than one in every three women are obese in most countries of the region. Prevention programmes have not fully been achieved in most of these countries and the projected future is not optimistic. Comprehensive surveillance and monitoring of metabolic diseases, robust multisectoral systems that support primordial and primary preventions, continuous education of health-care providers, as well as collaboration between countries for joint projects in this region are urgently needed to overcome the paucity of data and to improve the metabolic health status of inhabitants in the Middle East and north Africa.

Quality and barriers of outpatient diabetes care in rural health facilities in Uganda - a mixed methods study

BACKGROUND

Despite the increasing burden of diabetes in Uganda, little is known about the quality of type 2 diabetes mellitus (T2DM) care especially in rural areas. Poor quality of care is a serious limitation to the control of diabetes and its complications. This study assessed the quality of care and barriers to service delivery in two rural districts in Eastern Uganda.

METHODS

This was a mixed methods cross-sectional study, conducted in six facilities. A randomly selected sample of 377 people with diabetes was interviewed using a pre-tested interviewer administered questionnaire. Key informant interviews were also conducted with diabetes care providers. Data was collected on health outcomes, processes of care and foundations for high quality health systems. The study included three health outcomes, six elements of competent care under processes and 16 elements of tools/resources and workforce under foundations. Descriptive statistics were computed to determine performance under each domain, and thematic content analysis was used for qualitative data.

RESULTS

The mean age of participants was 49 years (±11.7 years) with a median duration of diabetes of 4 years (inter-quartile range = 2.7 years). The overall facility readiness score was 73.9%. Inadequacies were found in health worker training in standard diabetes care, availability of medicines, and management systems for services. These were also the key barriers to provision and access to care in addition to lack of affordability. Screening of clients for blood cholesterol and microvascular complications was very low. Regarding outcomes; 56.8% of participants had controlled blood glucose, 49.3% had controlled blood pressure; and 84.0% reported having at least one complication.

CONCLUSION

The quality of T2DM care provided in these rural facilities is sub-optimal, especially the process of care. The consequences include sub-optimal blood glucose and blood pressure control. Improving availability of essential medicines and basic technologies and competence of health workers can improve the care process leading to better outcomes.

Audit of diabetes mellitus among patients attending an employee health clinic at a tertiary care centre in Riyadh, Saudi Arabia

Purpose:

To assess the clinical practices in the management of patients with type 2 diabetes mellitus (T2DM) as a basis for establishing a guideline that focuses on risk factors and complications.

Methods:

We conducted a retrospective audit of the medical records of 450 patients (aged 20–65 years) diagnosed with T2DM attending an employee health clinic at King Fahad Medical City, Riyadh (Saudi Arabia) during the period from 1 January to 1 July 2016. All patients requiring emergency treatment were excluded. A checklist of demographic variables, co-morbidities, clinical examinations, and laboratory investigations was used for collecting data.

Results:

In total, 303 (67.3%) were women and 312 (69.3%) were Saudis. Forty-five (10%) patients were not receiving current treatment for diabetes and body mass index was not calculated for 117 (26%). Retinal and neurological examinations were not performed in 363 (80.7%) and 109 (24.2%) patients, respectively. Cardiovascular and peripheral vascular system examinations were not conducted for 112 (24.9%) and 114 (25.3%) patients, respectively. For laboratory investigations, 2-h glucose tolerance tests and vitamin B12 tests were not performed for 473 (97.1%) and 436 (96.9%) patients, respectively. Moreover, TSH/T4 and eGFR tests were not performed for 220 (48.9%) and 135 patients (30%), respectively.

Conclusions:

We concluded that current clinical practice for management of T2DM patients is not comprehensive and that the quality of healthcare should be improved with continuous checking of patient records.

The perspectives of patients and physicians on the role of pharmacists in improving medication adherence in type 2 diabetes: a qualitative study

BACKGROUND

Pharmacy practice has been expanded to include responsibility for the outcomes of medication therapy. However, in developing countries the pharmacist's role is still limited to dispensing medications. The aim of this study is to explore the perspectives of patients and physicians on the pharmacist's role in improving medication adherence in type 2 diabetes.

METHODS

Data were collected via semi-structured interviews with patients and physicians. The interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis.

RESULTS

A total of 40 patients and 21 physicians were interviewed. The interviews revealed different pharmacy-related issues that negatively affected patients' adherence, such as a lack of pharmacist counselling and inappropriate scheduling of refills. Various recommendations to improve adherence were emphasised such as dedicating some pharmacists to counselling patients and providing pharmacists with the appropriate training.

CONCLUSION

From the perspectives of patients and physicians, the pharmacist's role in the management of type 2 diabetes is still limited to dispensing medications. In order to improve medication adherence and consequently patient outcomes, policy-makers need to be aware of the importance of supporting pharmacists and providing them with the appropriate training.

Patient-Related Determinants of Glycaemic Control in People with Type 2 Diabetes in the Gulf Cooperation Council Countries: A Systematic Review

The aim of this systematic review is to assess patient-related factors affecting glycaemic control among people with type 2 diabetes in the Arabian Gulf Council countries. MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane CENTRAL databases were searched from their date of inception to May 2016. Two researchers independently identified eligible studies and assessed the risk of bias. A total of 13 studies met the inclusion criteria. One study was population based, six recruited participants from multiple centres, and the remaining were single centred. The majority of the studies were of low to moderate quality. Factors associated with poor glycaemic control include longer duration of diabetes, low level of education, poor compliance to diet and medication, poor attitude towards the disease, poor self-management behaviour, anxiety, depression, renal impairment, hypertension, and dyslipidaemia. Healthcare providers should be aware of these factors and provide appropriate education and care especially for those who have poor glycaemic control. Innovative educational programs should be implemented in the healthcare systems to improve patient compliance and practices. A variation in the results of the included studies was observed, and some potentially important risk factors such as dietary habits, physical activity, family support, and cognitive function were not adequately addressed. Further research is needed in this area.

Patients' management of type 2 diabetes in Middle Eastern countries: review of studies

The increased prevalence of diabetes in Middle Eastern countries is a health policy priority. Important risk factors for diabetes have been identified. Lifestyle interventions and adherence to medications are central to disease prevention and management. This review focuses on the management of type 2 diabetes mellitus in Middle Eastern countries. The aim is to identify the ways in which knowledge, health beliefs, and social and cultural factors influence adherence to medication and lifestyle measures. Thirty-four studies were identified following a systematic search of the literature. The studies describe the influence of knowledge, health beliefs, culture, and lifestyle on the management of type 2 diabetes mellitus in the Middle East. Findings indicate a lack of health knowledge about diabetes among populations, which has implications for health behaviors, medication adherence, and treatment outcomes. Many identified health beliefs and cultural lifestyle factors, such as religious beliefs, beliefs about fasting during Ramadan, and sedentary lifestyles played a role in patients' decisions. For better management of this disease, a collaborative approach between patients, their families, health care professionals, and governments should be adopted. Implementing behavioral strategies and psychological interventions that incorporate all health care professionals in the management process have been shown to be effective methods. Such services help patients change their behavior. However, the utilization of such services and interventions is still limited in Arabian countries. Physicians in the Middle East are the health care professionals most involved in the care process.