Community Medicine Section DOI : 10.7860/JCDR/2015/11540.6215
Year : 2015 | Month : Jul | Volume : 9 | Issue : 7 Page : LC07 - LC10

Quality of Diabetic Care among Patients in a Tertiary Care Hospital in Bangalore, South India: A Cross-sectional Study

Carolin Elizabeth George1, Sapna Mathew2, Gift Norman3, Devashri Mukherjee4

1 Consultant, Department of Community Health, Bangalore Baptist Hospital, Hebbal, Bellary Road, Bangalore, Karnataka, India.
2 DNB Resident, Department of Community Health, Bangalore Baptist Hospital, Hebbal, Bellary Road, Bangalore, Karnataka, India.
3 Professor and Head, Department of Community Health and Family Medicine Department, Bangalore Baptist Hospital, Hebbal, Bellary Road, Bangalore, Karnataka, India.
4 Research Consultant, Department of Community Health, Bangalore Baptist Hospital, Hebbal, Bellary Road, Bangalore, Karnataka, India.


NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Carolin Elizabeth George, Consultant, Department of Community Health, Bangalore Baptist Hospital, Hebbal, Bellary Road, Bangalore, Karnataka-560024, India.
E-mail: carolinelizabethj@gmail.com
Abstract

Background

Despite high prevalence of diabetes, translation of practice recommendations to care is still deficient in Asian and developed countries. The objective of this study is to assess the quality of care provided to diabetic patients and extent of knowledge transfer by the provider to these patients as a measure of the quality of service.

Materials and Methods

A cross divtional study was done among 190 diabetic patients over a period of 6 months. All type II diabetic patients, 30 years and above, who were diagnosed at least 1 year back without any other co-morbidity satisfied the inclusion criteria. They were interviewed based on an audit checklist formulated by National Diabetes Quality Improvement Alliance.

Results

The results revealed that blood pressure is the only parameter which is regularly monitored in majority (93%) of the diabetics. Hb1AC, LDL cholesterol and eye check up were less common and done only in 40%, 52.6% and 56.8% of diabetics respectively. Only 33(17.37%) had at least 5 of the 7 essential parameters monitored at least once in the last year. The knowledge questionnaire showed that more than 70% of the diabetic patients know that their condition requires lifelong management, diet modifications and exercises. There was no difference in the knowledge scores between the people who had no essential tests done and those diabetics who got 5 essential tests done. Gender, education, occupation and duration of diabetes were associated with knowledge score.

Conclusion

There is a need to formulate the local standards of care and clinical practice guidelines for the management of diabetes that are easily affordable and available to the health care providers and applicable to our country at the national level. Continuing audit of patients with diabetes is a feasible and a very useful method of promoting and helping to achieve the management goals of a good quality care.

Introduction

National guidelines and standards of care for diabetes are now available in many countries in the world [13]. Despite high prevalence of diabetes, serious long term complications and established evidence-based guidelines for management [13], translation of practice recommendations to care is still deficient in Asian [45] and developed countries [69].

Available literature suggests that the management of diabetes in India is sub-optimal for the majority of patients. Only 40–50% of individuals achieve the target for glycemic control, while lower numbers achieve targets for blood pressure and lipid control [4,10,11]. Studies from other countries have identified several provider and patient-related factors which can influence outcome measures in people with diabetes [12,13].

It is important to assess the quality of diabetic care to identify the extent of lacunae and its reasons to suggest measures to address the same. The present study is an attempt in this direction.

Objectives of The Study

To assess the quality of care provided to diabetic patients attending the medicine outpatient department by using quality indicators laid down by the National Diabetes Quality Improvement Alliance [14].

To assess the extent of knowledge transfer by the provider to the patients regarding diabetes and its complications as a measure of the quality of service.

