Corrected Proof Pcd_109-1

ARTICLE IN PRESS

PCD 109 1–6

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 0 9 ) xxx–xxx

Contents lists available at ScienceDirect

Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd

1 2 3 4

OF

2

Do current standards of primary care of diabetes meet with guideline recommendations in Trinidad, West Indies? Lexley M. Pinto Pereira a,∗ , Avery Hinds b , Issa Ali a , Ravita Gooding a , Michelle Ragbir a , Kavita Samaroo b , Shivananda B. Nayak a Q1 a Faculty of Medical Sciences, The University of the West Indies, St Augustine, West Indies, Trinidad and Tobago b

The North West Regional Health Authority, Trinidad, West Indies, Trinidad and Tobago

5

6

RO

1

a r t i c l e

i n f o

a b s t r a c t

7

Article history:

Aims: Primary care management of diabetes was examined using the Caribbean Health

9

Received 4 December 2008

Research Council (CHRC) guidelines.

10

Received in revised form

Methods: We retrospectively examined a cross-section of 646 type 2 people with diabetics

11

13 February 2009

over 12 months with 1st visit between 1997 and 2005.

12

Accepted 22 March 2009

Results: There were more women (65.8%) than men (34.2%) with age range between 29 and

DP

8

89 years. Blood pressure and weight were evaluated in >95% of patients at each centre. Waist circumference and BMI were not measured at any time and HbA1 c was infrequently

14

Keywords:

measured (1.6–7%) over the 12 months. Information on family history (87.5%), smoking and

15

Type 2 diabetes

alcohol (78.1%), exercise (21.4%), socioeconomic status (19.4%) and education (0.3%), and

16

Caribbean

fasting blood sugar (97.2%), lipid profile (51.8%) and serum creatinine (37.9%) were assessed

17

Primary health care

at the 1st visit. At follow-up patients were advised on treatment compliance (47.2%), diet

18

Guidelines

(34.2%), exercise (18.5%) and rarely on home monitoring of blood glucose (0.3%). Peripheral

EC

TE

13

sensations, pedal pulses (6%), visual acuity (3.3%), fundoscopy (12.1%) and ECG (3.9%) were scarcely examined at the annual visit. Conclusions: Current management of diabetes in primary care in Trinidad falls short of Caribbean guideline recommendations. The CHRC and Ministry of Health should jointly

RR

educate caregivers of diabetes to implement the guidelines, with annual audits to identify

1.

1 2 3 4 5 6

© 2009 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe.

Diabetes, a chronic progressive illness from deficient insulin production or utilisation to its full potential, is characterised by high circulating glucose. The total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030, and most of this increase will occur as 150% in developing countries [1]. Among the 15 leading causes of death, diabetes will move up 4 ranks from 11th in 2002 to 7th

UN

0

Introduction

CO

shortfalls in management.

in the 2030 global projection [2]. In the region of the Americas diabetes prevalence of 35 million in 2000 is expected to rise to 64 million in 2025 [3]. Without any urgent action deaths due to diabetes are likely to increase by approximately more than 50% in the next 10 years and are projected to increase by over 80% in upper-middle income countries between 2006 and 2015 [2]. Chronic non-communicable diseases inflict a heavy burden of illness in the middle income Caribbean nations where

∗ Corresponding author at: The University of the West Indies, Faculty of Medical Sciences, EWMSC, Trinidad and Tobago. Tel.: +1 868 663 8613; fax: +1 868 663 8613. E-mail address: [email protected] (L.M.P. Pereira). 1751-9918/$ – see front matter © 2009 Published by Elsevier Ltd on behalf of Primary Care Diabetes Europe. doi:10.1016/j.pcd.2009.03.003

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations PCD 109 1–6 in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003

7 8 9 10 11 12 13 14

21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53

2.

