Diabetic Type 2 Chart Review Primary Care Clinic
Introduction
Diabetes mellitus (DM) is considered as ane of the mutual chronic diseases in the world present.i In 2011, in that location were more than 366 million people who had diabetes worldwide.2 Blazon 2 diabetes represents 85%–95% of the total diabetes patients in the globe, and without intervention, it is estimated that the number will increase up to 552 million in the year 2030.two Bahrain, Kuwait, Lebanon, Oman, Saudi Arabia, and UAE are vi of ten countries with the highest prevalence of diabetes in the world.ii According to a recent study, almost thirty% of developed Saudi populations were institute to accept DM.3
There are dissimilar practices of DM management in Kingdom of saudi arabia, similar other parts of the earth, with a considerable variation between different locations. People with diabetes may exist managed nether general family medicine dispensary, general internal medicine clinic, specialized diabetic clinics nether different specialties with different available resources and supportive services. This for certain will issue in variable levels of care and control and demand to be taken in to consideration in comparing results of dissimilar local studies.
In a written report done in Albany, New York, adherence to American Diabetic Association clinical exercise recommendations and lower levels of glycosylated hemoglobin (A1C) was found to be significantly better in the endocrinology clinic than in the primary care clinic.4 Some other similar written report done in Nippon, constitute contradicting upshot where mean A1C level for patients treated by general practitioners was found significantly lower compared to patients treated by the diabetes specialists.5
In 2006, a study was done in the US to evaluate the direction of type 2 diabetes in the primary care setting and included 95 primary care clinicians and 822 patients with type 2 DM. The report showed that just modest number of patients achieve established targets of diabetes control.6
In the US, family unit practices employing nurse practitioners were found to perform better than those with physicians only and those employing physicians administration, especially with regard to diabetes procedure measures.7 Another means of dramatic improvement in glycemic control is through community health intendance back up systems, specifically psychological support.8 A local study, published in 2014, compared diabetes control among patients with type ii DM managed in the primary health intendance clinics and patients managed at diabetes center at King Saud Academy Hospitals in Riyadh, Saudi Arabia. People with diabetes managed at principal intendance clinics were found to have amend control in terms of A1C level.9
Another report published in the United states in 1997 compared the quality of ambulatory diabetes care delivered by physicians in the diabetes clinic versus the general medicine clinic with 112 patients divided every bit between both clinics. It showed that the proportion of patient visits coming together the minimally acceptable levels of quality was better in the diabetes dispensary than the full general medicine clinic and the diabetes clinic performed dramatically amend than the general medicine dispensary in regard to complete foot and examination, A1C measurement and diabetic instruction referral.10 Like results were found in a meta-analysis of randomized trials comparing general exercise and shared intendance with follow-up in a infirmary outpatient dispensary.xi
Some other study compared clinical functioning for people with diabetes by traditional general practitioner clinics and diabetes clinics run past full general practitioners with special interests. It found no evidence that patients in specialist clinics do better than patients in routine principal care clinics.12
The aim of this study was to appraise and compare the level of command betwixt patients attending diabetic clinic under family medicine and patients attending diabetic clinic nether endocrinology, and to explore the event of different variable on the level of control in both groups. The primary outcome to measure out in this study was A1C as recognized indicator for DM control.
Materials and methods
This was a nautical chart review study washed in the period from May 2013 to Dec 2014. The medical charts reviewed belonged to patients with type two DM who were being followed in two centers: Diabetic Centre, King Abdul Aziz Housing Family Medicine Clinics, and Diabetic clinics, Convalescent Care Eye (ACC), King Abdul Aziz Medical City, National Guard, Riyadh, Kingdom of saudi arabia.
The Diabetic Centre at King Abdul Aziz Housing Family Medicine Clinics is a specialized eye for the management and follow-upwardly of patients with diabetes run past family medicine consultants. Diabetic clinics at the Ambulatory Care Heart, King Abdul Aziz Medical Metropolis are specialized clinics for the management and follow-upwards of patients with diabetes run by endocrinologist. Both centers provided health intendance for patients with diabetes with multidisciplinary approach (diabetic educator, dietician, ophthalmologist, and podiatrist).
The inclusion criteria comprised adult patients with type ii DM aged 20–65 years, seen at least once in the 6 months menses prior to the written report. The exclusion criteria comprised patients with type 1 DM, patients with diabetes due to secondary causes, patients with double follow-ups in both settings (diabetic eye at family medicine dispensary and diabetic clinics at ACC), meaning female person patients, patients aged younger than xx years and older than 65 years.
