Diabetes control in a primary care setting: a retrospective study of 651 patients

A systematic review of factors associated with uncontrolled diabetes and meta-analysis of its prevalence in Saudi Arabia since 2006

The study aims to systematically review the literature for risk factors associated with poor glycaemic control among type 2 diabetes mellitus (T2DM) patients in Saudi Arabia (SA) and conducts a meta-analysis of its prevalence. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol, we searched the Scopus, PubMed, PsycINFO, Web of Science, and CINAHL Plus databases from May to November 2018. The search terms were T2DM, glycaemic control, and SA. The inclusion criteria include the following: observational studies which were conducted in T2DM patients in SA reporting prevalence or/and personal, psychological or behavioural predictors in papers published after 2006. Articles were assessed using a modified Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) tool. Studies included in the meta-analysis defined uncontrolled T2DM as glycated haemoglobin ≥7% (53 mmol/mol), and reported results were based on a random-effects model. Eighteen of the following articles (3 retrospective cohort studies, 1 case-control study, and 14 cross-sectional studies) were included. The quality of the studies (high: 2; moderate: 7, and low: 9) varied. The pooled prevalence of uncontrolled T2DM in SA was 77.7% (95% CI, 71.2-84.2). In the included studies, the most consistent predictors of poor glycaemic control were longer diabetes duration, lack of self-efficacy, and low knowledge of diabetes. However, significant variations in research designs were observed across the studies. A national diabetes prevention and treatment program is needed to lessen the burden of diabetes in SA. Future studies should address the personal, psychological, and behavioural factors of poor glycaemic control in SA at national level.

Mortality and potential years of life lost attributable to non-optimal glycaemic control in men and women with diabetes in the United Arab Emirates: a population-based retrospective cohort study

OBJECTIVES

Numerous studies reported that achieving near-normal glycated haemoglobin (HbA1c) levels in patients with diabetes may delay or even prevent vascular complications. However, information regarding the impact of non-optimal HbA1c control on adverse health outcomes in an Arab population is unknown. The aim of this study was to estimate the fraction of deaths and potential years of life lost (PYLL) attributable to non-optimal HbA1c control among Emirati men and women with diabetes in the United Arab Emirates (UAE).

DESIGN

A retrospective cohort study.

SETTING

This study was conducted in outpatient clinics at a tertiary care centre in Al Ain, UAE, between April 2008 and September 2018.

PARTICIPANTS

The sample comprised of 583 adult UAE nationals, aged≥18 years, with diabetes. Overall, 57% (n=332) of the study participants were men and 43% (n=251) were women.

EXPOSURE

Non-optimal HbA1c control, defined as HbA1c≥6.5%.

PRIMARY OUTCOME MEASURE

All-cause mortality, defined as death from any cause.

RESULTS

At the end of the 9-year follow-up period, 86 (14.8%) participants died. Overall, up to 33% (95% CI 2% to 63%) of deaths were attributable to non-optimal HbA1c control among patients with diabetes mellitus (DM). Stratified by sex, the adjusted fraction of avoidable mortality was 17% (95% CI -23% to 57%) for men and 50% (95% CI 3% to 98%) for women. Both deaths and PYLL attributable to non-optimal HbA1c control were higher in women compared with men.

CONCLUSIONS

Up to one-third of all deaths in adult UAE nationals with DM could be attributed to non-optimal HbA1c control. Effective sex-specific interventions and healthcare quality-improvement programmes should urgently be implemented.

The Referral System between Primary and Secondary Health Care in Saudi Arabia for Patients with Type 2 Diabetes: A Systematic Review

BACKGROUND

In Saudi Arabia, the mortality of diabetes is currently reported at 6%. A well-administered referral system is crucial in aiding the management of this disease.

METHOD

A single reviewer employed a systematic approach to searching the literature databases with regard to the question: what are the attributes of referral systems in Saudi Arabia for patients with type 2 diabetes (T2D)? The results were analysed in order to provide recommendations to improve the Saudi health system.

