Contributed by Meghan Denchfield
Context: This project was funded in part by the Declaration of the Americas on Diabetes (DOTA) and the Pan American Health Organization (PAHO). The purpose of this study was to evaluate the quality of care for people with diabetes mellitus (DM) in four outpatient clinics in The Bahamas, one specialized clinic in Jamaica, and two hospitals in Saint Lucia. The study was an audit of medical records. Initially, the study was planned to be done only in outpatient clinics; but it was found that clinics in Saint Lucia do not keep patient records. Therefore, the audit was conducted in two hospitals in that country. Overall, 563 patient charts were reviewed (297 in Jamaica; 147 in Santa Lucia; 119 in The Bahamas) by trained data-collectors.
IDENTIFYSTAKEHOLDERS AND WHAT THEY CARE ABOUT.
The main people and organizations that had something to lose or gain for the evaluation included the hospitals, the workers in the hospitals, the patients, DOTA, and PAHO. The people involved in operating the program were DOTA and PAHO. They worked together with medical record personnel at each of the hospitals. Those served and affected by the effort included the patients who were served by the hospitals evaluated, as well as the staff, doctors, and owners of the hospitals. The communities as a whole were affected because the evaluation allowed them to see what efforts were currently in place in these hospitals and what important practices were being left out. The primary intended uses of the evaluation were as starting points for these organizations to show the hospitals how to better care for and educate the people they are serving in their communities.
DESCRIBE THE PROGRAM OR INITIATIVE'S FRAMEWORK OR LOGIC MODEL .
The problem or goal that the effort is addressing is diabetes care and education, which are believed to be two of the central features that affect the fight against diabetes. The effort is very important because proper diabetes control goes hand in hand with a higher quality of life and survival.. Diabetes is becoming more and more prevalent worldwide and the Caribbean is no exception to this. In fact, diabetes has presented a relatively heavy burden on the Caribbean and the current procedures in diabetes care and education in the area are sub-optimal. There is a great necessity to take action now to change current practices and move toward ones that foster prevention strategies in hopes that patients will have a longer life expectancies and better quality of life.
FOCUS THE EVALUATION DESIGN.
The purpose of this evaluation was to improve how treatments and education programs were being implemented by showing these hospitals where their programs are failing the people they serve and find a way to provide some funding and advice on how to change their practices. The specific objectives of the evaluation were to measure the proportion of people receiving foot and eye examinations and HbA1c and lipid tests, and to evaluate the proportion of people receiving diabetes education and diet and exercise counseling. Monitoring the quality of diabetes care with the intention of introducing measures that can assure better outcomes is a significant challenge.
The groups that will act on the evaluation findings are PAHO and DOTA, and hopefully the hospitals, public health organizations, and governments in the regions evaluated. Their interest is whether the current programs are up to international health codes in regards to diabetes care.
The evaluation questions concerned eye exams, foot exams, blood pressure monitoring, resting glucose levels, glycemic control, and whether the patients and doctors asked pertinent and necessary questions during health evaluations.
The method for collecting information was a questionnaire. All of the data was collected by trained officers. The data was then computer captioned, processed, and analyzed at the PAHO headquarters’ office in Washington, DC. Data was collected from March to December 2002.
GATHER CREDIBLE EVIDENCE – DECIDED WHAT IS EVIDENCE AND WHAT FEATURES AFFECT CREDIBILITY OF THE EVALUATION.
The indicators of success were created by WHO. The organization compiled a list of specific criteria that could be used to judge the success of all diabetes programs. The list included services that should be made available for people with diabetes, ranging from basic care services to more specialized services offered at diabetes centers in tertiary care referral facilities which provide a comprehensive range of health care services. The evaluation looked at how well each of these clinics/hospitals provided these services.
The evaluation started with a look at the structure of all 7 participating clinics/hospitals. The next step was to create country teams. These teams were composed of the PAHO official in charge of non-communicable diseases and a national official from the Ministry of Health or the Diabetes Association. These teams were then pared with the programs they would be evaluating.
The sources of evidence were the medical records from the hospitals/clinics, as well as patient surveys. The teams obtained selected medical records to be viewed by qualified data collectors in order to evaluate previously selected important aspects of the processes and outcomes of the quality of diabetes care. This audit of medical records was completed for each of the 4 public clinics in The Bahamas, the private diabetes clinic in Jamaica, and the 2 major hospitals in St. Lucia.
