Treatment of diabetes mellitus--physicians' adherence to clinical guidelines in Norway

Compliance of medical practitioners with diabetic treatment guidelines in West Rand, Gauteng

BACKGROUND

Diabetes mellitus is increasing globally and is associated with multiple complications. Guidelines have been formulated to standardise care among people living with diabetes mellitus (DM), but research shows poor compliance with treatment guidelines. The aim of this study was to assess how well healthcare practitioners in a district hospital in Gauteng complied with the most recent diabetic treatment guideline, Society for Endocrinology Metabolism and Diabetes South Africa (SEMDSA) 2017.

METHODS

A retrospective cross-sectional review of patient record living with diabetes was done. This study was conducted in the out-patient department of Dr Yusuf Dadoo hospital in the West Rand, Gauteng. A total of 323 records of patients seen from August 2019 to December 2019 were reviewed, and some of the basic variables were assessed according to the most recent diabetic treatment guidelines SEMDSA 2017.

RESULTS

Files were audited in four categories: comorbidities, examinations, investigations and the presence of complications. Six monthly glycated haemoglobin (HbA1c) was assessed in 40 (12.4%), annual creatinine assessed in 179 (55.4%) and lipogram in 154 (47.7%) of patients. More than 70% of patients had uncontrolled glycaemia and two people were screened for erectile dysfunction.

CONCLUSION

Monitoring and control parameters were infrequently done as per guideline recommendations. The resultant effects were poor glycaemic control and thus numerous complications.Contribution: Targeted strategies to improve medical practitioner compliance to guidelines including further research to study factors associated with poor compliance with guidelines are needed to improve the overall care of people living with DM in the West Rand and thus minimise the risk of complications among patients in the district.

Healthcare Professionals' Perceptions of Type 2 Diabetes Mellitus Care in the Mediterranean Region

INTRODUCTION

This study aimed to assess the adherence to guidelines by practitioners working in the Mediterranean region and to identify the reasons for non-compliance.

METHODS

A opportunistic self-administered questionnaire was circulated among members of the Mediterranean Group for the Study of Diabetes (MGSD) and regional diabetic associations. The study was limited to the Mediterranean region; 2841 medical practitioners participated in the study. Intervention involved a self-administered questionnaire enabling demographic and personal details to be correlated to relevant information related to practice and continuing health professional education (CHPE) attitudes, perceptions related to diabetes and healthcare systems in the community, and physicians' attitudes to healthcare practices and target goals relevant to type 2 diabetes mellitus (T2DM). The main outcome measure was adherence to evidence-based guidelines.

RESULTS

While the majority of respondents (69.9%) reported being confident in managing these patients, and 79.2% reported being aware of the availability of local guidelines; only a fifth opted to manage patients by strictly targeting an HbA1c value below 6.5%, while 3.3% were happy to maintain an HbA1c value of up to 8.0%. These goals appeared to be tempered by fear of eliciting hypoglycaemia in the belief that patients and their families do not have the skills to manage the complication. Endocrinologists/internists preferred more rigid control.

CONCLUSION

It is clear that the promulgation of evidence-based guidelines cannot assume automatic adoption in clinical practice since adoption is tempered by on-the-ground practice circumstances that make the practitioner reluctant to fully endorse and adopt the targets defined by the guidelines. The evidence-based guidelines need to be modified for local or regional circumstances.

FUNDING

This study and the Rapid Service Fee were supported by a financial grant from the Mediterranean Group for the Study of Diabetes which is supported by an unrestricted educational grant from Servier.

Is there an association between disease ignorance and self-rated health? The HUNT Study, a cross-sectional survey

OBJECTIVE

To explore whether awareness versus unawareness of thyroid dysfunction, diabetes mellitus or hypertension is associated with self-rated health.

DESIGN

Large-scale, cross-sectional population-based study. The association between thyroid function, diabetes mellitus and blood pressure and self-rated health was explored by multiple logistic regression analysis.

SETTING

The second survey of the Nord-Trøndelag Health Study, HUNT2, 1995-1997.

PARTICIPANTS

33 734 persons aged 40-70 years.

PRIMARY OUTCOME MEASURES

Logistic regression was used to estimate ORs for good self-rated health as a function of thyroid status, diabetes mellitus status and blood pressure status.

RESULTS

Persons aware of their hypothyroidism, diabetes mellitus or hypertension reported poorer self-rated health than individuals without such conditions. Women with unknown and subclinical hypothyroidism reported better self-rated health than women with normal thyroid status. In women and men, unknown and probable diabetes as well as unknown mild/moderate hypertension was not associated with poorer health. Furthermore, persons with unknown severe hypertension reported better health than normotensive persons.