56 57 58 59 60 61 62 63 64 65 66 67 68 69 70

This was a retrospective observational study in type 2 diabetes in the county of SGW. There are eight health centres in this county of which five, Maraval, Woodbrook, St. James, Carenage, and George Street were selected based on highest patient attendance. The study was approved by the Ethics Committee of The University of the West Indies, the North West Regional Health Authority (NWRHA) and the County Medical Officer of Health of SGW. At each centre the Chronic Disease Book provided a census of patients who had received a doctor diagnosis of type 2 diabetes. Patients attending the clinic for at least 1 year with a 1st visit anytime from 1997 to 2005 were studied. Pregnant patients, people with type 1 diabetics, those with complications and under specialist care were excluded. Data was collected from the clinic records of each patient for the 1st, 2nd, 3rd-monthly and 6th-monthly visits and the annual visit. The 2nd visit was the next follow-up visit at the clinic after

CO

55

Methods

UN

54

100

2.1.

101

OF

20

diagnosis was established, irrespective of the time elapsed, which varied from 2 weeks to 3 months. For all patients data for visit 2, and the 3rd and 6th monthly visits were collectively expressed as ‘every visit’ if at each of these visits every recommended assessment had been documented. Case records of eligible patients were studied for history taking, physical examination; laboratory investigation and referrals as recommended in the Caribbean guidelines. For the initial visit records were examined for age, gender, education, socioeconomic level (based on Ministry of Health criteria of utility items), history of medical conditions, family history, regular exercise smoking and alcohol habits. Physical examination was studied for weight, Body Mass Index (BMI), waist circumference, blood pressure, examination of skin, eyes, mouth, feet, cardiovascular and central nervous systems. Home monitoring of blood glucose (HMBG), fasting plasma glucose, HbA1c, serum creatinine, haemoglobin, fasting lipid profile, liver and thyroid function, microalbuminuria, ketones/proteinuria, an ECG and referrals were documented from the case notes. At each of the 2nd, 3rd and 6th monthly visits, patient records were examined to note documentation of smoking and alcohol habits, weight/BMI, waist circumference, blood pressure, HMBG, dietary and exercise advice, foot inspection, advice on compliance with treatment and inspection of insulin injection sites (if relevant). HbA1 c evaluation, recommended at all visits was noted. For the annual visit, the records were assessed for advice on smoking and/or alcohol, weight/BMI, waist circumference, blood pressure, HMBG, HbA1 c, foot pulses and sensations, visual acuity, urea, BUN, lipids, fundoscopy, oral and mental health.

RO

19

diabetes appears to have reached epidemic proportions [4]. After China and India, the highest increase in prevalence from 1995 to 2025 is expected to occur by 41% in Latin America and the Caribbean [3]. Migration studies suggest the interaction of lifestyle factors with genetic susceptibility causes non-insulin dependent diabetes mellitus (NIDDM) to be more common particularly in the African and the Indian diasporas. Prevalence rates of NIDDM in African diaspora populations were 9%, 11% and 2% for blacks from the Caribbean, the UK and the USA, and from Nigeria respectively [5]. In Trinidad, patients of Indian ancestry are at higher risk of developing NIDDM than other ethnicities [6]. Diabetes inflicts a heavy burden of illness and is the 3rd leading cause of death in Trinidad and Tobago [7]. In a survey in North Trinidad 12% of adults above 25 years had diabetes [8]. In a 1993 report people with diabetics comprised 13.6% of admissions to general medical, surgical and ophthalmology wards at a major hospital in North Trinidad, incurring an annual financial cost of TT $10.7 million (US $1.8 million) [9]. In Trinidad, the larger of the two islands of the twin island republic primary health care is delivered through 104 government-run health centres spread through the geographic boundaries of five regional health authorities (RHAs). A County Medical Officer of Health (CMOH) has administrative responsibility for the health centres in a county, and at each centre physicians, community nurses and pharmacists deliver health care. The country is divided into eight counties, of which St. George is the largest and most densely populated. It has three subdivisions, St. George West (SGW), St. George Central (SGC) and St. George East (SGE); St. George West is the most thickly populated. In 1995 the Caribbean Health Research Council (CHRC) produced guidelines entitled “Managing Diabetes in Primary Care in the Caribbean” and updated them in 2006 [8]. An early baseline survey in 2005 reported a large proportion of people with diabetics were uncontrolled [9]. The current study examined the management of type 2 diabetes in public sector primary health care in the county of St. George West, referencing recommendations made in the guidelines.

