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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. 102 km 2 (39.5 square miles), mainly mountainous terrain.

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Quality of Diabetes Care in Montserrat, West Indies

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  1. 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

  2. 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

  3. 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

  4. 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

  5. Causes of Death, 1996 • Diabetes. • Heart disease. • Malignant neoplasm. • Hypertensive disease. • Cerebrovascular accidents. • Malnutrition. II Workshop on Quality of Diabetes Care, Miami, May 2003

  6. 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. Public Clinics II Workshop on Quality of Diabetes Care, Miami, May 2003

  17. 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

  18. 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

  19. 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

  20. 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

  21. Thank you II Workshop on Quality of Diabetes Care, Miami, May 2003

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