CONCLUSIONS

People with undiagnosed but prevalent hypothyroidism, diabetes mellitus and hypertension often have good self-rated health, while when aware of their diagnoses, they report reduced self-rated health. Use of screening, more sensitive tests and widened diagnostic criteria might have a negative effect on perceived health in the population.

Compliance with diabetes guidelines at a regional hospital in KwaZulu-Natal, South Africa

Background

Diabetes is a major problem in South Africa and throughout the world. The management of type 2 diabetes aims at maintaining normoglycaemia and preventing the development of complications arising from diabetes. The Society for Endocrine Metabolism and Diabetes of South Africa (SEMDSA) guidelines are based on a number of international trials which showed that strict control of blood sugar leads to a reduction in the development of diabetic complications. However, many studies have shown poor adherence to national guidelines by doctors caring for diabetes patients.

Objectives

The aim of this study was to assess doctors’ compliance with the SEMDSA diabetes guidelines at a regional hospital in KwaZulu-Natal.

Method

Seven hundred and fifty diabetic patient records were selected by systematic sampling of cases from the diabetic clinic and reviewed against SEMDSA guidelines.

Results

Eighty three per cent of the patients had high values of glycated haemoglobin (HbA_1c). Lipid examination was rarely performed, and comprehensive foot examination was carried out in only 6% of patients. Although blood pressure and weight were regularly checked, these examinations were performed by the nursing staff, and medical staff generally did not respond to abnormal results.

Conclusion

This study demonstrates poor compliance with current diabetic guidelines. There is an urgent need to review how guidelines are disseminated and implemented in South African public sector hospitals if evidence-based guidelines are to have any impact on patient care.

Fast laboratory test results alone cannot deliver the benefits of near patient testing: a follow-up study after 3 years of extended laboratory service at a primary health care centre

OBJECTIVES

Technological development has progressed towards point-of-care testing (POCT) at primary health care centres (PHCs). However, to our knowledge, there has been no extensive evaluation of the effects on patient and clinical logistics when an extended laboratory service (ELS) is offered.

METHODS

Questionnaires were used to evaluate patient logistics before the introduction of ELS and after 6 months, as the proportion of consultations completed within one visit. That is, the patient is sampled, the test result is made available, and the patient is informed of the clinical decision. After 3 years of ELS, clinical logistics were followed up using questionnaires and by measuring turnaround time (TAT) from sampling to available test result (TATa) and from sampling to a clinical decision (TATd), and the proportion of laboratory test results reported back to the patient on the day of sampling (TATi).

RESULTS

After 6 months of ELS, the theoretical proportion of consultations which could be completed within 1 day had increased from 20% to 68%, while the proportion of patients desiring this situation had increased from 72% to 85%. After 3 years of ELS, the TATi was 56%. However, the majority of these tests were from the menu available before ELS. While 66% of patients wished to receive the laboratory test results at the consultation, this was achieved in 42% of cases. Patients below 65 years of age were more anxious than older patients to complete the consultation within a single PHC visit.

CONCLUSIONS

The clinical logistics concerning TATi did not correspond to the patients' wishes. When the consultation was completed within 1 day, the majority of the laboratory analyses were from the menu available before ELS. An ELS alone cannot deliver all the desired benefits of POCT.

Guidelines improve general trend of lowered cholesterol levels in type 2 diabetes patients in spite of low adherence

BACKGROUND

New guidelines were introduced in Sweden in 1999 to reduce the risk of cardiovascular disease among diabetes patients. The impact of the new guidelines on lipid levels in a diabetes patient population has not been extensively studied. Our aim was to study whether the introduction of treatment goals for dyslipidaemia was reflected in lower cholesterol levels in patients with diabetes in a general population.

METHODS

In a population of 59,338 individuals, 971 (1.6%) had diabetes. All subjects were 40, 50 or 60 years of age and participated in the Vasterbotten Intervention Programme in 1995-2004. Cholesterol levels and use of lipid-lowering drugs were measured, and trends in cholesterol levels were analysed before and after the guidelines were introduced in 1999.

RESULTS

In this effectiveness study, there was a marked decrease in mean plasma total cholesterol levels among patients with diabetes (5.79 (+/- 1.21) mmol/1 in 1995-1999 and 5.07 (+/- 1.00) mmol/1 in 2000-2004 (p<0.001)) as well as in the non-diabetic population (5.79 (+/-1.15) mmol/1 and 5.41 (+/-1.07) mmol/1 (p<0.001)). The trend in diabetes patients was influenced by increased use of lipid-lowering agents, even though only 25.3% (male/female 26.8%/23.2%) of the diabetes patients received lipid-lowering treatment after the introduction of the new guidelines.

CONCLUSIONS

Since the introduction of the guidelines, an increasing number of diabetes patients are receiving lipid-lowering drugs, which enhance a strong general trend of lowered cholesterol levels. Yet, the vast majority of diabetes patients with hypercholesterolaemia still do not receive medical treatment in accordance with the guidelines.

