Quality of Care of Diabetes in Jamaica 1995

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Quality of Care of Diabetes in Jamaica(1995)
Rainford Wilks Epidemiology Research Unit Tropic
al Medicine Research Institute
University of the West Indies

(DOTA/UDOP, Ocho Rios, Jamaica, March 2002)
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Epidemic of Type 2 Diabetes (2)

• Indo-Trinidadian (35-69 years)
• Prevalence Men Women
• 1961-62 11.6 18.9
• 1977 19.5 21.6
• Afro-Trinidadian (35-69 years)
• Prevalence Men Women
• 1961-62 2.5 5.4
• 1977 8.2 14.8

Poon King et al. 1968 Beckles et al.,1986
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Epidemic of Type 2 Diabetes (3)

• Prevalence in Jamaica
• 1960 (15 years) 1.3
• 1970 (25-64 years) 8.1
• 1995 (15 years) 17.9
• 1999 (25-74 years) 13.4

Tulloch 1961 Florey et al 1972 Ragoobirsingh et
al 1995 Wilks et al 1999
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Diagnosis of DiabetesThree Methods

• 1. Random plasma glucose 11.1 mmol/L on 2
  separate occasions symptoms (polyuria,
  polydipsia, unexplained weight loss)
  
• 2. FPG 7.0 mmol/L on 2 separate occasions
• 3. 2-hour plasma glucose 11.1 mmol/L during
  OGTT on 2 separate occasions

Adapted from The Expert Committee on the
Diagnosis and Classification of Diabetes
Mellitus. Diabetes Care. 1997201183-1197.
World Health Organisation 1999. Report of a WHO
Consultation Definitions, diagnosis and
classification of diabetes mellitus and it
complications
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Glucose Tolerance Categories
Adapted from The Expert Committee on the
Diagnosis and Classification of Diabetes
Mellitus. Diabetes Care. 1997201183-1197.
1-2
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Components of Cardiovascular Risk

• Major Risk Factors
• Smoking
• Dyslipidaemia
• Diabetes Mellitus
• Age 60 years
• Gender (Men and Postmenopausal women)
• Family history of cardiovascular disease
• Women

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Components of Cardiovascular Risk Stratification
in Patients with Hypertension (TOD)

• Heart Diseases
• Left Ventricular hypertrophy
• Angina or prior myocardial infarction
• Prior coronary revascularisation
• Heart failure
• Stroke or transient ischaemic attack
• Nephropathy
• Peripheral arterial disease
• Retinopathy

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Blood Pressure Categories JNC VI
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(No Transcript)
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Risk Stratification and Treatment
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Type 2 DiabetesManagement Goals

• Eliminate symptoms and improve well-being
• Prevent and retard microvascular complications
• optimize glycemic control
• target blood pressure levels
• Reduce macrovascular events
• optimize glycemic control
• target blood pressure levels
• target lipid levels

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Type 2 DiabetesMetabolic Targets

• Parameter Target Value
• Fasting glucose whole blood 4.4-6.7
  mmol/Lplasma-referenced 5.0-7.2 mmol/L
  
• HbA1coptimal 8
• Total cholesterol
• LDL-C optimal treatment 3.35 mmol/L
  
• HDL-C 1.15 mmol/L
• Triglycerides
• Blood Pressure

ADA Clinical Practice Recommendations 2001
Diabetes Care 2001 Supplement, Jan. 2001
DaADAa from American Diabetes Association.
Diabetes Care. 2001 24 (suppl 1) S33-S43 The
National Cholesterol Education Program (NCEP)
Expert Panel. JAMA. 1993 209 2015-3023.
4-2
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Treatment Algorithm
Nonpharmacologic therapy
Very symptomatic Severe hyperglycemia Ketosis L
atent autoimmune diabetes
Pregnancy
Monotherapy Sulfonylureas/Benzoic acid analogue
Biguanide Alpha-glucosidase inhibitors Thiazolid
inediones
Insulin
Combination therapy
Insulin
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BackgroundHypertension

• Adequate control of HTN reduces morbidity and
  mortality
  
• HTN can be asymptomatic
• surveillance is critical to detection
• HTN often co-exists with other risk factors for
  cardiovascular disease eg obesity, smoking,
  sedentary lifestyle, dyslipidaemia

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Aims of Quality-of-Care Studies

• To evaluate the level of surveillance for
  Hypertension and Diabetes.
  
