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International Journal for Quality in Health Care 15:301-307 (2003)
© 2003 International Society for Quality in Health Care

Outcomes of diabetes care: a population-based study

LISBETH M. FÄRNKVIST1 and BERIT M. LUNDMAN2,

1 Research and Development Unit, Primary Health Care, Sundsvall, Sweden
2 Department of Nursing, Umeå University, Umeå, Sweden

Aims. To describe prevalence, metabolic control, and complications of diabetes mellitus in a county in Northern Sweden, in order to improve diabetes care and guide decision makers.

Methods. A population-based, cross-sectional, retrospective study of medical records of all registered persons with diabetes mellitus (n = 5251) in the area. Assessments and examinations concerning metabolic control and complications were studied over a period of 15 months.

Results. Of the 5143 patients included, 13% had Type 1, 86% Type 2, and 1% other types of diabetes. An annual check-up was performed in 84% of patients. Glycosylated haemoglobin (HbA1c) was assessed in 88%, and had a mean value of 7.3% (sd 1.3%). Metabolic control was good in 33% and acceptable in another 26%. Risk factors for complications were found in 64%; in 35% body mass index was >30; 50% had hypertension; 22% were smokers; 51% had macro- and/or microvascular complications; ischaemic heart disease 26%; a cerebrovascular lesion 13%; amputation 1.8%; proteinuria 7.9%; microalbuminuria 2.6%; peripheral neuropathy 30%; impaired peripheral circulation 29%; and retinopathy 37%.

Conclusions. The majority of patients with diabetes in the study area attended an annual check-up, had acceptable metabolic control and severe complications were uncommon. Nevertheless, the number of undocumented examinations was high, 40% of the patients had unacceptable metabolic control and more than 50% had macrovascular risk factors. These findings emphasize the importance in diabetes care of smoking cessation and intensive treatment of high blood pressure.

Keywords: complications, diabetes mellitus, metabolic control, population-based study, quality of care

Address reprint requests to Berit Lundman, Department of Nursing, Umeå University, S-901 87 Umeå, Sweden. E-mail: Berit.Lundman{at}nurs.umu.se Back

Accepted for publication March 31, 2003.

Diabetes mellitus (DM) is a major health problem with a prevalence of 3–4% in Sweden. The majority of cases are Type 2 DM [1] and it is estimated that another 1% is undiagnosed [2]. It is predicted that the prevalence of Type 2 DM will increase rapidly owing to such changes in the population as a higher proportion of elderly, increased body weight, decreased physical activity, improved life expectancy due to earlier detection of the disease, screening for complications, and progress in medical treatment [3]. The new international criteria for diagnosis [4] will also contribute to increased prevalence [5].

As the most important clinical problem connected with diabetes is the risk of micro- and macrovascular complications, it is necessary to have strategies for early diagnosis, patient education, and primary and secondary prevention, as well as optimal medical therapy. Recent studies including the Diabetes Control and Complication Trial (DCCT) [6], the UK Prospective Diabetes Study (UKPDS) [3], and other reports on Type 1 [7,8] and Type 2 DM [9] have shown that intensive glycaemic control can prevent or slow down the progression of micro- and macrovascular complications. Despite this convincing evidence many people with diabetes still have unsatisfactory metabolic control [10–12].

In many countries, including Sweden, clinical guidelines have been developed in order to improve and ensure quality of diabetes care [4,13]. Many local diabetes care programs have been developed, based on the Swedish National Guidelines [13]. There is a recommendation for screening for diabetes among people with high risk for Type 2. In Sweden a National Diabetes Register (NDR) [14] is in progress, and results concerning metabolic control and complications have so far been reported for about 10% of people with diabetes. In practice, however, management of diabetes often fails to achieve the established goals [11,12].

The aim of the present study was to describe prevalence, metabolic control, and complications of DM in a county in Northern Sweden, in order to be able to compare results between settings and over time. The perspective is mainly that of health care providers and decision makers.


