Quality of Care of Diabetes in Jamaica (1995)

1. Quality of Care of Diabetes in Jamaica(1995) Rainford Wilks Epidemiology Research Unit Tropical Medicine Research Institute University of the West Indies (DOTA/UDOP, Ocho Rios, Jamaica, March 2002)

2. 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

3. 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

4. Diagnosis of Diabetes:Three 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. 1997;20:1183-1197. World Health Organisation 1999. Report of a WHO Consultation: Definitions, diagnosis and classification of diabetes mellitus and it complications

5. FPG 2-Hour PG on OGTT Diabetes Mellitus Diabetes Mellitus 126 mg/dL 7.0 mmol/L 200 mg/dL 11.1 mmol/L Impaired Fasting Impaired Glucose Glucose Tolerance 110 mg/dL 6.1 mmol/L 140 mg/dL 7.8 mmol/L Normal Normal Glucose Tolerance Categories Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197. 1-2

6. 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 <65 y or men <55 years

7. 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

8. Blood Pressure Categories JNC VI

10. Risk Stratification and Treatment

11. 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

12. 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 <6%goal <7%action level >8% Total cholesterol <5.2 mmol/L LDL-C optimal <2.6 mmol/L initiate treatment >3.35 mmol/L HDL-C >1.15 mmol/L Triglycerides < 2.30 mmol/L Blood Pressure < 130/80 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

13. Treatment Algorithm Nonpharmacologic therapy Very symptomatic Severe hyperglycemia Ketosis Latent autoimmune diabetes Pregnancy Monotherapy Sulfonylureas/Benzoic acid analogue Biguanide Alpha-glucosidase inhibitors Thiazolidinediones Insulin Combination therapy Insulin

14. 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

15. 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.

16. 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

17. 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

18. Characteristics of Study Population by Clinic Type (Diabetes)

19. Prevalence of Treatments Types by Clinic Type

20. Monitoring and Control of Blood Glucose, by Clinic Type, Jamaica, 1995 ** *** *** PUBMC=government polyclinic; PRMC=group private general practice; SPMC=specialist public-hospital diabetic clinic **p<0.01; ***p<0.001

21. Surveillance of Lifestyle and Other Risk Factors by Clinic Type

22. Monitoring and Control of Hypertension (1) by Clinic Type (Jamaica, 1995) * *** *** *p<0.05; ***p<0.001

23. Good Blood Pressure Among Diabetics with Hypertension on Treatment

24. Monitoring and Control of Hypertension (2) by Clinic Type (Jamaica, 1995) *** ** ** *** *** *** * *p<0.05; **p<0.01 ***p<0.001

25. Surveillance of Complications of Diabetes by Clinic Type (Jamaica, 1995) *** *** ***p<0.001

26. Surveillance of Complications of Diabetes and Management of Lifestyle Factors by Clinic Type(Jamaica, 1995) *** *** *** ***p<0.001

27. Management of Lifestyle Factors by Clinic Type (Jamaica, 1995) *** ***p<0.001

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

29. Monitoring and Control of Blood Glucose by Clinic Type (Diabetes)

30. Surveillance of Complications of Diabetes by Clinic

31. Management of Lifestyle Risk Factors by Clinic (Diabetes)

32. Collaborators Kingston, Jamaica - Terrence Forrester -- Franklin Bennett - Norma McFarlane-Anderson - Marvin Reid - Lincoln Sargeant

33. Hypertension, Diabetes & Lipid Status in Jamaica: Prevalence & Incidence Surveys & Quality of Care Rainford Wilks Epidemiology Research Unit Tropical Medicine Research Institute, UWI

34. Quality of Care ofHypertension & Diabetes in Jamaica

35. Baseline Characteristics by Clinic Type (Hypertension)

36. Monitoring and Control of Hypertension by Clinic Type (Hypertension)

37. Monitoring and Control of Hypertension by Clinic Type (Hypertension)

38. Drug Treatment of Hypertension by Clinic Type (Hypertension)

39. Surveillance of Lifestyle Risk Factors by Clinic (Hypertension)

40. Management of Lifestyle Risk Factors by Clinic (Hypertension)

41. 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.

42. 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.

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

44. 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