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Quality of Diabetes Care in Montserrat, West Indies. Dr. C.V. Alert Family Physician (Barbados). II PAHO-DOTA Workshop on Quality of Diabetes Care Diabetes Research Institute (DRI), University of Miami 14–16 May 2003. Demography. 102 km 2 (39.5 square miles), mainly mountainous terrain.

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quality of diabetes care in montserrat west indies

Quality of Diabetes Care in Montserrat, West Indies

Dr. C.V. Alert

Family Physician(Barbados)

II PAHO-DOTA Workshop on Quality of Diabetes Care

Diabetes Research Institute (DRI), University of Miami

14–16 May 2003

demography
Demography
  • 102 km2 (39.5 square miles), mainly mountainous terrain.
  • Leeward Island.
  • Population: 2-11,000.
  • Capital: Plymouth.
  • Three main volcanic ridges.
  • Soufrière volcano has been active since 1995.

II Workshop on Quality of Diabetes Care, Miami, May 2003

health picture
Health Picture
  • Health expenditure per capita: US$ 383.
  • Represents 6.5% of total GDP.
  • Primary care clinics: 12 in 1994, 3 in 1997.
  • Main hospital: St. John’s hospital, 30 beds (Glendon hospital, 65 beds, was destroyed by volcano).

II Workshop on Quality of Diabetes Care, Miami, May 2003

changing demographics
Changing Demographics
  • Volcano has caused mass exodus— especially of younger people, but also of health-care personnel.

II Workshop on Quality of Diabetes Care, Miami, May 2003

causes of death 1996
Causes of Death, 1996
  • Diabetes.
  • Heart disease.
  • Malignant neoplasm.
  • Hypertensive disease.
  • Cerebrovascular accidents.
  • Malnutrition.

II Workshop on Quality of Diabetes Care, Miami, May 2003

causes of death 1997
Causes of Death, 1997
  • Volcano-related deaths were three times higher than diabetes-related deaths.

II Workshop on Quality of Diabetes Care, Miami, May 2003

audit of primary care 2001
Audit of Primary Care (2001)
  • Ministry of Health, Montserrat.
  • PAHO.
  • Similar protocol followed to audits of primary care in
    • Barbados,
    • British Virgin Islands,
    • Trinidad & Tobago (1992/1993), and
    • Jamaica (1995/1996)

in project sponsored by UK Government.

II Workshop on Quality of Diabetes Care, Miami, May 2003

standard of care
Standard of Care
  • Quality of care measured against 1986 document entitled“The Control of Diabetes Mellitus in the Caribbean Community”, after a PAHO Workshop.
  • Clinical parameters only recorded.
  • Patient satisfaction not considered.

II Workshop on Quality of Diabetes Care, Miami, May 2003

survey of medical records
Survey of Medical Records
  • 4 Public clinics:
    • 1 hospital-based outpatient clinic.
    • 1 clinic dedicated to diabetes.
    • 2 general practice clinics.
  • 137 records reviewed.
  • For each record selected, care reviewed over a 12-month period.

II Workshop on Quality of Diabetes Care, Miami, May 2003

demographics
Demographics
  • 137 patients.
  • Females: 78 (57%).
  • Mean age 68 years.
    • Inter-quartiles 54, 76 years.

II Workshop on Quality of Diabetes Care, Miami, May 2003

processes measured
Processes Measured
  • Blood sugar measured: 94%
  • HBA1c measured: 2%
  • BP measured: 97%
  • ‘Lipids’ measured: 73%

II Workshop on Quality of Diabetes Care, Miami, May 2003

processes measured 2
Processes Measured (2)
  • Eyes examined: 4%
  • Feet examined: 24.5%
  • Urine tested for protein: 46%
  • Significant deficiencies in the quality of service offered to diabetic patients.

II Workshop on Quality of Diabetes Care, Miami, May 2003

diabetes education
Diabetes Education
  • Nutrition management: 40%
  • Exercise: 30%
  • Smoking status not recorded: 77%
  • Alcohol status not recorded: 89%

II Workshop on Quality of Diabetes Care, Miami, May 2003

outcome measures
Outcome Measures
  • Blood pressures: >130/85 mmHg 67%
  • ‘Spot’ blood sugars: > 180 mg/dl 52%
  • Total cholesterol: > 200 mg/dl 47%
    • LDLs, Triglycerides not specifically examined.
  • Poor control of risk factors for diabetic complications.

II Workshop on Quality of Diabetes Care, Miami, May 2003

changing targets
Changing Targets
  • Very few patients reached 1986 targets, suggesting sub-optimal quality of care.
  • Likelihood of complications developing is high.
  • Since 1986, diagnostic criteria, targets for standard of care have changed.

II Workshop on Quality of Diabetes Care, Miami, May 2003

public clinics
Public Clinics

II Workshop on Quality of Diabetes Care, Miami, May 2003

quality of diabetic care
Quality of Diabetic Care
  • Poor, in all islands studied, over last decade.
  • Yet no effort has been made to modify this situation.
  • Primary care needs to be organized for this task.

II Workshop on Quality of Diabetes Care, Miami, May 2003

comments
Comments
  • Lack of specific local coordinating agency/agent to take responsibility for diabetic care.
  • “Denial” of seriousness of situation.
  • Prevention (primary, secondary) not practiced.

II Workshop on Quality of Diabetes Care, Miami, May 2003

comments 2
Comments (2)
  • No evidence of systematic diabetic education.
  • No commitment to periodic audit and/or follow-up.
  • No desire to learn from experiences of neighbors.

II Workshop on Quality of Diabetes Care, Miami, May 2003

definition
Definition
  • In the Caribbean, diabetes education is absent and diabetic care is sub-optimal.
  • The result: diabetes is “a state of premature death complicated by hyperglycemia” (Miles Fisher, 1988).

II Workshop on Quality of Diabetes Care, Miami, May 2003

thank you
Thank you

II Workshop on Quality of Diabetes Care, Miami, May 2003