الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of different organs, especially the eyes, kidneys, nerves, heart, and blood vessels. Diabetes is a major lifestyle disorder, the prevalence of which is increasing globally. Its high prevalence constituted chiefly by T2D, is a global public health threat. The prevalence among adults aged 20-70 years is expected to rise from 285 million in 2010 to 438 million by the year 2030.Diabetes mellitus is a chronic illness that requires continuing medical care and ongoing patient self-management education and support to prevent acute complications and to reduce the risk of long-term complications.A variety of multifaceted quality improvement programs have been implemented worldwide to support guideline adherence and improved quality of care for patients with diabetes.Selection and identification of quality of care indicators in each specific program depended on local conditions of the countries as availability of data, health resources, administrative roles of health system, and applicability of indicators. Quality of care indicators could be classified as “process-of-care” and “outcome-of-care” indicators, with further classifications of the later into proximal and distal ones.
The current study was formulated to describe the socio-demographic, personal and clinical characteristics of patients with T2D attending the PHC diabetes clinics in the State of Kuwait, assess the “process-of-care” indicators in the selected diabetes clinics, measure the “outcome-of-care” indicators among the study subjects, and identify factors that could be associated with insufficient quality of care provided for T2D patients.
To achieve these objectives a cross sectional descriptive epidemiological approach was carried out. The present study was carried out in 5 specialized diabetes clinics located in the PHC centers in the state of Kuwait; one from each health region. These five clinics were randomly selected from 42 specialized diabetes clinics. All T2D patients attending the selected centers during the duration of the field work were the target population of this study. Newly diagnosed cases (less than one year duration) and patients with T1D were excluded from the sample. Pregnant females were also excluded.
The required sample sized was estimated to be 682. Considering a non-response rate of 20%, a total of 850 subjects having T2D were recruited in the study. Data were daily collected from T2D patients attending the selected clinics. The proportional allocation method was used to determine the required sample size from each center according to the total registered number of T2D patients in each center.
A pre-designed structured questionnaire was utilized for data collections. It included the following domains: socio-demographic characteristics, personal data, diabetic history, associated co-morbid conditions, receiving health education about self-care management, referral to other specialists, utilization of health care and its frequency, utilization of laboratory investigations, history of admission to hospital, practicing of self-care, self-rated assessment of the received quality of diabetic care. Clinical and laboratory data were collected from patients’ records. Process and outcome diabetes quality of care indicators were calculated according to the Kuwait guidelines based mainly on American Diabetes Association standards.
A pilot study was carried out to test both the questionnaire and the administrative aspects of the study. The Ethical Committee of the Kuwaiti Ministry of Health approved the research. A written format explaining the purpose of the research was prepared and signed by the participants after explaining the aim and procedures of the study and before filling the questionnaire.
Daily revision of the completed data was routinely carried out. Data were fedto the computer and statistically analyzed using Statistical Package for Social Science (SPSS, version19).
The results of the present study can be summarized as follows:
The age of selected diabetic cases ranged from 39.9 to 88 years with a mean of 54.2 ± 10.9 years. Nearly half the sample were men (49.9%). The majority were married (92.9%), and Kuwaitis patients were more presented (57.0%). Almost half (49.4%) of the sample were not working, and with low level of education (53.5% were illiterate). The majority were either living in a flat (41.6%) or a middle income house (40.4%), and about one third (32.1%) had an income more than 1000 KD.
Overall, 81.5% of the participants were non-smokers, 72.3% did not used to practice physical activity, 48.8% were obese or severely obese (62.0% of females and 35.6% of males) as indicated by BMI, whereas WC was higher than normal levels in 93.9% of patients (93% among females versus 41.3% among males. Also, WHR was higher than normal in 91.8% of participants (93.9% among females versus 89.6% among males).
The studied T2D patients suffered from diabetes for a duration ranging from 1 – 40 years with an average of 8.9 ± 6.4 years. About two thirds of participants (62.0%) used oral drugs as a sole treatment, whereas 34.1% of patients used insulin as single or combined with tablets treatment with a higher proportion in females than males. Only 7.2% of participants reported a history of hospitalization. Among them, admission was related to diabetes or its complications in 46.0%, 15.8% and 50.0% in first, second and third admission respectively.
About two third of participants reported a history of one or more co-morbid conditions as hypertension (26.4%), CVD (9.8%), urinary tract disease (2.5%), endocrine disease (4.2%), dyslipidemia (14.0%), or liver disease (1.4%).
Inquiry about patients’ practice revealed that 97.1% reported their regular follow-up visits, 65.9% were compliant with diet regimen, 73.9% were compliant with treatment instruction, and 43.8% practiced regular exercises. Self-care management was generally low except for foot and skin care. Self-care management was reported in 2.3% of participants for testing urine glucose, 24.2% for testing blood glucose, 5.2% for measuring blood pressure, 56.7% for foot and skin care, 2.3% for using urine strips other than glucose,15.4% for management of hypoglycemia and 9.7% for SMBG.
