|Year : 2014 | Volume
| Issue : 3 | Page : 109-113
Quality of diabetic care in family practice centre, Aseer Region, Saudi Arabia
Yahia Mater Al-Khaldi
Joint Program of Family Medicine, Aseer region, Abha, Saudi Arabia
|Date of Web Publication||31-Jul-2014|
Yahia Mater Al-Khaldi
Joint Program of Family Medicine, Aseer, PO Box 2653, Abha
Objective: The objective of this study was to assess quality of diabetic care at a family practice centre in Saudi Arabia, Asser region.
Materials and Methods: This study was conducted at the Al-Manhal Postgraduate Family Practice Centre. All diabetic records at the centre were extracted and reviewed. Processes and outcomes of diabetic care were evaluated based on Standards of Care Delivery issued by the Primary Care Department at the Ministry of Health. Data was inputted and analysed using SPSS version 15. Relevant statistical tests were used accordingly and P-values were considered significant if their value were less than 0.05.
Results: The total number of diabetic records reviewed was 637. The majority of patients were married Saudis. The mean age was 60 years while the mean duration of diabetes was 12 years. Weight and blood pressure were recorded for 82% while lipid profile and kidney functions tests were done for 40% of the patients. Two-thirds of the diabetics (64%) were on oral hypoglycaemic agents and more than three-fourths (77%) were prescribed aspirin. More than two-thirds were overweight and obese while 40% had dyslipidaemia. Less than one-third (30%) had a good metabolic control while 26% had poor diabetic control.
Conclusion: Care of diabetics in our practice showed some improvement compared to the previous studies. However, we still face some challenges such as weak recall system and poor coordination with our referral hospital that needs urgent action. Providing centres with advanced laboratory facilities would help to implement annual check-ups particularly lipid profile and kidney function tests.
Keywords: Aseer region, diabetic care, family practice, quality
|How to cite this article:|
Al-Khaldi YM. Quality of diabetic care in family practice centre, Aseer Region, Saudi Arabia. J Health Spec 2014;2:109-13
| Introduction|| |
Diabetes mellitus (DM) is a common chronic disorder in Saudi Arabia. In recent epidemiological studies, it was found that its prevalence among Saudi adults was about 23.7%.  There is good evidence that long-term complications of diabetes can be prevented through proper diabetic control.  Proper diabetic control requires a healthcare team approach, patient centred care with a well-structured diabetic setting. 
Audit is known to play a vital role in improving the quality of healthcare for diabetics as reported by different countries. ,, However, only a few studies were conducted in the past to evaluate the diabetic care in a primary care setting in Saudi Arabia. ,, In 1995 and 1996, Khattab et al., conducted two consecutive audits of diabetic care in Aseer region. The main findings of these studies showed that quality of diabetic care was less satisfactory due to inadequate infrastructures and could be improved by providing primary health care centres (PHCCs) with such infrastructures in addition to suitable training for the healthcare team. , One year later (1997), Al-Khaldi and Khan studied the role of a mini-clinic in improving the diabetic care in another PHCC in Aseer region. In that study, they concluded that establishment of a mini-clinic resulted in improving the processes and outcomes of diabetic care in PHCC.  Since then, there was no evaluation carried out to assess the quality of diabetic care in PHCC settings in Aseer region. In this study, we aim to assess the quality of diabetic care in an academic family practice setting in Aseer region by comparing it with the previous two audits and national standards.
| Materials and Methods|| |
This study was conducted at Al-Manhal Postgraduate Family Practice Centre, which lies in Abha city, the capital of Aseer region. This centre has been accredited for postgraduate studies in Family Medicine since 1991. It serves about 18,000 inhabitants through 10 clinics and 10 physicians. Each centre is provided with support services such as X-ray equipment and laboratory. Diabetes care was conducted by 4 family physicians with proper training in diabetic care. Two nurses were also trained to manage diabetic patient files, measure vital signs, schedule appointments, follow-up defaulters and educate patients. The healthcare team followed the Standards of the Quality Assurance Manual for Diabetic Care issued by the Ministry of Health (MOH) Primary Care Department.  Patient records were reviewed and assessed by the investigator at the end of 2009. Weight as well as height were measured and body mass index (BMI) was calculated by the nurse in charge using the following formula, BMI = weight (kg)/height (m 2 ). Weight status was classified based on BMI as follows: Normal weight 18.5 - 24.9, overweight 25 - 29.9), mild obesity 30 - 34.9), moderate obesity 35 - 39.9, morbid obesity (≥ 40).  Hypertension (HTN) was classified as controlled if the last reading was less than 130/80 mmHg based on the Saudi Hypertension Management Guidelines.  Due to the unavailability of glycosylated haemoglobin, diabetic control was assessed based on the average of the last three readings of fasting plasma glucose as follows: Good control (< 126 mg/dl), fair control (126 - 179 mg/dl), poor control (≥ 180 mg/dl).  Patients were diagnosed to have hypercholesterolaemia and/or hypertriglyceridaemia if the fasting total cholesterol was ≥ 200 mg/dl or if the triglyceride was ≥ 150 mg/dl, based on the third report of the National Cholesterol Education Program.  All laboratory investigations were done in Abha General Hospital laboratory which carries out regular standardisation to ensure the accuracy of its results.
