MANAGEMENT OF TyPE 2 DIABETES MELLITUS IN GREENLAND ...

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Management of diabetes care in Greenland

ORIGINAL ARTICLE

Management of type 2 Diabetes mellitus in Greenland, 2008: Examining the quality and organization of diabetes care Michael Lynge Pedersen Center for Primary Health Care in Nuuk, Nuuk, Greenland Received 14 October 2008; Accepted 8 January 2009

 

ABSTRACT Objectives. To analyse the management of type 2 diabetes mellitus (T2DM) in Greenland in 2008. Study design. Observational and cross-sectional study, including a review of medical records and databases. Methods. Data on adult (>19 years old) T2DM patients were collected from each primary health care centre in Greenland. Information was collected about age, gender, HbA1c, blood pressure, blood lipids, and from eye, feet and urine examinations from 15 of the 17 health care districts in Greenland, which represent 90% of the whole adult population of Greenland. Three clinics were excluded because of too few patients (only 7). The management of T2DM patients is described and is based on 6 processes and 3 biological indicators. Results. The 12 clinics together performed quite well looking at the monitoring of HbA1c (79%), blood pressure (69%) and blood lipids (83%). However, the screening rates were low within 2 years for microalbuminuria (47%), eye (50%) and foot examinations (29%). Great variation in the management of the treatment was observed among the clinics. No clinic achieved all the standards suggested in this paper. Screening for diabetic retinopathy seemed to be implemented, but the records were not fully updated, whereas screening for microalbuminuria and foot examinations clearly were not routine in most clinics. Conclusions. The management of type 2 diabetes mellitus is a major task for the heath care system in Greenland. It is recommended that the implementation of a national strategy based on national guidelines, local diabetes registers and feedback to the clinics get underway as soon as possible. (Int J Circumpolar Health 2008; 68 (2):123–132) Keywords: Greenland, diabetes mellitus, care, quality International Journal of Circumpolar Health 68:2 2009

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INTRODUCTION Previously, the prevalence of diabetes mellitus type 2 (T2DM) was low in Greenland (1). New epidemiologic studies of the population in Greenland performed during the period 1998 to 2001 indicate a dramatic change in the prevalence of diabetes, suggesting an age-standardized prevalence of diabetes among men and women of 10.8% and 9.4%, respectively. Furthermore, 70% of those with diabetes had not previously been diagnosed (2). A high prevalence of diabetes has also been reported among Greenlander migrants living in Denmark (3). Furthermore, it has been predicted that the prevalence of T2DM will increase in Greenland (4). The prevalence of patients aged at or above 40 years with diagnosed T2DM is only around 2% (5). The prevalence of overweight and obese persons is also increasing rapidly (6–7), which supports the risk of a type 2 diabetes epidemic, which has been seen in other Westernized countries. T2DM thus seems to be a major challenge to the public health service in Greenland. However, knowledge regarding the actual clinical management of the diabetes population is very limited. The population of Greenland is around 56,000 inhabitants, widely spread out geographically along the coast in a country with a total area of approximately 2,166.086 km2 (8). The public health care system is divided into 17 districts. Each district is composed of 1 town and a varying number of small settlements coupled with a primary health care centre, which also functions as a local hospital. The management of patients with T2DM is dealt with locally in each district, and the condition of a small group is monitored by the outpatients’ 124

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clinic at the Department of Internal Medicine, Queen Ingrid’s Hospital in Nuuk. In 2 towns, Nuuk and Aasiaat, the primary health care centres have focused on the management of patients with T2DM. This provided the basis for the establishment of an electronic database, Fyns Diabetes Database (FDDB), which was implemented to improve the management of T2DM in November of 2006. The health care system was able to start a 3-year project to improve the management of T2DM in Greenland based on a generous donation from Novo Nordisk A/S. The aim of this study is to describe the actual management of T2DM in Greenland, to establish a method to evaluate the management of T2DM patients in Greenland and to compare the health care management in the 17 different districts.

MATERIAL AND METHODS The 17 local districts were contacted and asked to make a list of patients with T2DM and to include related information regarding age and gender. The data were collected in a standard Microsoft excel spreadsheet after an introduction to the procedure was provided. The clinical diagnosis in the medical records was used to classify the patients. Results of the latest examinations of blood pressure, blood lipids, microalbuminuria, eyes (performed by an ophthalmologist) and feet were collected from the database in Nuuk and Aasiaat and from health records in the other districts. Only districts with 10 or more T2DM patients were included. Analysis of venous blood for lipids and glycosylated haemoglobin and of urine (night sample) for excretion of albumin were performed at the Central Laboratory at Queen