We estimated the number of patients with type 2 DM at King Abdul Aziz Housing Family Medicine Clinics, Riyadh to be iii,500 patients. By using sample size calculator with confidence level of 95%, with a margin mistake 5%, response distribution of 50%, and population size of three,500 patients with diabetes, the recommended sample size was 347 patients with diabetes. The sample size was increased to 352 to ensure data completeness. The medical nautical chart was selected by choosing every other medical record number in the list of patients with diabetes booked in both settings.
Data was collected by reviewing patients' medical charts both newspaper re-create file and e file using predesigned collecting canvass. The data collection sheet consists of 3 parts: part one for personal and demographic information (medical tape number, nationality, age, sexual practice, educational level), part 2 for DM data (duration of disease, comorbidities, and the dispensary of follow-up), and office 3 for glycemic control data (last measured A1C, number of follow-up visits in the last 12 months, handling blazon). The information collection sheet was designed subsequently reviewing the published literature and based on the required information.
Information were entered and analyzed using Statistical Package for Social Sciences (SPSS) version 18 (IBM Corp., Chicago, IL, USA). The chi-foursquare test was used to depict the association or deviation betwixt variables in different categories. All results were declared statistically pregnant with a P-value <0.05.
Ethical approving for patients' chart review was obtained from King Abdullah International Medical Research Center (KAIMRC) in Riyadh. The report was washed in accordance with principles of the Announcement of Helsinki.
Results
Among 352 patients, 176 (50%) patients were from family medicine clinics and 176 (fifty%) patients were from endocrine clinics. In the family medicine clinics, 87 (49%) patients were males and 89 (51%) were females and in the endocrine clinics, 63 (36%) were males and 113 (64%) were females.
The mean age of patients in the family medicine clinics was 49.ane±8.5 years and 51.9±9.1 years for patients in the endocrine clinic, with no significant difference between two groups.
At that place was significant difference in the duration of the disease betwixt the two groups (7.8±6.3 years in the family unit medicine clinics patients and 10.eight±7.three years in the endocrine clinics patients) with a P-value <0.05.
In comparing comorbidities, no significant difference for hypertension was found betwixt family unit medicine patients and endocrine patients (57% and 59%, respectively) or stroke (ane% in both groups). For hypothyroidism, there was a significant difference (10% and 20%, respectively) with a P-value =0.005, as well for dyslipidemia (92% and 67%, respectively) with P-value <0.001.
None of the patients in the family medicine clinics were treated with life style modifications alone, whereas 49% were treated with oral hypoglycemic agents (OHA), 5% were treated with insulin lonely, and 47% were treated with combined OHA and insulin. In the endocrine clinics, v% of the patients were treated with life style modifications lonely, 38% were treated with OHA, 29% were treated with insulin lone, and 28% were treated with combined OHA and insulin (Tabular array 1).
  | Table 1 Patients and disease characteristics (n=352) |
In regard to level of command, mean A1C was establish to be 8.97±1.87 for all patients. It was nine.01±1.75 for the family unit medicine clinics equally compared to viii.93±one.98 for the endocrine clinics, with no pregnant deviation between 2 groups (P-value =0.66) (Table 2).
 | Tabular array 2 Mean A1C in both groups |
When categorized into <vii, vii–8, 8–ix, 9–10, and >10, A1C was found in the study population as follows: 12.5%, 21.6%, xx.seven%, 17.nine%, and 27.3%, respectively. The percentage of well-controlled patients (A1C<7) was constitute higher in endocrinology setting (xv.ix%) than in family medicine setting (9.xi%) (Table 3). At that place was no difference for dissimilar categories of A1C with regards to age (Table 4).
 | Table three A1C categories for study population in both settings (n=352) |
 | Table iv Age distribution in relation to A1C categories (due north=352) |
There was no significant correlation for A1C level with age, duration of disease, number of follow-upwardly visits, and comorbidities in both settings (Tables 5 and 6).
 | Tabular array 5 Correlation betwixt A1C, age, duration of illness, and number of follow-upwards visits |
 | Table 6 Correlation between A1C and comorbidities |
Discussion
This study aimed to identify and compare the level of command of type 2 DM between two clinical settings: diabetic clinic nether family medicine and diabetic dispensary under endocrinology. The 2 groups of patients were matching for age, sex but non for the duration of the disease. Both clinical settings were following multidisciplinary arroyo with the availability of trained nurses, dieticians, health educators, podiatrists, and physicians at consultant level.