   Patients and methods
Top
 Patients and methods
Results
 Discussion
 References
 
Population and patients
This cross-sectional, retrospective and descriptive study was carried out in a Swedish county (Härnösand-Medelpad) with about 151 000 residents. The region contains mainly rural and some urban areas. The diabetes care is organized in 21 primary health care centres, two outpatients clinics, the youth clinics at two hospitals, employer health care offices, and in private practices. Of the 5251 persons registered with diagnosed diabetes, 5143 (97.9%) were non-pregnant adults aged 18 years or above. These 5143 patients were included in the study. The period studied extended from 1 July 1996 to 1 October 1997, and all records were examined by one of the authors (L.F.). This study follows the Swedish ethics rules (according to the Declaration of Helsinki 1977).

Diagnostic criteria for DM were: fasting blood glucose (venous) >=6.1 mmol/l (>=110 mg/dl) or 2-h post-prandial glucose load >=10.0 mmol/l (>=180 mg/dl) [4]. Type of diabetes was classified according to the WHO recommendations [4]. Glycosylated haemoglobin, HbA1c was analysed using a high-performance liquid chromatography (HPLC) method. The normal range is 3.6–5.3% and coefficient of variation (CV) was <1.4. All samples were analysed at one central laboratory using the same method throughout the study period.

HbA1c categories were: HbA1c <6.5% defined as ‘good’; 6.5–7.5% defined as ‘acceptable’; and >7.5% defined as ‘unsatisfactory’ metabolic control.

Examinations, tests and result classifications are shown in Table 1. Definitions of diabetic complications and associated diseases are shown in Table 2.


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  		Table 1 Examinations, tests, and result classifications according to the Swedish National Guidelines1

 

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  		Table 2 Definitions of diabetic complications and associated diseases

 
A special form of checklist was used for recording assessments and measurements (in accordance with the Swedish National Guidelines).

Statistics
The data were analysed using SPSS v. 7.5. The prevalence values were standardized for age. For the purpose of calculating the prevalence of the disease in each primary health care district, the total population in the county was used as standard population. {chi}2 analysis was used for calculations of gender differences. For mean values presented in the Results section standard deviation (sd) is given.


   Results
Top
 Patients and methods
 Results
Discussion
 References
 
Prevalence
The prevalence of known diabetes was found to be 3.5% (or, after standardization for age, 3.3%) and varied between different primary health care districts from 2.3 to 5.8%. The highest figure was found in a rural area with a high proportion of elderly. The prevalence for Type 1 DM was 0.4% and for Type 2 DM 3.0%. The proportion of Type 1 was 13%, of Type 2 86%, and of other types of diabetes 1%.

Distribution and clinical characteristics of the study population
The majority of patients (82%) were cared for by general practitioners and diabetes nurses (92% of Type 2 and 15% of Type 1 patients), 15% were cared for at outpatient clinics, 1.6% at youth clinics, and 1.4% at other care providers. Of patients with Type 2 DM, 7.5% see an endocrinologist regularly.

The mean age for those with Type 1 was 44 years (sd 15.0) and for Type 2 DM 68 years (sd 12.1); 46% were women. The duration of diabetes varied from 1 week to >60 years, with a mean value of 10 years (sd 9.0) [in Type 1 average duration was 22 years (sd 13.7), in Type 2 DM 8.6 years (sd 6.7)]. Diabetes duration of >30 years was found in 26% of Type 1 and in 1% of Type 2 DM.

Assessments and examinations performed
In 84% of patients an annual check-up was performed during the period studied, with an even higher proportion (91%) of those with Type 1 DM. A checklist was used with 35% of all patients (in Type 1 with 74%, in Type 2 DM with 30%). The frequencies of assessments and examinations are shown in Table 3.