Process-of-care indicators were assessed based on receiving health education, clinical examination, referral to other specialists, utilization of laboratory facilities,and receiving prophylactic agents. The proportions of patients who received health instruction were 60% among smokers, for cessation of smoking, 84.1% for ideal body weight, 89.6% for practicing exercise, 92.4% for diet regimen, 21.9% among females in the child bearing age for family planning, 18.8% among severely obese for bariatric surgery, and 43.6% for adherence to treatment. On the other hand the proportions of patients who received self-management instructions were 93.8% for foot care, 88.6% for skin87.7% for assessment of blood glucose, 61.4% for self-care of hypoglycemia, and 53.4% for SMBG.
The majority of participants reported their clinical examination for the different items within the previous year as 98.3% reported the clinical examination for blood pressure, 95.5% for foot inspection, 94.2% for foot palpation, 92.0% for pin brick sensation of foot, 91.8% for vibration perception of foot, 92.2% for neurological examination, 98.0% for eye fundus, 92.4% for ECG, and nearly all patients were examines for weight and height. However, as measuring blood pressure and foot inspection and palpation were recommended to be performed in each follow-up visit, the proportion of patients who achieved these recommended frequency of clinical examination were lower as only 35.5% reported for measuring blood pressure, none for foot inspection and palpation in each follow up visit. Referral to other specialists were reported by 85.4% for dietitian, 3.6% for psychologist, 49.5% for ophthalmologist, 4.0% for neurologist, 2.9% for cardiologist, 76.6% for dentist and 2.25 or nephrologist.
Nearly all participants utilized laboratory facilities for investigation of the recommended parameters during the previous year. However, as A1C was recommended to be investigated each 3 months, only 9.2% of patients achieved this frequency.
Regarding prophylactic agents, 60% of males< 50 years and 74.6% of females < 60 years old reported receiving regular prophylactic low aspirin dose, 29.0% received influenza vaccine and 26.4% received pneumococcal vaccine.
Outcome-of-care indicators were assessed based on the presence of long-term diabetic complications, measured value of blood pressure, serum lipids, presence of protienuria,and BMI value. More than half of the participants (55.3%) were complaining from one or more of chronic diabetic complications. About a third of patients (35.5%) had CVD, 9.4% had nephropathy, 21.5% had neuropathy, 16.6% had retinopathy, 9.4% had lower limb complications, and 5.9% had sexual complication.
It was found that 44.7% of participants suffered from hypertension after diagnosis of diabetes as indicated by systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90 mmHg, or had a history of receiving hypotensive drugs.
Results of laboratory investigations showed that the mean value of FBG was 9.08 ± 3.34 mmol/L, with only 34.5% of patients reached the recommended level of 7.2 mmol/L. The mean level of A1c was 8.47±1.85% with 18.9% of patients achieved the recommended value of 7%. The mean values for total cholesterol, TG, HDL and LDL were 4.77±1.01, 1.85±1.19, 1.18±.0.65, and 2.88±0.88 mmol/L. The percentages of patients who achieved the recommended levels (5.6, 2.1, 3.4 and 0.91 mmol.L respectively) were 82.8%, 77.1%, 35.8% and 76.9% respectively.The percentage of participants with positive microalbuminuria was 14.1%.
BMI calculation, revealed that 48.8% of patients were obese or severely obese. However, the percentages (67.7% and 91.8%) were higher when WC and WHR were considered respectively.
Self-rated quality assessment revealed that 57.1% of participants viewed it as very good and 16.9% reported excellent score. Females, older patients, and Kuwaiti participants were more satisfied than males, younger and non-Kuwaiti patients.
Logistic regression analysis to determine factors that could be associated with denoting lower quality of care among diabetic patients revealed that being females (OR = 2.2, CIs: 1.5 – 3.2), severe obese (OR = 2.1, CIs: 1.2 – 4.1) and insulin treated (OR = 4.2, CIs: 1.4 – 13.1) were indicators of lower quality of care. Among the protective factors were higher level of education (OR = 0.5, CIs: 0.2 – 0.8), higher monthly income (OR = 0.3, CIs: 0.1 – 0.8), working (OR = 0.5, CIs: 0.3 – 0.7), practicing of moderate exercise (OR = 0.5, CIs: 0.2 – 0.9), compliance with treatment (OR = 0.6, CIs: 0.4 – 0.9), compliance with diet regimen (OR = 0.5, CIs: 0.2 – 0.8), and testing urine glucose at home (OR = 0.2, CIs: 0.4 – 0.8).
To summarize, the process of care in Kuwait is relatively good as compared with many other countries. However, it is still lower than that in many developed countries as US, Europe and Japan. On the other hand, High proportion of patients with T2D had one or more of the long-term diabetic complications and prevalence of obesity among them is very high denoting that the outcome of care is not satisfactory indicating the urgent need of a national health program regarding this issue.