RESULTS

Twelve primary studies were identified from a systematic search. Overall, the 12 studies did not clearly mention any of the factors of a good referral system. The referral problems identified by this study included patients' unnecessary requests for referral, unstructured referral letters, and unclear dissemination guidelines for referral.

CONCLUSIONS

This research attempted to identify the efficiency of the referral processes that were implemented for patients with T2D. The majority of the included studies were completely silent on the main referral factors for patients. If this review is representative of the referral system in Saudi Arabia, then, in the context of T2D, current referrals are unsafe. Further research on the quality of the referral system, taking into account at least some of the WHO referral guidelines, is required.

Factors Associated with Long-Term Control of Type 2 Diabetes Mellitus

Aims. This study assessed factors associated with glycemic control among Saudi patients with Type 2 diabetes mellitus (T2DM). Methods. We conducted an analytical cross-sectional study, which included a random sample of 288 patients with T2DM proportional to the diabetes population of each primary health care center in Jazan city, Kingdom of Saudi Arabia. Results. More than two-thirds (74%) of patients had poor glycemic control. Lack of education, polypharmacy, and duration of diabetes ≥ 7 years were significantly associated with higher glycated hemoglobin (HbA1c). Moreover, patients who were smoker or divorced were significantly more likely to have higher HbA1c. The patients who did not comply with diet or take their medications as prescribed had poor glycemic control. The study found lower HbA1c levels among patients who received family support or had close relationship with their physicians. Similarly, knowledgeable patients towards diabetes or those with greater confidence in ability to manage self-care behaviors had a lower HbA1c. In contrast, risk factors such as depression or stress were significantly correlated with poorer glycemic control. Conclusion. The majority of T2DM patients had poor glycemic control. The study identified several factors associated with glycemic control. Effective and tailored interventions are needed to mitigate exposure to these risk factors. This would improve glycemic control and reduce the risks inherent to diabetes complications.

Level of control among patients with type 2 diabetes mellitus attending diabetic clinic under family medicine compared to diabetic clinic under endocrinology

OBJECTIVES

To assess and compare level of control among patients with type 2 diabetes mellitus attending diabetic clinic under family medicine service and patients attending diabetic clinics under endocrinology service, and to explore the effect of different variables on the level of control in both groups.

METHODS

Retrospective cross-sectional study by reviewing medical records of patients with type 2 diabetes mellitus and laboratory studies from Hospital Information System at King Abdul-Aziz Medical City, National Guard, Riyadh - Saudi Arabia using predesigned sheet for data collection.

RESULTS

Among 352 patients enrolled in the study, 176 (50%) patients were from the family medicine setting and 176 (50%) patients were from the hospital setting. The mean glycosylated hemoglobin for the whole study population was 8.97±1.87. There was no significant difference between the two groups in regard to level of control (9.01±1.75 in the family medicine setting compared to 8.93±1.98 in the hospital setting). No significant correlation was found between level of control and age, duration of disease and number of follow-up visits in both settings.

CONCLUSION

Patients with type 2 diabetes mellitus in this study were found to be poorly controlled in both the settings, diabetic clinic under family medicine and diabetic clinic under endocrinology. More research should be done to explore quality of care in a family medicine setting for patients with type 2 diabetes mellitus, as such a setting is expected to be more accessible, more convenient, and more cost effective to patients.

Cardiovascular risk profiles of adults with type-2 diabetes treated at urban hospitals in Riyadh, Saudi Arabia

Diabetes mellitus substantially increases cardiovascular disease (CVD) risk. Among Saudi Arabian citizens with diabetes, little is known about the prevalence and control of other CVD risk factors.

We extracted data from medical records of a random selection of 422 patients seen between 2008 and 2012 at two diabetic clinics in Riyadh, Saudi Arabia. We calculated the proportion of patients who had additional CVD risk factors: obesity (body mass index ⩾ 30 kg/m²), hypertension (BP ⩾ 140/90 mmHg), elevated cholesterol fractions, and multiple risk factors). Further, we calculated the proportion of patients meeting the American Diabetes Association’s recommended care targets for each risk factor.