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  		Table 3 Proportion of patients with documented assessments and examinations and information on tobacco use in the 15 months prior to the study

 
The only significant gender differences in recorded frequencies of examinations were found in body mass index (BMI) (47% in women, 53% in men; P<0.001) and in information about smoking habits (72% in women, 82% in men; P<0.001).

Treatment
In total, 19% of the patients were treated with dietary changes only, 40% received oral hypoglycaemics, 29% received insulin, and 12% received a combination of oral hypoglycaemics and insulin (mostly those with Type 2 and long diabetes duration). In patients with Type 2 DM almost 60% received oral hypoglycaemics (either alone or in combination with insulin), and 20% received insulin only. In all, one-third of the patients were treated with insulin and among those with duration of >15 years, 72% received insulin.

Among oral hypoglycaemic agents sulfonylurea dominated (72%), followed by biguanids (22%) and alphaglucoseoxidase inhibitors (6%).

Attainment of goals
HbA1c value was assessed in 88% of the patients (95% in Type 1, 87% in Type 2 DM). The overall mean value of HbA1c was 7.3 (sd 1.3); 7.7 (sd 1.6) in Type 1 and 7.3 (sd 1.6) in Type 2 DM. For women the mean value was 7.4 (sd 1.6) and for men 7.3 (sd 1.6).

When the values of HbA1c were categorized, 34% had good (<6.5%), 26% acceptable (6.5–7.5%), and 40% unsatisfactory (>7.5%) metabolic control. The distribution of HbA1c by percentages of patients and categories within Type 1 and Type 2 DM respectively is shown in Figure 1. No gender differences were found in this respect.



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  		Figure 1 Distribution of glycosylated haemoglobin among patients with Type 1 and Type 2 DM in the study population1. 1n = 4506; 2HbA1c, glycosylated haemoglobin; 3HbA1c values missing for 12% of patients.

 
In all, good metabolic control was found in 75% of the patients treated by dietary means only; acceptable metabolic control was found in 59% of those treated with oral hypoglycaemics, in 50% of those treated with insulin and in 38% of those treated with a combination of oral hypoglycaemics and insulin. Among patients with Type 1, 49% had acceptable metabolic control. Among patients with Type 2 DM acceptable metabolic control was found in 93% of those treated by dietary methods only, in 59% of those treated with oral hypoglycaemics, in 50% of those treated with insulin, and in 38% of those treated with a combination of insulin and hypoglycaemics.

Concerning weight-overweight, the mean value of BMI in the whole group was 28 (sd 4.8); in Type 1 it was 25 (sd 3.4) and in Type 2 DM 29 (sd 4.8). Among those with Type 1, 40% had BMI >=25, 8% had a BMI of >30. Among those with Type 2, 78% had a BMI of >=25 and 35% had a BMI of >30. Among women, 68% had a BMI of >=25 and 33% had a BMI of >30; among men 72% had a BMI of >=25 and 27% had a BMI of >30.

Risk factors and complications
In all, 64% of the study population (60% in Type 1 and 64% in Type 2 DM) had one or more risk factors for complications and 54% (58% in Type 1 and 54% in Type 2 DM) had one or more complications. The frequencies of ischaemic heart diseases in the study population are shown in Table 4.


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  		Table 4 Proportion of patients in the study population with ischaemic heart diseases

 
The prevalence of risk factor control (blood pressure, smoking) and macrovascular complications [acute myocardial infarction (AMI), cerebro-vascular accident, amputation], and proportion of patients with HbA1c >7.5%, proteinuria, and retinal damage, are presented in Table 5.