Materials and Methods

The study design was cross-sectional where the diabetic patients were interviewed by the principal investigator. The audit was conducted among 190 patients with diabetes who attended the Medicine outpatient department over a period of 6 months from Feb 2011 to July 2011. All type II diabetic patients, 30 years and above, who were diagnosed at least one year back without any other co-morbidity satisfied the inclusion criteria. The purpose of the study was explained to the patients and informed consents were taken from those who were willing to take part in the study. The interview schedule included basic demographic data, process indicators, outcome indicators and questions to assess the knowledge of the diabetic patients.

The study methodology comprised of an audit to assess the quality of care provided to the diabetic patients using the quality indicators for diabetes care. These indicators were formulated by the National Diabetes Quality Improvement Alliance based on the priority measures and indicators recommended by American Diabetes Association, American Medical Association, American College of Physicians, Agency for Healthcare Research and Quality, American Academy of Family Physicians, American Association of Clinical Endocrinologists and other well accepted international diabetic guidelines. The audit checklist consisted of diabetes specific process and outcome indicators. The process indicators consist of basic tests that are required to be done in a patient with diabetes. The proximal outcome measures laid down criteria for HB1Ac, BP and LDL cholesterol in the context of evaluating the quality of care [Table/Fig-1].

Audit checklist for quality of care

Process measures
Percentage of patients with one or more HbA1c tests annually
Percentage of patients with at least one LDL cholesterol test annually
Percentage of patients with at least one test for microalbuminuria during the measurement year or who had evidence of medical attention for existing nephropathy
Percentage of patients who received a dilated eye examination or evaluation of retinal photography by an ophthalmologist or optometrist during the current year or during the prior year if the patient is at low risk of retinopathy
Percentage of patients receiving at least one foot examination annually
Percentage of patients whose smoking status was ascertained and documented annually
Outcome measures
Percentage of patients with most recent HbA1c level >9.0% ( poor control)
Percentage of patients with most recent LDL cholesterol <130 mg/dl
Percentage of patients with most recent blood pressure <140/90 mmHg

Source: National Diabetes Quality Improvement Alliance [14]


There were five process indicators and each positive response was given a score of one. A score of five or more was considered good and any score less than or equal to three was considered poor. Similarly each positive response for a proximal outcome indicator was given a score of one. A score of three was considered as good and score of 0 was considered poor.

Diabetes is a disease for which 95% of the care lies with the patient. A good quality service should transfer the knowledge about the disease condition, its complications, the behaviour modifications which it warrants and the importance of regularity of the follow up. Therefore, the level of knowledge provided is critical to patients’ ability to care well for their diabetes and the assessment in turn indicates the quality of care given to the patients [15].

The diabetic knowledge was assessed by a semi structured questionnaire which measured the knowledge in four key concepts in Diabetes care namely chronicity, knowledge about target blood sugar level, life style modifications (diet and exercise) and complications (Hypoglycemia, complications related to heart and kidney). There were a total of nine questions and each correct response carried one mark. The knowledge was interpreted as poor, average and good, if the scores were less than 4, 4-6 and more than 7 respectively. The study was approved by the Institutional Review Board of the hospital.

Statistical Analysis

Data was entered in Microsoft Excel and analysis was done using SPSS version 20. Descriptive analysis was done for all the variables. Frequencies, percentages were calculated for categorical variables and mean and standard deviation was calculated for continuous variables like scores. Chi-square test was done to find the association of quality of care indicators with variables age, gender, education, duration of disease etc. ANOVA was used to compare the knowledge scores with the standard of quality of care indicators.

Results

More than half (59.5%) of the studied population were between the age group of 30 and 60 years, almost half (50.5%) were females. One fifth of them (23.2%) were illiterate and 35.8% were graduates. 24.7% were professionals and another 20% were engaged in agriculture. About half those (56.8%) had diabetes for less than five years.