Of 422 patients (mean age, 52 years), half were women, 56% were obese, 45% had hypertension, and 77% had elevated LDL concentrations. In addition to diabetes, 70% had two or more CVD risk factors. Although 9% met both target HbA1c and BP values, only 3.5% had optimum HbA1c, BP, and lipid values.

In Saudi Arabia’s best diabetes clinics, most patients have poor control of their disease. This huge disease burden and related care gaps have important health and financial implications for the country.

Glycemic Control among Patients with Type 2 Diabetes Mellitus in Countries of Arabic Gulf

Type 2 diabetes mellitus is a growing, worldwide public health concern. The countries of Arabic Gulf appear to have a higher prevalence of diabetes than the global average. The recent and rapid socio-economic development of these countries has been associated with this rising prevalence. Although the rate of type 2 diabetes management based on glycosylated hemoglobin level in the countries of Arabic Gulf is labeled as poor, the outcomes are almost similar to those reported from elsewhere. Unfortunately, overweight and obesity are driving the global diabetes epidemic. A minority of patients with type 2 diabetes had a normal body weight which might make the control of diabetes difficult. Anyhow, Greater efforts are urgently needed to properly manage diabetes early in order to prevent short and long-term complications. Practical strategies aimed at more effective management of type 2 diabetes patients are strongly needed.

Diabetic patients' willingness to use tele-technology to manage their disease - A descriptive study

Objectives: Diabetes mellitus is a public health concern worldwide. TeleHealth technology may be an effective tool for empowering patients in the self-management of diabetes mellitus. However despite the great impact of diabetes on healthcare in Saudi Arabia, no research has investigated diabetic patients' willingness to use this technology. This study investigates diabetic patients' willingness to use tele-technology as a tool to monitor their disease.

Methods: Data were collected from diabetic patients attending the diabetes education clinic at the Ministry of National Guard Health Affairs (MNGHA) in the Eastern region of Saudi Arabia over a three month period. A survey was developed which measured patients' willingness to use tele-technology in the self-management of their diabetes as well as their perceived expectations from the technology.

Results: The study found that the majority of patients were willing to use tele-technology to self- monitor their diabetes. However, a minority (11.3%) indicated willingness to use the system daily and only half indicated preference to use it once a week (53.8%). Patients who were younger, had higher education levels, were employed, had internet access and had Type II diabetes were significantly more likely to report willingness to use the technology.

Conclusions: Diabetic patients could be ready to play a more active role in their care if given the opportunity. Results from this study could serve as a baseline for future studies to develop targeted interventions by trialing tele-technology on a sample of the diabetic population. Patients with diabetes need to be in charge of their own care in order to improve health outcomes across the country.

Quality of medical management in coronary artery disease

BACKGROUND AND OBJECTIVES

Patients with coronary artery disease (CAD) are at high risk of recurrent adverse cardiac events. Such risk can be diminished through a guideline-recommend optimal medical therapy (OMT), defined as adherence to appropriate antiplatelet therapy, lipid-lowering agents, beta-blockers and angio.tensin-converting enzyme inhibitors, blood pressure < 140/90 mm Hg ( < 130/80 mm Hg in diabetics and renal disease patients), low-density lipoprotein (LDL) < 2 mmol/L, smoking cessation and aerobic physical activity, and hemoglobin (Hb) A1c < 7%. Unfortunately, preliminary data suggest a wide gap between recommended and actual practices. The study aims to estimate the rate of achieving of OMT in CAD patients in Qassim Province.

DESIGN AND SETTINGS

This observational study enrolled 207 consecutive CAD patients seen in cardiology clinic in Prince Sultan Cardiac Center in Qassim between January 2012 and May 2012.

METHODS

Eligible participants were over the age of 18, with CAD documented by either noninvasive testing or by coronary angiogram. We collected the demographic, medications, laboratory, and clinical data through in-person interviews, medical records, and an electronic patient database.

RESULTS

OMT was achieved in only 10.4% of CAD patients. The rate of achievement of target systolic blood pressure was 76.5%, target diastolic blood pressure 88%, target LDL 68%, adherence to medications 91%. Diabetes was common (64% of all patients), and only 24% of these patients achieved the target HbA1c.

