Abstract
Background: Type 2 diabetes mellitus is one of the most common chronic conditions, which requires appropriate management and care at PHC level, which is described in guidelines. However, guideline adherence at the international arena is insufficient and little is known about the reasons for guideline non-adherence. Objective: The aim of the survey was to analyse to what extent the Lithuanian family practitioners adhere to diabetes guidelines in order to compare to international data and to discover the factors associated with better diabetes care. Methods: The present study is a part of EUPRIMECARE Project, which sets out to develop a framework aiming at the analysis of PHC across Europe. The sample strategy was based on an unequal probability sampling design. An audit of 4 public and 6 private PHC medical records of the year 2011 was carried out in Kaunas region, clinical records of 382 diabetes type 2 patients were reviewed. Demography, diseases and diabetes performance indicators data were collected using a uniform template. Binary and multivariable logistic regression analyses were used in the investigation of the factors related to better diabetes guideline adherence. Results: Three guideline adherence levels were identified: high performance (performed in more than 90% cases) - BP measurement and HbA1c exam; good performance (performed in more than 50% cases) - ECG examination and serum creatinine check; insufficient performance (performed in less than 50% of cases) - annual endocrinologist consultation, eye fundus and foot examinations, LDL check and BMI calculation. Insufficient glycaemic control was positive associated with increased endocrinologist consultation and foot exam rates, elevated BP demonstrated the positive effect to creatinine check rate, multimorbidity had positive association to the annual eye, ECG, creatinine check rates; frequent FP attendance showed no positive effect on process indicators. Rural patients have a negative association to foot and ECG exam rates compared to urban patients. In a stepwise logistic regression model, 3 dependent variables had statistically significant impact on overall diabetes care indicator performance: negative - rural location of patients (OR 0.4, 95% CI 0.2-0.8), elevated mean BP (OR 0.6, 95% CI 0.4-0.9); positive - multimorbidity (OR 2.0, 95% CI 1.2-3.4). Conclusion: Guideline adherence for T2DM is not optimal in Lithuanian PHC. The best are BP and HbA1c checks. Suboptimal are BMI and LDL annual checks. The situation with these is almost the same as in other European countries. The better guideline adherence has been observed in urban (foot exam, ECG exam), multimorbidity (eye, ECG, creatinine exams), controlled by means of BP patients (serum creatinine test).
Highlights
Diabetes care is a complex process requiring ongoing patient self-management, education and support with multifactorial risk reduction strategies to prevent acute complications and to reduce the risk of long-term complications [1]
The better guideline adherence has been observed in urban, multimorbidity, controlled by means of blood pressure (BP) patients
All heads of primary health care (PHC) centres signed written agreements on participation provided that they would receive the report from the research team about the performance of a particular PHC centre
Summary
Diabetes care is a complex process requiring ongoing patient self-management, education and support with multifactorial risk reduction strategies to prevent acute complications and to reduce the risk of long-term complications [1]. Diabetes type 2 (T2DM) is one of the most common chronic conditions at primary health care (PHC) level, which requires good organisation and coordination in PHC practices [2]. Results of the studies carried out demonstrated a range of factors positively associated with higher guideline adherence - practice characteristics, computerisation, nurse employment [7], managed care (centralised organisation, coordination, responsibility and centralised annual assessment) [8], consultation frequency, patient gender and age [9]. Despite some debates on the guideline adherence associated to better patient health outcomes [8, 10] and the correctness of their application for patients with multimorbidity [11], there is a need to follow the guidelines as they are in line with the best available evidence of clinical practice and cost-effectiveness. Guideline adherence at the international arena is insufficient and little is known about the reasons for guideline non-adherence
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