Promoting health in type 2 diabetes: nurse-physician collaboration in primary care

The purpose of this study is to examine effects of a nurse-physician collaborative approach to care of patients with type 2 diabetes and to determine possible effect sizes for use in computing sample sizes for a larger study. Forty patients from a family practice clinic with type 2 diabetes were randomly assigned to control or experimental groups. The control group received standard care, whereas the experimental group received standard care plus home visits from a nurse, as well as consultation with an exercise specialist and/or nutritionist. Follow-up continued for 3 months. Clinical end points included standard measures of diabetes activity as well as quality-of-life indicators. Focus group interviews were used to explore patients' responses to the program. Although findings were not statistically significant, a trend toward small to moderate positive effect sizes was found in glycosylated hemoglobin and blood pressure. Quality of life measures also showed a trend toward small to moderate, but nonsignificant, improvements in physical functioning, bodily pain, vitality, social and global functioning, energy, impact of diabetes, and health distress. Focus group interviews indicated a very positive response from patients, who expressed feelings of empowerment. In this study, patients treated with nurse-physician collaboration demonstrated small, but nonsignificant, improvements in blood chemistry after only 3 months. Physical and social functioning, energy, and bodily pain also showed a small improvement. Changes in awareness of effects of diabetes on health and an expressed sense of self-efficacy suggest that effects could be sustainable over the longer term.

Quality of recording of data from patients with type 2 diabetes is not a valid indicator of quality of care. A cross-sectional study

BACKGROUND

The quality of recording of clinical data in diabetes care in general practices is very variable. It has been suggested that better recording leads to improved glycaemic control.

OBJECTIVES

The purpose of this study was to assess the completeness of recording by GPs of data from type 2 diabetes patients; to compare recorded and missing data; and to investigate the association between completeness and glycaemic control.

METHODS

A cross-sectional survey was carried out in 52 general practices. Medical records were scrutinized for the presence of 11 variables. Examining patients through an active approach completed incomplete records. We compared recorded and unrecorded items. Completeness of recording was determined at both patient and practice levels.

RESULTS

Fifty-two general practices with 1641 type 2 diabetes patients cared for by the GP participated. The frequency of absence of any particular item ranged from 20 to 70%. Weight, systolic blood pressure and HbA(1c) were slightly lower in patients with those items missing on their files, and more such patients were non-smokers (P < 0.05). The percentage of patients with unrecorded variables that exceeded target values ranged from 39 to 75. Neither at practice level nor at patient level was any association between the completeness of the data recording and HbA(1c) found.

CONCLUSION

Records often were incomplete, which hampers a systematic approach to care of diabetic patients. However, the lack of association between completeness of data recording and control of glycaemia indicates that improved recording is not a valid indicator of good quality of care.

Action levels for obesity treatment in 40 to 42-y-old men and women compared with action levels for prevention of coronary heart disease

BACKGROUND

Guidelines for treating overweight and obesity have been suggested by the World Health Organization and other expert groups. We asked whether most men and women targeted in obesity guidelines would already be included in existing clinical recommendations for the prevention of coronary heart disease (CHD) or whether a new group of patients would be added to current workloads.

SUBJECTS AND METHODS

In 1997 the Norwegian National Health Screening Service examined CHD risk factors in subjects aged 40-42 y living in three counties. We studied 6911 men and 7992 women who did not report treatment for diabetes, hypertension or the presence of cardiovascular disease. Estimated 10 y risk of CHD was calculated using the Framingham equation.

RESULTS

The prevalence of single risk factors (systolic blood pressure > or =160 mmHg, diastolic blood pressure > or =95 mmHg, total cholesterol level > or =7.8 mmol/l and nonfasting glucose > or =11.1 mmol/l) ranged between 0 and 11% among subjects with body mass index > or =25 kg/m2. Adding low HDL cholesterol (<1.0 mmol/l for men, <1.1 mmol/l for women) and 10 y risk CHD risk to the classical risk factors increased prevalence to 16-50% (one or more risk factors or 10 y risk > or =10%). Sensitivities and specificities of using body mass index (BMI) or BMI and waist circumference as a screen for elevated CHD risk ranged between 22 and 91%. Screening for 10 y CHD risk of > or =10% or one or more risk factors among men and screening for one or more risk factors among women gave positive predictive values of 19-50%; however, the positive predictive value of screening for 10 y CHD risk of > or =10% was only 1-2% among women. Compared with men with BMI<30 kg/m2 or waist circumference <102 cm, those with measurements equal to or above these levels had statistically significantly higher adjusted odds ratios of elevated CHD risk (1.49, 95% CI 1.24-1.79 and 1.48, 95% CI 1.22-1.80, respectively); these associations were not observed among women.

