The assesment of the quality of care and monitoring of patients with diabetes mellitus living Manisa city center

Purpose: The purose of this thesis is to assess the quality of care and monitoring of patients with diabetes mellitus living Manisa city center, Turkey. Methods: The results of this cross sectional study represents about 30.518 patients with type 2 diabetes mellitus who are living in central town of Manisa province. This study universe (30.518 patients) is an estimated figure that was calculated, based on the Turkey's crude 13.7% prevalance of diabetes mellitus in 222.766 census over 20 years of age in Manisa. Minimum study sample size were calculated as 384 patients with type 2 diabetes mellitus by 95% confidence, 5% standard deviation and poor metabolic control (HbA1c>6.5) rate as 35%. Sample selection was done by a multistage, stratified simple random sampling techique in 98 Family Physician Units (AHB) that were stratified into three strata: urban (n=58), periurban (n=28) and rural (n=12). Twenty four AHBs were randomly identified among the 98 AHBs and 20 patients were randomly identified form each of the selected AHBs. The distribution of the selected 24 AHBs to the three residential strata (urban=14, periurban=7 & rural=3) were done proportinal to their census weights in 98 AHBs. In case of refusals and missing addresses, an additional 50% sample size of diabetics were randomly identified according the weights of three strata as well. The objective assesment of monitoring and care were done by menas of HbA1c and the Turkish version of the Patient Assessment of Chronic Illness Care- PACIC was used for the purpose of qualitative evaluation of care and monitoring of patients. The questionnaire battery that consists of PACIC, sociodemographic, clinical and health service utility variables were applied to the patients via face to face interviews. Ciritical HbA1c value as an indicator of objective metabolic control was taken as 7.0 mg/dl and PACIC scales were dicotomised by median value in the logistic regression analyses. SPSS 15.0 package was used during the data analyses. Student's t-test and One Way ANOVA tests and Chi Square test were run in parametric distributions and Kruskal Wallis ve Mann Whitney U tests in case of non-parametric test assumtions. Results: Of the study sample, % 56.4% was living is urban neighbourhoods, 30.9% in periurban and 12.7% in rural neighbourhoods; 34.3%were male with a mean age of 57.9±12.3 years. The mean first age of diagnosis was 49.9±12.0 years. The rate of overweight or obesity (BMI>25.0) was 84.6% and the mean HbA1c value was found as 6.94±1.76 mg/dl. At least one HbA1c value could be obtained in only 56.8% of the patients and of these patients, metabolic control success rate (i.e. HbA1c ≤ 6.9) was 61,7%. 86.5 percent of the patients reported that they have had a regular physician for the monitoring of their diabetes with a regular rate of monitoring in every 3 months was 65.8%. On the other hand 15.8% of the patients reported that the last physician visits waslonger than1 year. The rate of free accessibility of their physician was 73.9% whereas 7,9% reported that it could never be possible to have access to the physician. Of the patients 43,6% reported that they utilised vegetables and fruits regulary in 7 days a week and the number of the meals was three and over in 80.4% of the patients. The diabetes education rates are quite poor among patients so that, just 11,9% reported that they have been exposed to any education session more than once in their life. Ever self-glocose monitoring rate was 69.5%; regular influenza vaccination rate was 13,9% whereas 76,8% were never vaccinated with influenza and 93,1 with pneumococus vaccine. The rates of ECG control, dilated eye examination and neurological examination were 63.8%, 58.4% and 21.3% respectively. Urine glucose, ketone and microalbuminuria examination rates at least one were 67.9%, 32.5% and 14,1% respectively. The rate of hypertension was 51,5%; diagnosed coronary heart disease 12,1%; retionpathy 27,5; cataract 18,8; peripheric neuropathy 29,5%; foot ulcer 9,7%, food/finger amputation 1,2%; renal insufficiency 2,4 and hypercholesterolemia 41,0. At least one diabetic complication were present in 49,7% of the sample. The mean PACIC scale scores were as follows: Patient activation 2.60±0.89; Delivery system design/decision support 2.58±0.91; Goal setting/tailoring 2.59±0.77; Problem solving/contextual 2.58±0.75; Follow-up/coordination 2.59±0.77 and overall score 2.59±0.62. The range of the ceiling and floor effects of the scales of PACIC were satisfactory with 0.2 – 8.1% and 0.0 - 1.2% respectively. Age, number of meals, exposure to a diabetes education, accessbility ot the physician and pneumococcus vaccination variables were found significantly related with PACIC; whereas level of income, self-blood glucose monitoring, insulin treatment, PACIC Delivery system design/decision support and Problem solving/contextual were significantly related to the variance of HbA1c . Conclusion: The rate of awareness of diabetes in Manisa was similar to the rate observed in Western regiond of Turkey even under the desired level. The majority of the diagnosed diabetics are under control of a physician but primary care services are rather poor fort his monitoring. On the other han deven as a developed region, the rate of metabolic control that was assessed by HbA1c levels was quite low. The rates of the requirements (regular monitoring itmes) that were listed in the quidelines of diabetes control were also insufficient. The self-glucore monitoring rate was found to be one of the major determinants of HbA1c. Patients who have a better access to health services and who have any role of decision setting are also more advantageous groups of the community. The development of the patients' decision-making and problem solving skills would help to increase patients' compliance on their regular monitoring and treatment. As a final conclusion, PACIC is a promising supportive tool for the evaluation of the quality of care and health services fort he diabetic patients. Key words: Diabetes mellitus, Chronic Care Model, Metabolic Control