The results revealed that majority of the study population (93%) got their blood pressure examined in their last visit to the hospital. More than half of the patients received LDL cholesterol check up (52.6%) and eye check up (56.8%) whereas only less than a third received urine micro-albumin examination (30%). Annual smoking status recording (0%) and foot examination (0%) proved to be the most unpopular of the recommended guidelines [Table/Fig-2]. The average number of tests per diabetic patient was 2.7. The process indicators were not associated with age (p =0.125), gender (p = 0.58) education (p=0.473), occupation (p=0.92) or duration of diabetes (p=0.24).

Proportion of diabetics who underwent process indicator tests/examination (N=190). (The values are expressed in percentage and the number of patients is given in brackets)

The outcome measures revealed that an alarming 61% (47/77) had a poor long term glycemic control whereas a reasonably good proportion of diabetic patients were maintaining target level blood pressure (78.5%) and LDL cholesterol levels (79%) [Table/Fig-3]. The outcome measures were not associated with age (p=0.332), gender (p=0.72) education (p=0.591) and occupation (p=0.863). The outcome indicators were better for diabetic patients with less than five years of duration (p=.02).

Proportion of diabetics with favorable proximal outcome indicators.

{Percentage (no of patients with favorable result/total number of patients who got the test done)}

The knowledge questionnaire showed that more than 70% of the diabetic patients know that their condition requires lifelong management, the required diet modifications and the exercises that they need to do and the symptoms of hypoglycemia. The mean score was 5.4. Only 57% and 46% knew their target fasting and post prandial blood sugar respectively [Table/Fig-4]. Gender, education, occupation and duration of diabetes were associated with knowledge score [Table/Fig-5].

Proportion of patients who had adequate knowledge in essential concepts in diabetes (N=190). (The values are expressed in percentage and the number of patients is given in brackets)

Association of variables with knowledge scores

ParameterCategoryGood score (> 7)Average score (4-6)Poor score (< 4)Totalp value
No.%No.%No.%No.
Age30-604438.94%4237.17%2723.89%1130.221
>602633.77%3849.35%1316.88%77
GenderMale4244.68%3031.91%2223.40%940.017
Female2829.17%5052.08%1818.75%96
EducationIlliterate613.64%2454.55%1431.82%440.00
1-10 years of schooling816.33%2346.94%1836.73%49
PUC3348.53%2739.71%811.76%68
Graduation2379.31%620.69%00.00%29
OccupationProfessional2042.55%1736.17%1021.28%47
Clerical2367.65%1029.41%12.94%340.00
Agriculture718.42%1950.00%1231.58%38
None2028.17%3447.89%1723.94%71
Duration of diabetes<5 years3027.78%4440.74%3431.48%108
5 - 10years2956.86%1733.34%59.80%510.00
>10 years1135.48%1961.29%13.23%31
7036.84%8042.11%4021.05%190

The mean knowledge scores were compared among people who had better process indicator and outcome indicators to others who had poor process and using ANOVA. The analysis revealed that there was no association between knowledge scores with process indicators and outcome indicators [Table/Fig-6].

Association of knowledge scores with process and outcome indicators

Parameter No. of peopleMean knowledge scoreStandard DeviationF-value p-value
No.%
Process indicator & Knowledge score
No tests73.75.92.42F-value: 0.033 p-value: 0.99
One test3719.56.22.31
Two tests5026.36.22.34
Three tests3518.46.12.32
Four tests2814.76.12.32
Five tests3317.46.22.30
Proximal outcome indicator & Knowledge score
No tests3719.55.422.31F-value:2.345 p-value =0.074
One test7338.45.22.307
Two tests6534.25.82.303
Three tests157.94.132.249

Discussion

Even though India is regarded as the Diabetic Capital of the World and multiple players are dealing diabetes at different settings, there are not many Indian studies which have assessed the quality of diabetes care. DEDICOM study done in Delhi is the only published study which had similar objective in mind.