CONCLUSION

Using BMI and waist circumference to screen for CHD risk yields low positive prediction values, thus doubling the number of men and adding even more to the number of women seen by the practitioner for prevention of CHD.

Randomised controlled trial of structured personal care of type 2 diabetes mellitus

OBJECTIVE

To assess the effect of a multifaceted intervention directed at general practitioners on six year mortality, morbidity, and risk factors of patients with newly diagnosed type 2 diabetes.

DESIGN

Pragmatic, open, controlled trial with randomisation of practices to structured personal care or routine care; analysis after 6 years.

SETTING

311 Danish practices with 474 general practitioners (243 in intervention group and 231 in comparison group).

PARTICIPANTS

874 (90.1%) of 970 patients aged >/=40 years who had diabetes diagnosed in 1989-91 and survived until six year follow up.

INTERVENTION

Regular follow up and individualised goal setting supported by prompting of doctors, clinical guidelines, feedback, and continuing medical education.

MAIN OUTCOME MEASURES

Predefined clinical non-fatal outcomes, overall mortality, risk factors, and weight.

RESULTS

Predefined non-fatal outcomes and mortality were the same in both groups. The following risk factor levels were lower for intervention patients than for comparison patients (median values): fasting plasma glucose concentration (7.9 v 8.7 mmol/l, P=0.0007), glycated haemoglobin (8.5% v 9.0%, P<0.0001; reference range 5.4-7.4%), systolic blood pressure (145 v 150 mm Hg, P=0.0004), and cholesterol concentration (6.0 v 6.1 mmol/l, P=0.029, adjusted for baseline concentration). Both groups had lost weight since diagnosis (2.6 v 2.0 kg). Metformin was the only drug used more frequently in the intervention group (24% (110/459) v 15% (61/415)). Intervention doctors arranged more follow up consultations, referred fewer patients to diabetes clinics, and set more optimistic goals.

CONCLUSIONS

In primary care, individualised goals with educational and surveillance support may for at least six years bring risk factors of patients with type 2 diabetes to a level that has been shown to reduce diabetic complications but without weight gain.

Assessment of coronary risk in general practice in relation to the use of guidelines: a survey in Denmark

BACKGROUND

There is a considerable gap between recommended and actually conducted preventive cardiology in general practice. The effect of guidelines is not fully evaluated.

METHODS

A questionnaire containing 10 questions on preventive cardiology, including the use of clinical guidelines, together with four case stories for cardiovascular risk estimation was mailed to 205 general practitioners (GPs).

RESULTS

Response rate was 81%. Twenty-five percent of the GPs had consultations in preventive cardiology at least once a day and 60% of the GPs thought lifestyle intervention had significant effect on cardiovascular risk. Approximately two-thirds of the GPs were regular users of national guidelines on prevention of cardiovascular disease. While the majority of GPs correctly assigned a patient with multiple risk factors to the high-risk category there was a much larger variation in risk estimations if fewer risk factors were present. GPs who reported use of guidelines overestimated coronary risk twice as frequently as nonusers of guidelines.

CONCLUSION

Preventive cardiology in general practice is common and the effect of lifestyle intervention is well accepted. Poor discrimination between high- and low-risk patients may, however, lead to suboptimal preventive care. The use of guidelines does not seem to improve risk estimation and further dissemination of better tools for risk estimation is needed.

Long-term effectiveness of a quality improvement program for patients with type 2 diabetes in general practice

OBJECTIVE

To assess the long-term effectiveness of a quality improvement program on care provided and patient outcomes in patients with diabetes.

RESEARCH DESIGN AND METHODS

A nonrandomized trial was performed with 312 patients with type 2 diabetes in the intervention group and 77 patients with type 2 diabetes in the reference group. The follow-up period was 42 months. The quality improvement program focused on improving both the provision of diabetes care and the patient outcomes. The program consisted of clinical practice guidelines, postgraduate education, audit and feedback, templates to register diabetes care, and a recall system. Data on the care provided were abstracted from medical records. Main outcomes on the provision of care were annual number of patient visits, blood pressure, and HbA(1c) and blood lipid levels. Main patient outcomes were blood pressure and HbA(1c) and blood lipid levels. Multilevel analysis was used to adjust for dependency between repeated observations within one patient and for clustering of patients within general practices.

RESULTS

Patients in the intervention group received care far more in accordance with the guidelines than patients in the reference group. Odds ratios ranged from 2.43 (95% CI 1.01-5.82) for the measurement of urine albumin to 12.08 (4.70-31.01) for the measurement of blood pressure. No beneficial effect was found on any patient outcome.

CONCLUSIONS

The quality improvement program improved the provision of diabetes care, but this was not accompanied by any effect on patient outcomes.