Items of process and outcomes of diabetic care were assessed and compared depending upon the standards issued by the MOH. 
A master sheet was used to collect relevant data (patients' characteristics and DM related data such as: duration, type, complications, control, clinical examination and investigations) which were inputted and analysed using SPSS version 15. Chi-square test was applied to determine the association between some demographic variables and outcomes. P-value was considered significant if it was less than 0.05.
| Results|| |
The total number of diabetics in Al-Manhal Postgraduate Family Practice was 637; most of them were Saudis (95%) and more than half were educated. The mean age was 60 and the mean duration of DM was 12 years. [Table 1] shows details of patients' characteristics.
|Table 1: Demographic characteristics of diabetic patients at Al- Manhal Family Practice, 2009 |
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[Table 2] indicates the processes of care for diabetics. Weight, blood pressure (BP) and glucose levels were recorded for about 82% of the diabetics. Kidney function and lipid profile tests were done for about 40% while 80% were referred for annual eye examination.
[Table 3] shows more than two-thirds of the diabetics were overweight/obese, 40% suffered from dyslipidaemia, and 17 - 25% had HTN, while retinopathy and coronary heart diseases (CHD) were reported among 5% and 2% of the patients respectively. As regards to diabetic metabolic control based on fasting blood sugar, 30% had good control, 44% had fair control while 26% had poor control.
Statistical analysis revealed no significant association between demographic variables and different items of diabetes processes and outcomes (P > 0.05). However, single diabetic patients showed good HTN control (63%) as compared to married diabetics (29%) and widowed patients (14%) (P = 0.009, X 2 = 9). Educated patients were found to have controlled BP as compared to illiterate patients (34% vs. 23%; P = 0.008, X 2 = 6). It was found that married individuals were referred to hospital more than single and widowed patients (80%, 79% and 76% respectively; P = 0.001, X 2 = 45). Association between demographic and weight status revealed that housewives were more obese than patients falling under retired and other jobs (71%, 33%, 47% respectively; P = 0.001, X 2 = 68). Similarly, females were found to be more obese as compared to males (68% vs. 36%; P = 0.001, X 2 = 65).
| Discussion|| |
Auditing is one of the important methods for improving quality of care in medical practice. This method helps healthcare providers identify the weak areas and suggest practical solutions. This study represents the third cycle of audit in Al-Manhal Postgraduate Family Practice since 1995. The first audit was conducted 15 years ago on 276 diabetic records. 
Although, the number of diabetics had increased since that date, the process of care improved for most items namely; recording database, measuring vital signs, conducting physical examinations, checking blood glucose levels and urine analysis. The reasons for this improvement include the establishment of a diabetic mini-clinic and proper training of the healthcare team in diabetic care. Compared to the previous two audits, the defaulter rate had reduced from 36 - 19% which may indicate the recall system's active role in our practice and the success of our appointment system.  However, more effort is needed to explore the real reasons for the high rate of defaulters among diabetics in our practice. Diabetics need shared and coordinated care in which many medical specialties are involved to provide ideal care. In this study, it was found that a high percentage of diabetics had no fundoscopy, lipid profile and kidney function tests which should be done annually. This gap between the standards and real situation indicated ineffective coordination with hospitals which was reported in previous reports from Aseer region. , In order to overcome this problem, referral to a family practice centre with a good laboratory and eye clinic is recommended to make such important facilities accessible for diabetics in our practice and nearby centres in Abha city.
More than 80% of diabetics were given health education about diet, physical activity and foot care. These figures indicate the efforts made by the healthcare team using different methods of education such as face to face approach, posters and pamphlets. These figures were higher compared to those reported by Al-Khaldi and Khan in 1997 from Abha city (77% for diet, 39% for foot care and 26% for physical activity).  In order to improve this area, large family practices should have a diabetic health educator or well-trained nurse in diabetic care management.
