Quality of Diabetes Care in Montserrat, West Indies

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 1416 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.

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. Johns hospital, 30 beds
  (Glendon hospital, 65 beds, was destroyed by
  volcano).

4
Changing Demographics

• Volcano has caused mass exodus especially of
  younger people, but also of health-care personnel.

5
Causes of Death, 1996

• Diabetes.
• Heart disease.
• Malignant neoplasm.
• Hypertensive disease.
• Cerebrovascular accidents.
• Malnutrition.

6
Causes of Death, 1997

• Volcano-related deaths were three times higher
  than diabetes-related deaths.

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.

8
Standard of Care

• Quality of care measured against 1986 document
  entitledThe Control of Diabetes Mellitus in the
  Caribbean Community, after a PAHO Workshop.
• Clinical parameters only recorded.
• Patient satisfaction not considered.

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.

10
Demographics

• 137 patients.
• Females 78 (57).
• Mean age 68 years.
• Inter-quartiles 54, 76 years.

11
Processes Measured

• Blood sugar measured 94
• HBA1c measured 2
• BP measured 97
• Lipids measured 73

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.

13
Diabetes Education

• Nutrition management 40
• Exercise 30
• Smoking status not recorded 77
• Alcohol status not recorded 89

14
Outcome Measures

• Blood pressures gt130/85 mmHg 67
• Spot blood sugars gt 180 mg/dl 52
• Total cholesterol gt 200 mg/dl 47
• LDLs, Triglycerides not specifically examined.
• Poor control of risk factors for diabetic
  complications.

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.

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Public Clinics
Barbados Trinidad Tortola Montserrat
Blood sugar recorded 79 33 94 94
Poor blood sugar 51 62 37 67
BP recorded 97 97 100 97
BP not controlled 83 78 42 61
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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.

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Comments

• Lack of specific local coordinating agency/agent
  to take responsibility for diabetic care.
• Denial of seriousness of situation.
• Prevention (primary, secondary) not practiced.

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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.

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).

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Thank you