The results revealed that blood pressure is the only parameter which is regularly monitored in majority of the diabetics. Hb1AC, LDL cholesterol and eye check-up were done only in 40%, 52.6% and 56.8% of diabetics respectively. Less than a third received urine micro-albumin examination (30%). Only 33(17.37%) had at least 5 of the 7 essential parameters monitored at least once in the last year. This reveals that the minimum standards have to be reinforced among doctors and patients to achieve quality.

Majority of the study population (93%) got their blood pressure examined in their last visit to the hospital. This is higher compared to CODI study (54.3%) and the study conducted by Rossi et al., (77%). No separate queue, no waiting time, no extra charges, being non invasive technique, patient demand and sensitized physicians may be attributed to the popularity of this measurement.

Urine micro albuminuria is relatively unpopular even in developed countries [16,17]. The physicians prefer to send for renal function tests (Serum Creatinine) even though urine micro albuminuria is the earliest and cost effective indicator for real failure. In general it was noticed that physician show more inclination towards blood tests than urine tests.

The proportion of people getting their eye check up was comparable to the studies conducted by Suwatee et al., [6]. The initial changes in the retina usually have no bearing on vision, hence the patients often postpone their ophthalmology consultation.

Only 40.5% had their Hb1AC checked in the last year. The proportion was considerably lower than the study conducted by Rossi M et al., [17] and Suwatee et al., [6]. However, it was better than CODI [18], Duncan et al., [19] and DEDICOM study. It was observed that the doctors relied on FBS and PPBS value for dose adjustments rather than Hb1AC. Annual smoking status recording (0%) and foot examination (0%) proved to be the most unpopular of the recommended guidelines.

Another important observation of the study was, there is no association between the knowledge scores of the patients and the tests undertaken. It was assumed that better the knowledge about the disease, the better will be the process indicators. But it was seen that there was no difference in the knowledge scores between the people who had no essential tests done and those diabetics who got five essential tests done. It shows that these tests are mainly provider driven.

The current study showed that there was no association between knowledge scores and test results. There was no significant variation in knowledge scores between people whose parameters were controlled and not controlled. If practice questions would have been asked instead of knowledge questions, there could have been a difference between groups. The achievement of indicators for quality of care in the current study namely HbA1c testing, LDL cholesterol, eye check-up and BP check-up can be considered to be better than other Indian Studies. But since the DEDICOM [10] and CODI [15] studies are population based studies, better results may be expected in the present study as care may be better in tertiary hospital samples. It is evident that the process and outcome indicators show better results when compared to other studies but still we have a long way to go in filling the gaps between provision and utilization of health care facilities.

Diabetes mellitus poses a major health challenge both epidemiologically and economically in India. Today’s challenges do not arise from a lack of efficacious diabetes treatments. Rather, these challenges lie with effectively implementing them across the population. Numerous barriers to implementation are located at several levels including the societal, health care system, provider, and patient levels [20]. A quality indicator is a measurable element of practice performance for which there is evidence or consensus that it can be used to assess the quality, and hence change the quality of care provided [14]. A well planned audit conducted regularly can bring about beneficial change for patient and clinician.

Conclusion

There is a need to formulate the local standards of care and clinical practice guidelines for the management of diabetes that are easily affordable and available to the health care providers and applicable to our country at the national level. Continuing audit of patients with diabetes is a feasible and a very useful method of promoting and helping to achieve the management goals of a good quality care.

Source: National Diabetes Quality Improvement Alliance [14]

References

[1]American Diabetes Association Position Statement: Standards of Medical Care in Diabetes 2013 Diabetes Care 2013 36:S11-S66.doi: 10.2337/dc13-S011  [Google Scholar]

[2]Guidelines for management of Type 2 Diabetes, New Delhi ICMR [Internet] 2005 [cited 2012 Mar 04]. Available from: http://icmr.nic.in/guidelines_diabetes/prelim.pdf  [Google Scholar]

[3]Canadian Diabetes AssociationClinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2008. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada Can J Diabetes 2008 32:S1-201.[cited May 2012] Available from http://www.diabetes.ca/files/cpg2008/cpg-2008.pdf  [Google Scholar]