DP

18

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 0 9 ) xxx–xxx

TE

17

2

EC

16

ARTICLE IN PRESS

RR

15

PCD 109 1–6

Statistical analysis

Data was analysed on SPSS version 16.0. Mean and median values and ranges were calculated for all numerical data. Frequencies were calculated for descriptive statistics.

3.

Results

3.1.

Study population

Records of 740 patients were available for analysis, but those of 646 patients were studied (87.3% response rate) due to incomplete or illegible documentation. Patients were between 29 and 89 years with a mean age of 57.90 (±10.76) years. There were twice as many women (65.8%) as men (34.2%) who were being treated for diabetes at the health centres (Table 1). Proportional patient representation was 7.0% from Maraval, 9.2% from Carenage, 16.7% from St. James, 29.9% from Woodbrook and 37.2% from George Street. At the 1st visit family history (87.5%), smoking and alcohol consumption (78.1%) and other medical conditions (96.1%) were noted but education status was rarely sought (0.3%) (Table 2). Less than a quarter of patients were asked about regular exercise (21.4%). Blood pressure (99.2%) and weight (97.1%) were nearly always recorded for patients. Waist circumference and BMI were never measured. Cardiovascular and central nervous system examination was done in 24% and 22.5% of patients

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations PCD 109 1–6 in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003

71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99

102 103 104

105

106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123

ARTICLE IN PRESS

PCD 109 1–6

3

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 0 9 ) xxx–xxx

Table 1 – Age and gender distribution of diabetic patients at the health centres.

132

Total (646)

57.90 (10.76)

29–89

425 (65.8)

221 (34.2)

Table 2 – Guideline conformance for patients (%) at the 1st visit. Assessment

Patients (%) managed in conformance with guidelines

History History of medical conditions Family history Exercise patterns Smoking Alcohol Education Socio economic level

620 (96.1) 535 (87.5) 138 (21.4) 504 (78.0) 505 (78.2) 2 (0.3) 125 (19.4)

Examination Waist circumference Weight BMI Blood pressure Skin Eyes Mouth Feet Central nervous system Cardiovascular system

0 (0) 627 (97.1) (0) 641 (99.2) 230 (35.9) 176 (27.5) 5 (0.8) 221 (34.2) 144 (22.5) 156 (24.3)

Laboratory investigation Haemoglobin HbA1ca Fasting plasma glucose Lipid profile Serum creatinine Liver function tests Thyroid function testsb Urine ketones

Urine protein Other ECG Referral to dietician Referral to ophthalmologist a b

133 (20.8) 10 (1.6) 628 (97.2) 330 (51.8) 242 (37.9) 144 (22.6) 34 (5.3) 518 (81.2)

504 (79.1) 14 (2.2) 220 (34.1) 4 (0.6)

All except one patient were from the Woodbrook health centre. 26 of 34 patients were from the Woodbrook health centre.

Males (%)

Table 3 – Guideline conformance for patients (%) at every visit.

OF

131

18 (30.0) 89 (37.1) 13 (8.9) 47 (43.5) 54 (28.0)

Assessment

Smoking Alcohol Weight BMI Waist circumference Blood pressure Inspection of feet Home monitoring of blood glucose Fasting plasma glucose HbA1ca Advice on diet Advice on exercise Counsel on compliance with treatment

RO

130

42 (70.0) 151 (62.9) 32 (71.1) 61 (56.5) 139 (72.0)

respectively. Fasting blood sugar was examined in the majority of patients (97.2%), lipid profile was estimated in just half of the patient population (51.8%) and serum creatinine (37.9%) and haemoglobin (20.8%) were estimated in few patients. The HbA1 c was evaluated in just 1.6% of patients all of whom were from the Woodbrook centre with the exception of one patient from Carenage. Urine protein and ketones were tested in approximately 80% of patients (Table 2). Only 2.2% of patients had an ECG at the initial visit. Thyroid function tests were done

Females (%)

DP

129

29–79 31–79 32–80 32–89 30–83

TE

128

55.47 (10.64) 58.46 (10.72) 55.33 (10.44) 58.87 (11.58) 58.02 (10.33)

EC

127

Carenage (60) St. George (240) Maraval (45) St. James (108) Woodbrook (193)

RR

126

Range (years)

CO

125

Mean age (SD)

UN

124

Centre (n)