CONCLUSION

The poor achievement of optimal medical therapy in CAD patients contributes to prevent.able mortality, morbidity, and health care costs. The observed shortcomings warrant investment in strategies to achieve OMT in these high-risk patients.

Barakat M, Al-Zakwani I, Elsayed MK, Al-Maskari M, M Al-Lawati N, Mohammed AJ. Control of risk factors for cardiovascular disease among adults with previously diagnosed type 2 diabetes mellitus: a descriptive study from a middle eastern arab population

BACKGROUND

Despite the high burden of type 2 diabetes mellitus (T2DM) in Oman, there are scarce data from a nationally representative sample on the level of glycaemia and other cardiovascular (CVD) risk factor control.

OBJECTIVE

To estimate the proportion of patients with T2DM at goal for glycaemia and CVD risk factors using the National Diabetes Guidelines (NDG) and the American Diabetes Association (ADA) clinical care guidelines; and to assess the quality of selected services provided to patients with T2DM.

METHODS

A sample of 2,551 patients (47% men) aged ≥20 years with T2DM treated at primary health care centers was selected. Patient characteristics, medical history and treatment were collected from case notes, Diabetes Registers and computer frameworks including the use of the last 3 laboratory investigations results and blood pressure (BP) readings recorded in 2007.

RESULTS

The overall mean age of the cohort was 54±13 years with an average median duration of diabetes of 4 (range 2 to 6) years. Over 80% of patients were overweight or obese (body mass index (BMI) of ≥25 Kg/m(2)). Sixty-nine percent were on oral anti-diabetic medication, 52% on anti-hypertensives and 40% on lipid lowering drugs. Thirty percent of patients were at goal for glycosylated haemoglobin level (<7%), 26% for BP (systolic/diastolic <130/80 mmHg), 55% for total cholesterol (<5.2 mmol/l), 4.5% for low-density lipoprotein cholesterol (<1.8 mmol/l), 52% for high-density lipoprotein cholesterol (>1 mmol/l for men, >1.3 mmol/l for women), and 61% for triglycerides (<1.7 mmol/l). Over 37% had micro-albuminuria and 5% had diabetic nephropathy.

CONCLUSION

Control of hyperglycaemia and other CVD risk factor appears to be suboptimal in Omani patients with T2DM and need to be addressed in the triad of patient, physician and health system.

Type 2 diabetes care for patients in a tertiary care setting in UAE: a retrospective cohort study

OBJECTIVE

We aimed to examine the quality of type 2 diabetes mellitus (T2DM) care in Al-Ain, in the United Arab Emirates (UAE).

DESIGN

A retrospective cohort study from 2008 to 2010.

SETTING

A diabetes centre located in a tertiary care hospital in Al-Ain, UAE.

PARTICIPANTS

People with T2DM receiving care from the diabetes centre.

RESULTS

382 Emirates patients with T2DM were included in the analysis. Overall in 2010, proportions of people with T2DM reaching the following targets were: glycated haemoglobin (HbA1c) 41%, low-density lipoprotein (LDL) 72%, systolic and diastolic blood pressure (SBP/DBP) 47% and 73%, respectively. There was a significant improvement from 2008 to 2010, respectively, in the mean for the following: (1) HbA1c (8.5% [95% confidence interval, CI: 8.33-8.67] versus 7.5% [95% CI: 7.36-7.63]); (2) LDL (2.60 mmol/L [95% CI: 2.51-2.70] versus 2.27 mmol/L [95% CI: 2.21-2.33]); and (3) SBP (133.1 mmHg [95% CI: 131.7-134.4] versus 131.0 [95% CI: 130.1-131.9]). Glycaemic and lipid control were similar in men and women; however, HbA1c levels in men and women aged 60+ years were significantly lower by (0.7% [P = 0.01] versus 0.8% [P < 0.001], respectively) than for those aged between 18 and 39 years.