• To evaluate the quality of care for Hypertension
  and Diabetes in 3 different settings.

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Methods (QC Survey)

• Case recruitment
• Diabetes
• sequential clinic attenders over 6 weeks
• Aim to recruit 200 subjects per centre
• Diabetes - Doctor diagnosed, on treatment with
  insulin or oral hypoglycaemics
  
• Hypertension
• surveillance of clinic attenders 30 yrs and over

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Data Collection

• Retrospective data from medical records
• Data used from index visit excluded
• Data
• Medical history
• Records of weight, height, blood pressure, blood
  glucose, urea, creatinine and urinalysis
  
• Medication
• Evidence of surveillance for TOD
• Provision of advice on non-pharmacological
  approach
  

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Characteristics of Study Population by Clinic
Type (Diabetes)
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Prevalence of Treatments Types by Clinic Type
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Monitoring and Control of Blood Glucose, by
Clinic Type, Jamaica, 1995



PUBMCgovernment polyclinic PRMCgroup private
general practice SPMCspecialist public-hospital
diabetic clinic
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Surveillance of Lifestyle and Other Risk Factors
by Clinic Type
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Monitoring and Control of Hypertension (1) by
Clinic Type (Jamaica, 1995)



p 23
Good Blood Pressure Among Diabetics with
Hypertension on Treatment
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Monitoring and Control of Hypertension (2) by
Clinic Type (Jamaica, 1995)







p 25
Surveillance of Complications of Diabetes by
Clinic Type (Jamaica, 1995)


p 26
Surveillance of Complications of Diabetes and
Management of Lifestyle Factors by Clinic
Type(Jamaica, 1995)



p 27
Management of Lifestyle Factors by Clinic Type
(Jamaica, 1995)

p 28
Quality-of-Care Summary

• Satisfactory blood glucose control was achieved
  in 40-50 of patients
  
• Surveillance for Target Organ Damage was
  infrequent
  
• Quality of care fell below accepted levels

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Monitoring and Control of Blood Glucose by Clinic
Type (Diabetes)
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Surveillance of Complications of Diabetes by
Clinic
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Management of Lifestyle Risk Factors by Clinic
(Diabetes)
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Collaborators

• Kingston, Jamaica
• - Terrence Forrester
• -- Franklin Bennett
• - Norma McFarlane-Anderson
• - Marvin Reid
• - Lincoln Sargeant

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Hypertension, Diabetes Lipid Status in Jamaica
Prevalence Incidence Surveys Quality of
Care

• Rainford Wilks
• Epidemiology Research Unit
• Tropical Medicine Research Institute, UWI

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Quality of Care ofHypertension Diabetes in
Jamaica
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Baseline Characteristics by Clinic Type
(Hypertension)
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Monitoring and Control of Hypertension by Clinic
Type (Hypertension)
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Monitoring and Control of Hypertension by Clinic
Type (Hypertension)
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Drug Treatment of Hypertension by Clinic Type
(Hypertension)
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Surveillance of Lifestyle Risk Factors by Clinic
(Hypertension)
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Management of Lifestyle Risk Factors by Clinic
(Hypertension)
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Summary

• Prevalence Estimates of Hypertension, Diabetes,
  Obesity and Hyperlipidaemia have been derived.
  
• Risk factors like obesity, excessive salt intake
  and sedentarism are all amenable to individual
  and population intervention.

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Summary

• Collaboration between all the related sectors,
  aimed at generating appropriate protocols is
  urgently required.
  
• Despite the need for further studies, there is
  sufficient data on which to guide policy,
  especially if these data are integrated with
  other sources, for example the Survey of Living
  Conditions.

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Summary

• Further studies are required
• to determine effectiveness of intervention
  strategies aimed at reducing the risk factors so
  far identified.
  

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Quality of Care Summary

• Satisfactory BP control was achieved in less than
  20 of patients
  
• Satisfactory blood glucose control was achieved
  in 40-50 of patients
  
• Surveillance for Target Organ Damage was
  infrequent
  
• Quality of care fell below accepted levels