Patients (%) managed conforming with guideline recommendations 1.0 (0.1) 1.0 (0.1) 600 (92.9) 0(0) 0(0) 612 (94.7) 55 (8.5) 20 (0.3) 0 (0) 21 (3.3) 220 (34.2) 119 (18.5) 305 (47.2)

Assessed for the 2nd, 3rd and 6th monthly visits. a

20 patients were from the Woodbrook health centre.

at three centres in 5.3% (34) of patients, of which 26 were from the Woodbrook centre. At follow-up visits approximately half of the patients (47.2%) were counselled on compliance with treatment and one third (34.2%) were advised about diet. Advice on HMBG (0.3%), smoking and alcohol (0.1%) was nearly never given (Table 3). Few patients were advised about regular exercise (18.5%). The HbA1 c was evaluated in 3.3% of patients who were all, with the exception of one, from the Woodbrook centre. At the annual visit, no patient was referred for oral or mental health evaluation. Blood pressure was measured in 95% of patients. Waist circumference and BMI were never recorded, but weight was measured in 94.9% of patients (Table 4). Peripheral sensations, pedal pulses and visual acuity were measured in ≤6% of patients. Fundoscopy was done in 12.1% of patients. Laboratory investigations were requested for lipid profile (50.2%), urea and creatinine (37.9%), and urine protein (43%). In 3.9% of patients an ECG was recorded at this visit and the HbA1 c was evaluated in 7% of patients who all, with the exception of two came from the Woodbrook centre.

4.

133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153

Discussion

This retrospective assessment of the management of type 2 diabetes in a cross-section of primary care patients in Trinidad, found that several recommendations in the CHRC

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations PCD 109 1–6 in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003

154 155 156

PCD 109 1–6

ARTICLE IN PRESS

4

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 0 9 ) xxx–xxx

Table 4 – Guideline conformance for patients (%) at the annual visit. Patients (%) managed in conformance with guideline recommendations

Advice on smoking and alcohol Weight BMI Waist circumference Blood pressure Foot pulses Foot sensation Visual Acuity Fundoscopy Oral and mental health Investigations HbA1 ca Lipid profile Blood urea Serum creatinine Urine protein ECG

162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191

RO TE

161

EC

160

RR

159

guidelines for managing diabetes in primary health care are not met. The observed higher gender prevalence of women with diabetics has been previously reported for diabetic admissions to a public sector hospital in North Trinidad [10]. Women with diabetics have a higher risk of developing coronary artery disease than their male counterparts regardless of menopausal status [11] and should be keenly followed up for optimal care. Prevalence of the disease in young patients of 29 years is a concern which signifies that the disease affects young individuals in this Caribbean island just as in the USA [12] and elsewhere [13,14]. Managing type 2 diabetes in youth presents a daunting challenge because of the difficulty in reversing obesity coupled with a typical non-adherence in this age-group. Childhood and adolescent obesity is a major public health concern [15] in Caribbean populations which have shown a steep increase in weight in young adults over 19 years between 1995 and 1999 [16]. Blood pressure and weight which were nearly always recorded at all visits in all centres are estimated by a clinical assistant but, BMI which is calculated by the physician was never measured. The high frequency of blood pressure measurement is significant as hypertension co-exists in 57.2% of diabetic patients attending primary health centres in Trinidad [17]. Waist circumference a surrogate marker for patients at increased risk for cardio-metabolic diseases, such as coronary heart disease and diabetes [18] was never measured at any visit, though like blood pressure it is simple enough to be assessed by trained nursing staff. Clinical assistants satisfactorily perform their assigned procedures on clinical measures and dipstick assessment of urine. They should be trained to record BMI and waist circumference, so that physicians would have more time for clinical evaluation. In a national survey of 127,420 US households, type 2 DM was more likely to be diagnosed in individuals with hypertension, dyslipidaemia and

CO

158

43 patients were from the Woodbrook health centre.