Current written report institute the mean A1C for all subjects at viii.97±1.87, which indicate poor control with no meaning difference between males and females. This finding is like to other studies of type two DM control in Saudi Arabia, which found the mean A1C to be 8.five±i.51nine and 8.20±one.89.13
In the electric current study, more than patients are well controlled in endocrinology than in family unit medicine setting, although the overall percentage is low (12.5%), which is really alarming and indicates the existent need for more than intensive management. Information technology is much less than what was found internationally. For example, for European patients with type 2 DM, 37·iv% had A1C ≥7% in PANORAMA study,fourteen while only i-quarter had adequate glycemic control in the Alvarez et al15 study. One report done on senior Malaysian patients with type 2 DM, found that ii-thirds of them had A1C ≥6.5%.sixteen Another study that assessed the prevalence of good and inadequate glycemic command across a 5-year period among patients with diabetes in the UK found >60% of patients had inadequate glycemic command (A1C ≥seven%).17 In another study done in Scotland, the overall control of patients with blazon 1 DM was establish to be poor with mean A1C >ix.i%.eighteen
The difference in the level of control tin be contributed to many factors. For example, a expert number of patients with type 2 DM are reluctant to outset insulin treatment despite the clinical demand, for dissimilar reasons. The issue of adherence to medication, underestimation of the disease past some patients, transportation difficulty for some female patients, all may be contributing factors.
In regard to the departure in DM control between the two settings, according to the current study, there was no significant departure between family medicine setting and endocrine setting. This outcome is contradicting results of other international studies. For example, a report conducted in Japan showed that the mean A1C level for all patients treated by full general practitioners was significantly lower than for those treated past the diabetes specialists (6.eight%±1.2% vs vii.0%±1.2%, P=0.0002).8 Another three studies done in Us, found amend control of patients with diabetes treated in the endocrinology clinic than in the primary care clinic.four,10,eleven The dissimilar results in those studies compared to the current study may be related to different setting, wherein our study was a diabetic dispensary under family unit medicine, while in the other three studies, it was a general practice setting.
For the level of control in the family unit medicine setting, the current report results are similar to the finding of another study done in US where simply modest number of patients achieved established targets of diabetes control.six A similar study done in US for patients with diabetes post-obit-upward in main care clinics, 41.half-dozen% merely achieved practiced control.19 A study, washed in Riyadh, Kingdom of saudi arabia, found almost similar findings for the level of control of diabetes patients treated in master care setting (9.0%±2.0%), although the management was conducted under general principal care clinics and not in specialized diabetic clinic.xx
In our report, nosotros found that patients with diabetes attending the endocrine dispensary were predominantly female (64%), which gives the possibility of endocrine medical atmospheric condition affecting females more commonly than males, such equally hypothyroidism, which accounted for xx% of the chronic medical conditions in the population attending the endocrine clinic only.
The level of control in both clinics was found to be better with patients who are treated with OHA alone, while it was worse with the patients who are treated with OHA and insulin. This can be correlated to the phase and complication of the disease in both groups.
In the current written report, for patients in both settings, the age, duration of illness, number of follow-up visits, and comorbidities had shown no effects on patients' glycemic control. This may not reverberate the actual clan due to the limited written report population size.
Conclusion
Patients with type 2 DM in this study were found to exist poorly controlled in both settings, diabetic clinic under family unit medicine and diabetic clinic under endocrinology.
Limitations
This study was limited to explore the level of control equally reflected by A1C level. There was no exploration of detailed aspects of DM management in either the processes or other outcomes.
In improver, this written report did non investigate the level of adherence to guidelines in management of DM in both settings. This may be an influencing factor affecting the level of control. Beingness retrospective, current study may exist liable to pick bias, which was done in 1 health care facility. Therefore, this study has express generalizability and should be interpreted as such.
Recommendation
Further studies are needed with larger sample size to explore difference in management of DM between family medicine-based intendance and endocrinology/hospital-based intendance and to explore other aspects similar accessibility, convenience, and cost effectiveness.
Acknowledgment
The work was not supported or funded past whatsoever drug visitor.
Disclosure
The authors report no conflicts of involvement in this work.
References
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