[4]Raheja BS, Kapur A, Bhoraskar A, Sathe SR, Jorgensen LN, Moorthi SR, Diab Care Asia - India Study: diabetes care in India: current status J Assoc Physicians India 2001 49:717-22.  [Google Scholar]

[5]Chuang LM, Tsai ST, Huang TY, Tai TY, The status of diabetes control in Asia: a cross-sectional survey of 24317 patients with diabetes mellitus in 1998 Diabetes Med 2002 19:978-85.  [Google Scholar]

[6]Suwatee PJ, Lynch C, Pendergrass ML, Quality of Care for Diabetic Patients in a Large Urban Public Hospital Diabetes Care 2003 26(3):563-58.  [Google Scholar]

[7]Peters A, Legorreta AP, Ossorio RC, Davidson MB, Quality of Outpatient Care Provided to Diabetic Patients: A health maintenance organization experience Diabetes Care 1996 9(6):601-06.  [Google Scholar]

[8]Beckles GL, Engelgau MM, Narayan KM, Herman WH, Aubert RE, Population-Based Assessment of the Level of Care Among Adults With Diabetes in the U.S Diabetes Care 1998 21(9):1432-8.  [Google Scholar]

[9]Chin MH, Auerbach SB, Cook S, Harrison JF, Koppert J, Jin L, Quality of diabetes care in community health centers Am J Public Health 2000 90(3):431-34.  [Google Scholar]

[10]Nagpal J, Bhartia A, Quality of diabetes care in the middle and high income group populace: The Delhi Diabetes Community (DEDICOM) survey Diabetes Care 2006 29(11):2341-48.  [Google Scholar]

[11]Venkataraman K, Kannan AT, Mohan V, Challenges in diabetes management with particular reference to India Int J Diabetes Dev Ctries 2009;29 (3):103-09.  [Google Scholar]

[12]Benoit SR, Fleming R, Philis-Tsimikas A, Ji M, Predictors of glycemic control among patients with type 2 diabetes: A longitudinal study BMC Public Health 2005 5:36  [Google Scholar]

[13]Matheka DM, Kilonzo JM, Munguti CM, Mwangi PM, Pattern, knowledge and practices of HbA1C testing among diabetic patients in a Kenyan tertiary referral hospital Globalization and health 2013 9:55doi:10.1186/1744-8603-9-55  [Google Scholar]

[14]Nicolucci A, Greenfield S, Mattke S, Selecting indicators for the quality of diabetes care at the health systems level in OECD countries Int J Qual Health Care 2006 18(1):26-30.doi: 10.1093/intqhc/mzl023  [Google Scholar]

[15]Gupta V, Suri P, Diabetes in elderly patients JK Practitioner 2002 91:258-9.  [Google Scholar]

[16]Bjork S, Kapur A, King H, Nair J, Ramachandran A, Global policy: aspects of diabetes in India Health Policy 2003 66(1):61-72.  [Google Scholar]

[17]Gomes MB, Gianella D, Faria M, Tambascia M, Fonseca RM, Réa R, Prevalence of Type 2 Diabetic patients within the targets of care guidelines in daily clinical practice: A Multi-centre study in Brazil Rev Diabet Stud 2006 3(2):82-7.  [Google Scholar]

[18]Gulabani M, John M, Isaac R, Knowledge of diabetes, its treatment and complications amongst diabetic patients in a tertiary care hospital Indian J Community Med 2008 33(3):204-06.  [Google Scholar]

[19]Blonde L, Dey J, Testa MA, Gutherie RD, Defining and measuring quality of diabetes care Primary Care 1999 26:841-55.  [Google Scholar]

[20]Lohr KN, Schroeder SA, A strategy for quality assurance in medicare N Engl J Med 1990 322(10):707-12.  [Google Scholar]