UN

157

45 (7.0) 324 (50.2) 245 (37.9) 245 (37.9) 245 (43.3) 25 (3.9)

DP

a

1 (0.2) 613 (94.9) 0 (0) 0 (0) 614 (95.0) 39 (6.0) 39 (6.0) 21 (3.3) 78 (12.1) 0 (0)

OF

Assessment

BMI > 28.5 [19]. Overall and abdominal adiposity are strongly related to the development of type 2 DM. The additive effect of these two factors on risk prediction makes waist circumference an important measurement in managing the diabetic patient [20]. Examination of skin, eyes, feet, peripheral pulses and sensations were recorded for about a quarter to a third of patients for the 1st visit and rarely thereafter, providing speculation that neuropathies and fundal changes and subsequent complications may have been missed in patients. The poor compliance of physician measured estimations compared with those done as nursing procedures could reflect the poor doctor–patient ratio at the centres. Health centres are over-crowded with at least 50 patients presenting to be seen by two doctors on the morning assigned to chronic diseases. The high proportion of patients in whom family history was elicited is most likely an awareness that the disease runs in families and afflicts several members at the same time. Educational and socioeconomic status of patients was infrequently enquired about. Patients of lower socioeconomic status are more likely to access government facilities [21] and have higher morbidity from diabetes with increased cardiovascular risk factors. In India a cross-sectional survey stratified by the level of urbanisation demonstrated an inverse relationship for higher education with low prevalence of hypertension and diabetes, suggesting that lower socioeconomic groups with lower educational status are vulnerable to these diseases [22]. Patients with low education and socioeconomic status should be targeted for continuous education for disease prevention and effective self-care. Though fasting blood glucose was nearly always determined at the 1st visit, less than 1% of patients were advised on HMBG at any visit. Blood glucose self-monitoring critical to achieving euglycaemia is endorsed by the American Diabetes Association [23]. The lipid profile estimated in approximately 50% of patients is encouraging considering that the prevalence of hypercholesterolaemia progressively increases when assessed with age, hypertension, type 2 diabetes and BMI [24]. Serum creatinine was investigated in less than half of the patients. Diabetic kidney disease inflicts a heavy social and economic burden prompting Trinidad’s Ministry of Health to institute in 2007 a cost-free dialysis facility. Compromised renal function is a contraindication for metformin, on which most patients are managed at the health centres, and failure to monitor renal function presents a serious concern. Even more worrying was the measurement of HbA1 c in not more than 7% of patients at the annual visit. It is not surprising that people with type 2 diabetes attending primary care clinics in Trinidad have poor glycaemic control [8,25]. This biological marker recommended by the ADA [23] screens undiagnosed diabetes and monitors disease progression. Lack of dedicated laboratory facilities at health centres could account for poor compliance with measurement of HbA1 c. Blood is sent to a central laboratory facility for HbA1 c estimation which is simple enough to be done immediately at the centres. It is not known if samples and/or reports were lost in transit or follow-up in the long wait before the patient’s next visit. Physicians at the centres express frustration about the poor doctor patient ratio and the lack of support for basic clinical chemistry investigations. Carter and Adams evaluated guidelines for hypertension and diabetes in Barbados, another Caribbean nation and

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations PCD 109 1–6 in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003

192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251

ARTICLE IN PRESS

PCD 109 1–6

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 0 9 ) xxx–xxx

5 299

254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273

275 276 277 278 279 280

TE

281 282 283 284

286 287 288 289 290 291 292 293

RR

EC

285

CO

Conflict of interest

All authors declare that they have no conflict of interest.

Q2

Uncited reference [28].