CONCLUSION

This study demonstrates that there is encouraging progress in diabetes care in Al-Ain, UAE as reflected by the overall improvement in the mean of HbA1c, LDL and SBP, and the increase in the number of people reaching the target for the same indicators from 2008 to 2010. The results however show that there is scope for additional enhancement of care, especially for better glycaemic control among young patients and better SBP control among men.

Quality of type 2 diabetes management in the states of the Co-operation Council for the Arab States of the Gulf: a systematic review

Type 2 diabetes mellitus is a growing, worldwide public health concern. Recent growth has been particularly dramatic in the states of The Co-operation Council for the Arab States of the Gulf (GCC), and these and other developing economies are at particular risk. We aimed to systematically review the quality of control of type 2 diabetes in the GCC, and the nature and efficacy of interventions. We identified 27 published studies for review. Studies were identified by systematic database searches. Medline and Embase were searched separately (via Dialog and Ovid, respectively; 1950 to July 2010 (Medline), and 1947 to July 2010 (Embase)) on 15/07/2009. The search was updated on 08/07/2010. Terms such as diabetes mellitus, non-insulin-dependent, hyperglycemia, hypertension, hyperlipidemia and Gulf States were used. Our search also included scanning reference lists, contacting experts and hand-searching key journals. Studies were judged against pre-determined inclusion/exclusion criteria, and where suitable for inclusion, data extraction/quality assessment was achieved using a specifically-designed tool. All studies wherein glycaemic-, blood pressure- and/or lipid- control were investigated (clinical and/or process outcomes) were eligible for inclusion. No limitations on publication type, publication status, study design or language of publication were imposed. We found the extent of control to be sub-optimal and relatively poor. Assessment of the efficacy of interventions was difficult due to lack of data, but suggestive that more widespread and controlled trial of secondary prevention strategies may have beneficial outcomes. We found no record of audited implementation of primary preventative strategies and anticipate that controlled trial of such strategies would also be useful.

Diabetes mellitus type 2 and other chronic non-communicable diseases in the central region, Saudi Arabia (Riyadh cohort 2): a decade of an epidemic

BACKGROUND

Follow-up epidemiologic studies are needed to assess trends and patterns of disease spread. No follow-up epidemiologic study has been done in the Kingdom of Saudi Arabia to assess the current prevalence of major chronic, noncommunicable diseases, specifically in the urban region, where modifiable risk factors remain rampant. This study aims to fill this gap.

METHODS

A total of 9,149 adult Saudis ages seven to eighty years (5,357 males (58.6%) and 3,792 females (41.4%)) were randomly selected from the Riyadh Cohort Study for inclusion. Diagnosis of type 2 diabetes mellitus (DMT2) and obesity were based on the World Health Organization definitions. Diagnoses of hypertension and coronary artery disease (CAD) were based on the Seventh Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and American Heart Association criteria, respectively.

RESULTS

The overall crude prevalence of DMT2 was 23.1% (95% confidence interval (95% CI) 20.47 to 22.15). The age-adjusted prevalence of DMT2 was 31.6%. DMT2 prevalence was significantly higher in males, with an overall age-adjusted prevalence of 34.7% (95% CI 32.6 to 35.4), than in females, who had an overall age-adjusted prevalence of 28.6% (95% CI 26.7 to 29.3) (P < 0.001). The overall crude prevalence of obesity was 31.1% (95% CI 30.1 to 32.0). The age-adjusted prevalence of obesity was 40.0%. The prevalence of obesity was higher in females, with an overall prevalence of 36.5% (95% CI 35.1 to 37.83), than in males (25.1% (95% CI 23.7 to 26.3)) (P < 0.001). The age-adjusted prevalence of hypertension and CAD were 32.6% (95% CI 31.7 to 33.6) and 6.9% (95% CI 6.4 to 7.4), respectively.

CONCLUSION

Comparisons of our findings with earlier data show that the prevalence of DMT2, hypertension and CAD in Riyadh, Saudi Arabia, has alarmingly worsened. Aggressive promotion of public awareness, continued screening and early intervention are pivotal to boosting a positive response.