Management of diabetes care in Greenland

Ingrid’s Hospital in Nuuk, using Architect 8000T from Abbott. The Central Laboratory is a member of the Danish quality control system for laboratories, DEKS. Some of the analysis for glycosylated haemoglobin was performed on capillary blood samples locally using a Nycocard Reader made by Axis-Shield PoC AS. The eye examinations were only included if done by an ophthalmologist (a travelling specialist from Denmark). The standard examination for retinopathy in Denmark is done by dilating the pupils. However, in this study, there was no effort to specify that the examination was done in this way. A foot examination was included in the investigation for neuropathy in Nuuk and Aasiaat, whereas any description of the foot in the medical records in the other clinics was included as a foot exam. Six different process indicators were used to describe the management of T2DM in the clinics. The following indicators were used for the analysis, with values designated as a percent of the total patients in each group: 1. The percentage of patients with T2DM in whom glycosylated haemoglobin was measured within the previous year. 2. The percentage of patients with T2DM in whom blood pressure was measured within the previous year. 3. The percentage of patients with T2DM in whom blood lipids were measured within the previous 2 years. 4. The percentage of patients with T2DM in whom urine was tested for microalbuminuria within the previous 2 years. 5. The percentage of patients with T2DM who had their eyes examined within the previous 2 years.

6. The percentage of patients with T2DM who had their feet examined within the previous 2 years. Standards for acceptable monitoring levels based on the model adopted by the Danish National Indicator Project (9) were used. Furthermore, the quality of the treatment was described using biological indicators where medians and percentiles concerning glycosylated haemoglobin, blood pressure and serum cholesterol were calculated for each district (clinic). Statistics Q-Q plots were used to analyse for distribution of normality. Medians were compared with the Kruskal Wallis test. Chi-square tests were used to compare frequencies. Linear regression was used to analyse for dependency of clinic, age and gender. Statistical analyses were performed using SPSS 17.0.

RESULTS Demographics All 17 districts were contacted and asked to collect information about adult patients (above 19 years of age) with T2DM. The data received from 15 of the districts represented 90% of the adult population in Greenland. Two clinics were not able to deliver the results before the deadline. Three clinics were excluded because of the small combined total number of T2DM patients (7), leaving 12 clinics as the basis for further analysis, representing thus 88% of the adult population in Greenland (8). Information about the latest examinations of blood pressure, blood lipids, microalbuminuria, eyes (as performed by an ophthalmoloInternational Journal of Circumpolar Health 68:2 2009

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gist) and feet was collected from the (FDDB) database in Nuuk and Aasiaat, and from health records in the other 10 districts. The number of patients registered in the 12 clinics totalled 440, of which 206 were women and 234 men. The number of patients in each clinic varied from 10 to 94. No significant variation difference in the distribution of males and females between the 12 clinics was observed (p=0.43). However, the median age of the patients between each clinic was significantly different. Thus, the clinics are not fully comparable. Process indicators The process indicators of the management of type 2 diabetes mellitus in each of the 12 clinics and all clinics together are shown in Table I. Furthermore, a standard monitoring level is suggested. The 12 clinics together perform quite well looking at the monitoring of glycosylated haemoglobin (79%), blood pressure (69%) and blood lipids (83%). However, the screening rates within

2 years for microalbuminuria (47%), eye (50%) and foot examinations (29%) are low. Great variation among the clinics is demonstrated. Thus, the percentage of patients with T2DM in whom glycosylated haemoglobin was measured within the previous year varies from 39% to 100%. The percentage of patients with T2DM in whom hypertension was measured within the previous year varies from 20% to100%, while the percentage of patients in whom blood lipids was measured within the previous 2 years varies from 36% to 100%. The examination of feet and the screening for microalbuminuria were done very sporadically in many of the clinics. It was observed that 8 out of the 12 clinics performed these examinations on less than 50% of their patients. In one of the clinics that maintained a database, the results of screening for microalbuminuria and foot examinations were not updated, resulting in an underestimation of the actual percentage of patients screened.

Table I. The quality of the management of type 2 diabetes mellitus among the 12 clinics (1–12) in Greenland.

Number of clinic 1 2 3 4 5 6 7 8 9 10 11 12 All (number of patients) (94) (46) (42) (51) (17) (11) (46) (23) (24) (10) (22) (54) (440) Health % of patients indicator with Standard Indicator T2DM in whom/who had: Metabolic glycosylated 98 91 98 39 88 91 70 57 83 100 82 63 79 95% haemoglobin was measured within the last year Hypertension blood pressure was 98 91 83 20 100 73 83 83 88 90 82 63 69 95% measured within the last year Blood lipids blood lipids were 96 89 95 63 76 100 91 72 96 100 36 69 83 90% measured within the last 2 years Micro- urine was tested 83 60 80 31 24 0 0 30 54 0 0 50 47 95% albuminuria for microalbuminuria within the last 2 years Eye their eyes examined 30 37 74 43 41 0 85 22 79 0 23 50 45 90% examination within the last 2 years Foot their feet examined 89 13 4 1 29 22 48 4 17 0 0 0 29 95% examination within the last 2 years 126

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