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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
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
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

epidemic of type 2 diabetes 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

diagnosis of diabetes three methods
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

glucose tolerance categories

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

components of cardiovascular risk
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
components of cardiovascular risk stratification in patients with hypertension tod
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
type 2 diabetes management goals
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
type 2 diabetes metabolic targets
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

treatment algorithm
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

background hypertension
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
aims of quality of care studies
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.
methods qc survey
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
data collection
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
monitoring and control of blood glucose by clinic type jamaica 1995
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

monitoring and control of hypertension 1 by clinic type jamaica 1995
Monitoring and Control of Hypertension (1) by Clinic Type (Jamaica, 1995)

*

***

***

*p<0.05; ***p<0.001

monitoring and control of hypertension 2 by clinic type jamaica 1995
Monitoring and Control of Hypertension (2) by Clinic Type (Jamaica, 1995)

***

**

**

***

***

***

*

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

slide26
Surveillance of Complications of Diabetes and Management of Lifestyle Factors by Clinic Type(Jamaica, 1995)

***

***

***

***p<0.001

quality of care summary
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
collaborators
Collaborators

Kingston, Jamaica

- Terrence Forrester

-- Franklin Bennett

- Norma McFarlane-Anderson

- Marvin Reid

- Lincoln Sargeant

hypertension diabetes lipid status in jamaica prevalence incidence surveys quality of care

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

Rainford Wilks

Epidemiology Research Unit

Tropical Medicine Research Institute, UWI

summary
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.
summary42
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.
summary43
Summary
  • Further studies are required
    • to determine effectiveness of intervention strategies aimed at reducing the risk factors so far identified.
quality of care summary44
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
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