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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). Epidemic of Type 2 Diabetes (2). Indo-Trinidadian (35-69 years)

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Quality of care of diabetes in jamaica 1995 l.jpg
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)


Epidemic of type 2 diabetes 2 l.jpg
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


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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


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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


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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


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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


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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


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Blood Pressure Categories JNC VI with Hypertension (TOD)


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Risk Stratification and Treatment with Hypertension (TOD)


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Type 2 Diabetes with Hypertension (TOD)Management 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


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Type 2 Diabetes with Hypertension (TOD)Metabolic 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


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Treatment Algorithm with Hypertension (TOD)

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


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Background with Hypertension (TOD)Hypertension

  • 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


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Aims of Quality-of-Care Studies with Hypertension (TOD)

  • To evaluate the level of surveillance for Hypertension and Diabetes.

  • To evaluate the quality of care for Hypertension and Diabetes in 3 different settings.


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Methods (QC Survey) with Hypertension (TOD)

  • 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


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Data Collection with Hypertension (TOD)

  • 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


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Characteristics of Study Population by with Hypertension (TOD)Clinic Type (Diabetes)


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Prevalence of Treatments Types with Hypertension (TOD)by Clinic Type


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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



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Monitoring and Control of Hypertension (1) Typeby Clinic Type (Jamaica, 1995)

*

***

***

*p<0.05; ***p<0.001



Monitoring and control of hypertension 2 by clinic type jamaica 1995 l.jpg
Monitoring and Control of Hypertension (2) Treatmentby Clinic Type (Jamaica, 1995)

***

**

**

***

***

***

*

*p<0.05; **p<0.01 ***p<0.001


Surveillance of complications of diabetes by clinic type jamaica 1995 l.jpg
Surveillance of Complications of Diabetes Treatmentby Clinic Type (Jamaica, 1995)

***

***

***p<0.001


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Surveillance of Complications of Diabetes and Management of Lifestyle Factors by Clinic Type(Jamaica, 1995)

***

***

***

***p<0.001



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Quality-of-Care Summary 1995)

  • 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





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Collaborators (Diabetes)

Kingston, Jamaica

- Terrence Forrester

-- Franklin Bennett

- Norma McFarlane-Anderson

- Marvin Reid

- Lincoln Sargeant


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Hypertension, Diabetes & Lipid Status in Jamaica: (Diabetes)Prevalence & Incidence Surveys & Quality of Care

Rainford Wilks

Epidemiology Research Unit

Tropical Medicine Research Institute, UWI


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Quality of Care of (Diabetes)Hypertension & Diabetes in Jamaica



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Monitoring and Control of Hypertension by (Diabetes)Clinic Type (Hypertension)


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Monitoring and Control of Hypertension by (Diabetes)Clinic Type (Hypertension)



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Surveillance of Lifestyle Risk Factors (Diabetes)by Clinic (Hypertension)


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Management of Lifestyle Risk Factors (Diabetes)by Clinic (Hypertension)


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Summary (Diabetes)

  • 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.


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Summary (Diabetes)

  • 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.


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Summary (Diabetes)

  • Further studies are required

    • to determine effectiveness of intervention strategies aimed at reducing the risk factors so far identified.


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Quality of Care Summary (Diabetes)

  • 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


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