With regard to pharmacological therapy, it was observed that more patients (29%) use insulin compared to a previous report conducted from the same practice in 1996 by Khattab et al., (18%) which is still higher than that reported by Al-Alfi from Qassim region (15.8%), and Dubai (11.6%). ,, This variation in type of management could be attributed to the physicians' good skills to convince their patients to change from oral hypoglycaemic agents to insulin. Furthermore, high percentage of patients had DM for longer time which indicates the need for insulin.
Aspirin was found to reduce the morbidity and mortality from CHD either as a primary or secondary preventive measure.  This study showed that more than 75% of diabetics were given aspirin. This figure indicates that our practice implements an evidence-based approach to manage diabetics particularly for preventive measures.
Angiotensin-converting-enzyme (ACE) inhibitors have been prescribed for more than half of the diabetics (52%), probably due to the high percentage of diabetics with HTN. Additionally, some patients should be given ACE to prevent diabetic nephropathy as recommended by many diabetic associations and organizations. 
Regarding diabetic control, it is obvious that there was an increase in the diabetics with good control (20 - 30%) and decrease in those with poor control (33 - 26%) as compared to the previous audit.  This improvement could be explained by the continuous health education efforts done for diabetics on the importance of diet, physical activities and self-awareness including good diabetic control which covered about 80% of the total number of diabetics. Comparing these figures of metabolic control to national studies conducted in Qassim region, it was found that 21% had good metabolic control, 35.8% had fair metabolic control and 42 - 8% had poor metabolic control.  Al-Hussein in his study, conducted in Riyadh city revealed that only 20.6% had good metabolic control, 24.7% had fair control and more than half (54.7%) had poor metabolic control.  In Egypt, Abou El-Enein et al., found that about half of the diabetics who had been followed-up in three hospitals in Alexandria had poor metabolic control (49.2%).  In UAE, Khattab et al., found that good diabetic control was between 20.6 - 31.7% among diabetic patients.  In Pakistan, Dhanani et al., found that 23.9% of diabetics attending a family practice had good diabetic control.  The differences between our findings and other studies could be explained by different methods used (HbA1c vs. blood glucose) and the cut-off points for diabetic control.
Co-morbidities among diabetics are common. In this study, it was found that 31% were overweight and 53% suffered from obesity. These findings are higher than that reported from the same practice 15 years ago (23% overweight and 20% obese)  but were similar to that reported from Qassim region in 2004 (32.7% overweight and 49.7% obese)  and Riyadh region (39% overweight and 44.8% obese).  In order to manage this common co-morbidity, our practice should be provided with a dietician along with drugs for obesity, in addition to intensification of health education on prevention and treatment of obesity in the community.
Among other medical problems seen in diabetics is HTN. Uncontrolled HTN was observed in most of the diabetics in our practice. This figure was higher compared to that reported by Al-Alfi et al., (35.2%)  and Alwakeel et al., (78%).  This problem should be managed appropriately by keeping BP < 130/80 mmHg as recommended by the American Diabetes Association.  To achieve this target, our practice should check BP at each visit and follow recommendations of HTN management in this regard.
Dyslipidaemia is common among diabetics, 40% and 27% of diabetics were found to have high cholesterol or triglycerides compared to 44% and 34% reported in Qassim  and 39% in Riyadh.  This difference could be due to that lipid profile was not done for a high percentage of diabetics. In order to manage this health problem, laboratories should be provided with adequate reagents and facilities to screen for hyperlipidaemia and manage it accordingly.
The prevalence of diabetes complications was found to range from 5% for retinopathy to 0.5% for diabetic foot. These figures were lower than what was reported 15 years ago in spite of the increase in the number of diabetics. These figures are in agreement with those reported by Al-Alfi et al.,  but lower than those observed in a University Hospital in Riyadh region. 
Limitations of the study
The findings of this study should be interpreted carefully as we used fasting blood glucose to assess diabetic control due to the lack of HbA1C in our practice. The other limitation was low percentage of some complications since some relevant investigations were not done for majority of the diabetics in our practice.
| Conclusion|| |
Comparing our audit to the previous audits, the results of the current study are encouraging, mainly for most of the items of process and, to some extent, for elements of outcomes. However, we still face some challenges that need quick action such as coordination with other health sectors to reduce the rate of defaulters and provide our practice with good laboratory and eye clinic. Such actions will tend to patients satisfaction, early detection of common co-morbidities and complications among diabetics.
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[Table 1], [Table 2], [Table 3]