UN

294

295

Acknowledgements 296 297 298

[1] S. Wild, G. Roglic, A. Green, R. Sicree, et al., Global Prevalence of Diabetes. Estimates for the year 2000 and projections for 2030, Diabetes Care 27 (2004) 1047–1053. [2] C.D. Mathers, D. Loncar, Projections of Global Mortality and Burden of Disease from 2002 to 2030, PLoS Med. 3 (11) (2006) e442. [3] H. King, R.E. Aubert, W.H. Herman, Global burden of diabetes, 1995–2025: prevalence, numerical estimates, and projections, Diabetes Care 21 (9) (1998) 1414–1431. [4] L.A. Sargeant, R.J. Wilks, T.E. Forrester, Chronic diseases—facing a public health challenge, West Indian Med. J. 50 (4) (2001) 27–31. [5] R.S. Cooper, C.N. Rotimi, J.S. Kaufman, E.E. Owoaje, et al., Prevalence of NIDDM among populations of the African diaspora, Diabetes Care 20 (3) (1997) 343–348. [6] G.J. Miller, G.H. Maude, G.L. Beckles, Incidence of hypertension and non-insulin dependent diabetes mellitus and associated risk factors in a rapidly developing Caribbean community: the St James survey, Trinidad, J. Epidemiol. Community Health 50 (5) (1996) 497–504. [7] J.E. Cohen, G.L.A. Beckles, The usefulness of death certificates as a tool for surveillance of diabetes and hypertension in Trinidad and Tobago, West Indian Med. J. 4 (Suppl. 1) (1992) 17. [8] Managing Diabetes in Primary Care in the Caribbean, Pan American Health Organisation and Caribbean Health Research Council Trinidad and Tobago, 2006. [9] D. Mahabir, M.C. Gulliford, Changing patterns of primary care for diabetes in Trinidad and Tobago over 10 years, Diabetes Med. 22 (5) (2005) 619–624. [10] M.C. Gulliford, S.M. Ariyanayagam-Baksh, L. Bickram, D. Picou, et al., Counting the cost of diabetic hospital admissions in North Trinidad, West Indian Med. J. 44 (Suppl. 2) (1995) 14. [11] M.J. Legato, A. Gelzer, R. Goland, S.A. Ebner, et al., Gender-specific care of the patient with diabetes: review and recommendations, Gend. Med. 3 (2) (2006) 131–158. [12] A.L. Rosenbloom, J.R. Joe, R.S. Young, W.E. Winter, Emerging epidemic of type 2 diabetes in youth, Diabetes Care 22 (2) (1999) 345–354. [13] F.R. Kaufman, Type 2 diabetes mellitus in children and youth: a new epidemic, J. Paediatr. Endocrinol. Metab. 15 (Suppl. 2) (2002) 737–744. [14] M. Marcovecchio, A. Mohn, F. Chiarelli, Type 2 diabetes mellitus in children and adolescents, J. Endocrinol. Invest. 28 (9) (2005) 853–863. [15] V. Bhatia, IAP national task force for childhood prevention of adult diseases: insulin resistance and Type 2 diabetes mellitus in childhood, Indian Paediatr. 41 (5) (2004) 443–457. [16] S.D. Nichols, F.I. Cadogan, Anthropometric reference values in an Afro-Caribbean adolescent population, Am. J. Hum. Biol. 20 (1) (2008) 51–58. [17] H.E. Bays, D.D. Bazata, N.G. Clark, J.R. Gavin, et al., Prevalence of self-reported diagnosis of diabetes mellitus and associated risk factors in a national survey in the US population: SHIELD (Study to Help Improve Early evaluation and management of risk factors Leading to Diabetes), BMC Public Health 7 (2007) 277–284. [18] S. Klein, D.B. Allison, S.B. Heymsfield, D.E. Kelley, et al., Association for Weight Management and Obesity Prevention; NAASO; Obesity Society; American Society for Nutrition; American Diabetes Association. Waist circumference and cardiometabolic risk: a consensus statement from shaping America’s health: association for Weight Management and Obesity Prevention; NAASO, the Obesity Society; the

DP

274

300

OF

253

references

RO

observed glycaemic control and BMI assessment and counselling on lifestyle issues did not meet with the recommended guidelines [26]. These authors observed the guidelines had not been implemented sufficiently and recommended concerted efforts to implement them. Quality of diabetic care evaluation in private and public clinics in Jamaica also revealed glycosylated haemoglobin was infrequently measured, foot and retinal examinations were scarcely done and advice on non-drug measures were infrequent [26]. In another study in Barbados, Trinidad and Tobago and Tortola (British Virgin Islands) foot and eye examinations were not done systematically and advice on diet and exercise was infrequent [27]. In the present analysis guideline recommendations were met, even though at a low level only at the Woodbrook health centre. Physicians at this centre were recent graduates of the newly instituted Diploma in Family Medicine by the University of the West Indies which while explaining the relatively better patient management, highlights the importance of continuing education for the primary care physician. In noting physicians’ adherence to the guidelines physicians’ notes were difficult to read and incomplete. Having relied solely on documentation in the notes, data from 12.7% of patients was lost due to illegible writing. As we were unaware if these patients had actually been evaluated or not we omitted them from the analysis. Physicians may have counselled and examined patients without making records, so that the current findings may underestimate actual management. If true, then continuous education for physicians to keep accurate patient records would be beneficial. Interviewing the physicians may have yielded more accurate information and further studies should incorporate physician interviews. In observing shortfalls in primary care of the type 2 diabetic according to the Caribbean guidelines, the question of whether the guidelines were appropriately disseminated or presented to and discussed with primary health care providers arises. At local presentations of the results physicians were unaware that the guidelines existed. We recommend the Ministry of Health work together with the CHRC to ensure distribution and reception of the guidelines. Annual audits should be set in place to identify barriers to implementation of the guidelines, and improve management at the primary care level.