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  		Table 5 Frequencies of risk factor control and main outcomes in the study population

 
The mean value of blood pressure was systolic 150 (sd 21.7) and diastolic 82 (sd 9.5) mmHg [in Type 1 132 (sd 20.3) and 76 (sd 9.5), in Type 2 DM 152 (sd 20.9) and 83 (sd 9.2)]. Blood pressure of 140/85 or above was found in 34% of the patients, and of these 30% were receiving treatment; 52% had blood pressure lower than 150/90 and 36% of these were receiving treatment. A total of 50% of the patients were receiving treatment for hypertension, 28% of Type 1 patients, and 75% among those who had signs of renal dysfunction. Among those receiving anti-hypertensive treatment, 23% had blood pressure lower than 140/85 and 38% had lower than 150/90.

The majority (29%) of patients with retinal damage had retinopathy (ICD-10, H36.0), in Type 1 40% and in Type 2 27%. Laser photocoagulation was performed in 11% of the patients (in Type 1 23% and in Type 2 8.1%).

In terms of gender, there were no differences in frequencies of current AMI or angina pectoris, but 7% of women and 14% of men had had one or more prior AMIs (P<0.001), and frequencies of cardiac failure and coronary invasive intervention showed differences [women 15% and 2%, men 12% and 6%, respectively (P<0.01 and <0.001, respectively)]. Among women, 20% were smokers, and among men 23%. There was significant difference between men and women with regard to persistent proteinuria (9.9% of men and 5.7% of women; P<0.05) and a non-significant difference in frequency of microalbuminuria.

Analyses of missing values
All medical records were available except nine. There were no missing values in several variables (year of onset, type of diabetes, treatment), but in others missing values varied from 12% (HbA1c) to 68% (oral tobacco use) (Table 3). People with missing values were slightly older, their treatment was to a greater extent in the form of dietary changes and/or oral hypoglycaemics, and most of them had Type 2 DM. When a checklist was not used, there was a greater proportion of missing values.


   Discussion
Top
 Patients and methods
 Results
 Discussion
References
 
‘Evaluation’ of health care and health care guidelines is a complex but important issue, especially regarding chronic diseases, in order to ensure the best care possible for the patients and to preserve and increase quality and competence within the caring professions. In the present study all residents in a health care area with a diabetes diagnosis were included. The age-standardized prevalence of diabetes and the distribution between different types of diabetes were comparable to other Scandinavian studies [15–17]. This indicates that most of those with diabetes in the study area had been identified, but there are reports of a considerable number of individuals with undiagnosed diabetes [17–19]. In Sweden the estimated prevalence of undiagnosed diabetes is 1% [2], a lower rate than the 4.3–6.3% that has been reported for the USA [19]. The variation of prevalence within the area (2.3 to 5.8%) can be understood as reflecting differences in resource allocation and priorities concerning screening for diabetes [10], as well as demographic and genetic variations in the population [20,21].

The fact that 84% of the patients (in Type 1 DM 91%) received an annual check-up can be regarded as an acceptable proportion, but still 16% had not been examined. This means that one crucial issue in the St Vincent Declaration [22] and the Swedish National Guidelines [13] was not fulfilled. However, these criteria can be understood as goals, and as not always possible for all patients to accomplish. Screening for complications can also sometimes be considered as unnecessary for those with newly diagnosed Type 1 DM and patients with established end-stage disease.

Another issue in diabetes care is that of metabolic control. In the present study we found that 19% in Type 1 and 35% in Type 2 DM had good metabolic control and 60% could be said to have acceptable metabolic control. In a recent study from the south of Sweden, satisfactory metabolic control was reported in 81% of the patients [23]. However, different methods for analysing HbA1c and different limits for degree of metabolic control make comparisons troublesome [10,11,16].

Most (75%) of our patients with satisfactory metabolic control received treatment through dietary changes only, and had a shorter duration of diabetes than the total group. There is a tendency for Type 2 DM to worsen as time passes, as shown in UKPDS, where 60% of those with long duration of Type 2 DM were treated with insulin [24]. This is in agreement with our result, where 72% of those with a diagnosis of diabetes for >15 years were treated with insulin. The high proportion of use of sulfonylurea in our study has nowadays diminished in favour of metformin, in agreement with results from UKPDS [25].