The information collected outside of the medical records was gathered using a questionnaire. All of the data was collected by trained officers. The data was then computer captioned, processed and analyzed at the PAHO headquarters’ office in Washington, DC.
It was expected that some quality regarding the accuracy of the information would be lost because the information came from medical records and may not entirely reflect actual practices being taken by the physicians. An attempt was made to preserve the integrity of the information by gathering the data using outside, qualified data collectors and ensuring that the sample was random and systematic. In St. Lucia, the data collector went even farther by collecting data for all the patients with a diabetes diagnosis who were discharged from the two participating hospitals.
There was a slight problem with the information collected because many of the records used from the 7 sites were incomplete. The majority left collectors without answers for questions concerning some of the important aspects of care, including a medical history pertaining to practices such as smoking or alcohol use, as well as details about what was actually explained to the patients by the physicians. Few of the records in The Bahamas and none in St. Lucia included the patients’ height, making it impossible to calculate the Body Mass Index (BMI).
MAKE SENSE OF THE DATA AND JUSTIFY CONCLUSIONS.
Diabetes care in the 7 different sites was not found to be consistent with international standards, a finding consistent with previous reports. The proportion of persons with poor glycemic control reported for the participating clinic in Jamaica and the two hospitals in Saint Lucia is comparable to previous studies in the Caribbean, but it was considerably lower in the centers in The Bahamas. The main predictors of good glycemic control were nutritional advice and non-pharmacological treatment such as diet, exercise, and weight reduction.
The remaining findings were as follows:
Eye examinations were reported to have been performed in 19% of cases, with the largest figure being reported in The Bahamas and the lowest in Jamaica. Foot examinations were reported to have been performed only in 25.2% of charts and were more frequently reported in The Bahamas (58%) than in the other sites. The lowest proportion of charts with reported foot examination was Saint Lucia (2.9%). Overall, 51% of cases were reported to have blood pressures of 140/90 mmHg or higher. The proportion was similar in all three sites. A fasting glucose of 8 mmol/L or higher was found in 66.7% of cases and was the highest in Saint Lucia (67.9%) and the lowest in The Bahamas (52.2%). Overall, 64.3% of patients were found to have poor glycemic control (HbA1c > 8% or FBG > 8 mmol/L). The proportion of patients with poor control varied from 38% in The Bahamas to 71.8% in Jamaica.
These findings can be interpreted to show that changes need to be made in the current programs and practices in order to improve the overall care and education provided to those diagnosed with diabetes in Caribbean regions.
Based on the results of the evaluation, the recommended actions to be taken would change the practices of diabetes care so that they will meet international standards and better the health of people in the Caribbean. The Declaration of the Americas on Diabetes (DOTA) outlines a strategic set of goals for the improvement of health among people with diabetes in the Americas. The DOTA strategic plan includes four major areas: Diabetes Education, Diabetes Epidemiology (Quality of Care and Surveillance), Diabetes Public Awareness, Children/Adolescents and Diabetes, and National Diabetes Programs. The World Health Organization declared that each hospital/clinic should have a diabetes team comprised of a physician and a professional educator. They make the point that having such a team is important for provision of quality diabetes care and education. A diabetes unit should be comprised of a diabetologist/endocrinologist, or an internist with special diabetes training, a professional educato,r and at least three additional multidisciplinary diabetes care professionals, such as a podiatrist, a dietitian, and a nephrologist.
USE THE INFORMATION TO CELEBRATE, MAKE ADJUSTMENTS, AND COMMUNICATE LESSONS LEARNED – TAKE STEPS TO ENSURE THAT THE FINDINGS WILL BE USED APPROPRIATELY.
The creation of the CCMRC12 guidelines for primary care and various other guidelines was an effort by people in the Caribbean to improve diabetes management. There are a number of international standards that can be used as references for the creation of guidelines targeting specific populations. Because proper diabetes care requires both the availability of technologies and adequate training of health professionals, preparations need to be made to increase funding so that these areas may be addressed. There needs to be follow up with Ministries of Health, scientific societies, and academic institutions to ensure sustainable planned medical education.
Post-evaluation, it was decided that medical charts should be reviewed periodically and the results discussed with providers. The information collected in medical charts should be sufficient to evaluate the provided care and its adherence to local and international standards.
It is apparent from data collected during the evaluation that the diabetes care in the sites studied needs to be improved. The data collected in the evaluation will be used to create a program that will cater to the separate needs identified in each particular site.