252

The authors thank Dr. Randolph Phillip, County Medical Officer, St. George West for facilitating the study at the various health facilities. Dr. Donald Simeon, Director CHRC made valuable comments on the manuscript.

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations PCD 109 1–6 in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003

301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 358 359 360 361 362 363 364 365

PCD 109 1–6

ARTICLE IN PRESS

6

p r i m a r y c a r e d i a b e t e s x x x ( 2 0 0 9 ) xxx–xxx

368

[19]

369 370 371 372 373

[20]

374 375 376 377 378

[21]

379 380 381 382

[22]

383 384

DP TE EC RR CO

386

[23]

[24] A. Lara, M. Rosas, G. Pastelin, C. Aguilar, et al., Hypercholesteolaemia and hypertension in Mexico: urban conjunctive consolidation with obesity, diabetes and smoking, Arch. Cardiol. Mex. 74 (3) (2004) 231–245. [25] N. Apparico, N. Clerk, G. Henry, J. Seale, et al., How well controlled are our type 2 diabetic patients in 2002? An observational study in North and Central Trinidad, Diabetes Res. Clin. Pract. 75 (3) (2007) 301–305. [26] A.O. Carter, O.P. Adams, Qualitative and quantitative evaluation of the use of diabetes and hypertension guidelines by practitioners and patients in Barbados available from http://www.chrccaribbean.org/files/Grant%20Studies%202007/A.%20Carter. pdf, 2007. [27] R.J. Wilks, L.A. Sargeant, M.C. Gulliford, M.E. Reid, et al., Management of diabetes mellitus in three settings in Jamaica, Rev. Panam Salud Publica. 9 (2) (2001) 65–72. [28] M.C. Gulliford, C.V. Alert, D. Mahabir, S.M. Ariyanayagam-Baksh, et al., Diabetes care in middle-income countries: a Caribbean case study, Diabet. Med. 13 (6) (1996) 574–581.

UN

385

American Society for Nutrition; and the American Diabetes Association, Diabetes Care 30 (6) (2007) 1647–1652. L.M. Pinto Pereira, L. Mc Dougall, Y. Clement, S. Gayadeen, et al., Drug prescribing for diabetes and hypertension in Trinidad health centers and adherence to clinical guidelines for managing diabetes, PAHO/WHO Trinidad and Tobago Report, 1998. C. Meisinger, A. Doring, B. Thorand, M. Heier, et al., Body fat distribution and risk of type 2 diabetes in the general population: are there differences between men and women. The MONICA/KORA Augsburg cohort study, Am. J. Clin. Nutr. 84 (3) (2006) 483–489. N. Chaturvedi, J.M. Stephenson, J.H. Fuller, The relationship between socioeconomic status and diabetes control and complications in the EURODIAB IDDM Complications Study, Diabetes Care 19 (1996) 423–430. K.S. Reddy, D. Prabhakaran, P. Jeemon, K.R. Thankappan, et al., Educational status and cardiovascular risk profile in Indians, Proc. Natl. Acad. Sci. 104 (41) (2007) 16263–16268. The American Diabetes Association, Standards of Medical Care in Diabetes, Diabetes Care 29 (2006) S4–S42.

OF

367

RO

366

Please cite this article in press as: L.M.P. Pereira, et al., Do current standards of primary care of diabetes meet with guideline recommendations PCD 109 1–6 in Trinidad, West Indies? Prim. Care Diab. (2009), doi:10.1016/j.pcd.2009.03.003

387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407