Despite long duration of the disease, 46% of the patients had no signs of complications. Assessment of renal function, measured as proteinuria, was performed in 84% of the patients in our study. This may be compared with the 73% assessed for renal function that was reported by Wändell et al. [11]. In the present study only 11% (in Type 1 19%, in Type 2 DM 10%) had signs of nephropathy. In another Swedish cross-sectional study 39% of those with Type 1 [26] and 27% of those with Type 2 DM had nephropathy [27]. However, it is not possible to compare frequencies of nephropathy, or any complication, because there are differences in sampling procedures and a lack of standardized methods.

Blood pressure was assessed in a high proportion of patients (90%), but 40% of the patients did not have acceptable blood pressure levels. Half of the patients with Type 2 DM were receiving anti-hypertensive treatment, almost the same proportion as in other Swedish studies [11,16], but among those receiving treatment, only 23% had blood pressure levels of <=140/85, which means that there is need for improved treatment.

One problem in this study was the fairly large proportion of missing values in some variables, and because of this, conclusions must be drawn cautiously. If a checklist was not used, there was a higher proportion of missing values. Our conclusion from this is that in order to maintain good quality in diabetes care it is important to have an adequate and easy-to-use checklist; otherwise, it is impossible to know whether the lack of documentation means that the examinations have not been performed or were just not documented.

One negative aspect of diabetes is that the patients have up to a 50% increased risk of developing ischaemic heart disease [27,28]. During the investigation period of our study the frequency of AMI was 0.4% in the study area, which is on the same level as in the general population in Sweden, compared with 2% for patients with diabetes in this area. This 5-fold increased risk of AMI is supported by other studies [29].

Information on smoking habits was available for 75% of the patients in our study, compared with 53% of diabetic patients in a study conducted in Stockholm in 1995 [11], and 22% were smokers, a little higher than the average proportion of smokers in Sweden [30]. Since smoking is known to double cardiovascular mortality in diabetic patients [31], to cause insulin resistance, to increase the risk (two to four times) of developing diabetes [32], and to interfere with metabolic control [33], one of the most important issues in diabetes care must be to convince smokers to stop smoking.

Methodological considerations
Population-based, cross-sectional studies have their disadvantages, owing to the time-consuming work and resulting high costs, but there are also advantages. A study in a defined area where all patients with a specific disease are included can serve as a base for prospective studies and make it possible to follow the progress of the disease for individual patients and groups, as well as the incidence and mortality. Some of the most important advantages in our view are the opportunity to give feedback to health care providers, and to make it possible for them to compare their own quality of care with that of the entire health care area to which they belong, with that reported in the National Diabetes Register, and also with international levels of quality of care.

A disadvantage of this study was that analyses of blood lipids were not included. Lipid disturbances are common among people with Type 2 DM and treatment of lipid disturbances is of critical importance, because cardiovascular disease is the leading cause of death among people with diabetes [27,34]. Other important parameters for good diabetic care that were not addressed in this survey were patient-related issues, such as changes in quality of life, wellbeing, and treatment satisfaction.

Conclusions and clinical implications
There is a need for improvement in the quality of diabetes care in the area studied. This is particularly important concerning treatment of high blood pressure, smoking cessation, and screening for complications. There is also a need for improvement in documentation. An effective intervention to reduce the number of missing values would be to create checklists, that are easy to complete and suitable for both paper and computerized medical records.

This study is consistent with a summary from a 3-year follow-up study of diabetes care [11] which emphasized that the frequency of documented examinations was unacceptably low and metabolic control was unsatisfactory in many cases, but that severe complications were uncommon. The most important issues in diabetic care, besides good metabolic control, are to reduce the high risk of macrovascular complications by adequate treatment of high blood pressure and to convince diabetic patients to stop smoking.


   References
Top
 Patients and methods
 Results
 Discussion
 References
 

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