Quality of Diabetes Care in the Middle- and High-Income Group Populace: The Delhi Diabetes Community (DEDICOM) survey

JITENDER NAGPAL ABHISHEK BHARTIA ME OBJECTIVE - We sought to evaluate the quality of care in known diabetic patients from the middle- and high-income group populace of Delhi. RESEARCH DESIGN AND METHODS - A cross-sectional survey was conducted using a probability proportionate to size (systematic), two-stage cluster design. Thirty areas were selected for a house-to-house survey to recruit a minimum of 25 subjects (known diabetes 1 year; aged 35- 65 years) per area. Data were collected by interview, by blood sampling, and from medical records. RESULTS - A total of 819 subjects (of 1,153 eligible) were enrolled from 20,666 houses. In total, 13.0% (95% CI 9.6 -17.3) of the patients had an HbA1c (A1C) estimation and 16.2% (13.5-19.4) had a dilated eye examination in the last year, 32.1% (27.5-36.6) had serum cholesterol estimation in the last year, and 17.5% (14.2-21.5) were taking aspirin. An estimated 42.0% (37.7- 46.2) had an A1C value 8%, 40.6% (36.5- 44.7) had an LDL cholesterol level 130 mg/dl, and 63.2% (59.6 - 66.6) had blood pressure levels 140/90 mmHg. CONCLUSIONS - A wide gap exists between practice recommendations and delivery of diabetes care in Delhi. - T health problem in India with an esype 2 diabetes is a major public timated 32.7 million patients (1) and a prevalence of 4 and 12% in rural and urban areas, respectively (2,3). Despite its high prevalence, serious longterm complications, and established evidence-based guidelines for management (4 6), translation of practice recommendations to care is still deficient in Asian (79) and developed countries (10 16). Assessment of quality of care in the community can help draw attention to the need for improving diabetes management and provide a benchmark for monitoring changes over time. The two major studies from urban India (8,9) are limited by their design by sampling only those patients who were being followed in health centers or were known to community health workers. In one of these studies, 94% of patients had a monthly family income below 10,000 rupees (225 U.S. dollars), and lower income predicted poorer care. We therefore conducted a population-based survey of quality of diabetes care restricted to the higher income group to reduce the impact of affordability. We chose to report our findings using the National Diabetes Quality Improvement Alliance (NDQIA) measures for better comparability (17). RESEARCH DESIGN AND METHODS This survey was conducted from September to December 2005. The inclusion criteria were known diabetes for 1 year (diagnosed by a registered medical practitioner on the basis of blood glucose estimation), age 35 65 years, family-owned car, and pucca house (house with brick-plaster walls and a concrete roof). Subjects were recruited from areas belonging to socioeconomic categories A, B, C, or D (the classifications used in Delhi for determining property tax; range AG, where A is the highest). Age limits were chosen on the basis of a trial run (n 145), which documented that type 1 diabetes (larger proportion below 35 years) was sometimes difficult to differentiate from type 2 diabetes in this populace (poor educational background and lack of medical records) and that subjects aged 65 years were largely dependent on their children for the quality of care received and tended to have multiple comorbidities. The exclusion criteria were type 1 diabetes; gestational diabetes; cancer, renal, hepatic, or intestinal disease requiring continuing treatment or hospital admission (1 week in the last 1 year); and inability to communicate (due to mental illness or physical disability). Thirty of the 150 wards were chosen using a random computer-generated seed value and then selected at a predefined sampling interval ([total population 30]/150; probability proportionate to size, systematic method) from the available population data (18). A house-toh o u s e s u r v e y w a s c o n d u c t e d i n a randomly selected area in the ward to identify 40 known diabetic subjects sequentially. The identified patients were visited by a research team to screen for selection criteria. It was anticipated that 25 subjects would consent for participation and blood sampling. If this number was not achieved in a particular cluster, then the survey was continued. The enrolled subjects were administered a standardized pretested proforma based on the Diabetes Quality Improvement Project (DQIP; updated as NDQIA) (19). The proforma was filled by interview or record review by the research team. An overnight fasting sample was subsequently drawn. Quality-of-care measures The baseline information included age, sex, ethnicity, education, marital status, medical benefits (government and private medical insurance or reimbursement), annual household income, smoking, alcohol use, duration since diagnosis (DSD), qualification of the primary care provider (PCP), place of health care, and number of visits to the PCP in the last year. Information on cholesterol; HbA1c (A1C); eye, urine, and foot examination; electrocardiogram; exercise testing; selfmonitoring of blood glucose (SMBG); and prescription of oral hypoglycemic agents (OHAs), insulin, aspirin, and lipidlowering drugs was collected from records and by interview. Standardization of recorded laboratory data was not feasible. Any emergency visits for blood glucose or blood pressure control were also noted. Considering the poor standardization and maintenance of blood pressure records in the trial run, we recorded only current blood pressure. It was not considered possible to determine the purpose of urine testing, and any routine urine examination was recorded as such. For patients without documentation, an eye examination after administration of pupil-dilating eye drops (based on drug name or photophobia after instillation) was taken as evidence of dilated eye examination (DEE). Weight was recorded on a manual weighing scale (sensitivity 500 g), height by using an SECA stadiometer (sensitivity 0.1 cm), waist circumference at the level of umbilicus using a measuring tape (sensitivity 0.1 cm), and blood pressure by using an OMRON electronic instrument (sensitivity 1 mmHg; accuracy 3 mmHg) validated in an earlier trial (20). Height, waist circumference, and weight were recorded with light clothing and without shoes. Three serial blood pressure recordings from the right arm were taken after 10 min rest at 10-min intervals in the sitting posture (mean was used for analysis) as per World Health Organization recommendations (21). Biochemical analysis Blood (5 ml) was divided into three cuvettes (plain lipid profile, fluoride blood glucose, and EDTA-A1C) and transported in ice within 3 h to the laboratory. The sample for A1C was stored at 4C until processing (within 48 h). The other cuTable 1Baseline characteristics of the population (based on n vettes were centrifuged at 3,000g, and the serum/plasma was immediately process (...truncated)