Clinical Audit on Diabetes care in UNRWA Health Centres.

Author(s) Yousef Shahin1, Anil Kapur2, Ali Khader3, Wafaa Zeidan 4, Akihiro Seita 5.
Affiliation(s) 1Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, Amman, Jordan, 2Diabetes care, World Diabetes Foundation (WDF), Delhi, India, 3Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, Amman, Jordan, 4Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, Amman, Jordan, 5Health, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA, Amman, Jordan.
Country - ies of focus Jordan
Relevant to the conference tracks Chronic Diseases
Summary Diabetes is a major health problem for the Palestine refugees we serve. The number of refugees living with diabetes is already large, more than 110,000 by 2012, and is steadily increasing by 3 to 5% every year. The financial pressure to maintain and expand diabetes care is significant. Insulin alone, for example, accounts for 15% of the entire expenditures on medicines.The audit, conducted in 2012, was the first extensive assessment of diabetes care in UNRWA in recent years. This was the collaboration with the World Diabetes Foundation and international experts on diabetes care. The results of the audit provided us priceless lessons to further improve our diabetes care in UNRWA.
Background UNRWA has delivered comprehensive primary health care services to Palestinian refugees in Gaza, West Bank, Jordan, Lebanon and Syria for over 65 years and has achieved some remarkable health gains particularly in relation to maternal and child health and communicable diseases. There is significant change in the epidemiological transition of disease burden. The main causes of mortality and morbidity among Palestinian refugees are non-communicable diseases (NCDs) such as diabetes mellitus (DM), cardiovascular diseases and cancer. Behavior risk factors like unhealthy diets, physical inactivity and smoking are increasingly prevalent among Palestinian refugees as well.
UNRWA has been providing diabetes and hypertension care at its health centers since 1992. The diabetes care includes screening of high risk groups, diagnosis, and treatment with lifestyle education and medical treatment including insulin therapy. In addition UNRWA invests in primary and secondary prevention activities through health education and the screening of complications. A total of 114,911 diabetic patients were registered at UNRWA health centers in its five fields of operation (Gaza, Jordan, Lebanon, West Bank and Syria) by the end of 2011.
Objectives The objective of this clinical audit was to acquire evidence-based information on the quality of diabetes care in all the five fields served by UNRWA (i.e. Gaza Strip, West Bank, Jordan, Lebanon and Syria). It was not possible, however, to conduct the study in Syria due to the ongoing conflict.
The findings of the clinical audit will be used to define a strategy to improve technical and managerial capacity within UNRWA’s health service and increase diabetes awareness among Palestine Refugees.
Specifically the audit examined the UNRWA health care services provided to diabetic patients under care, collected data on process, outcome and treatment indicators to establish the base-line and current status,  identified areas and means to improve the quality of clinical care provided at health centre level and identified the training needs of health staff in the field of diabetes care.
Methodology A total of 1,600 patients with DM were included in the audit. They were selected from the eight largest health centers in each of the four fields (Gaza, Jordan, Lebanon and West Bank): in total there were 32 health centers. In each health center, the first 50 DM patients attending to the health center for periodic assessment were selected irrespective of their age or sex. Patients with less than 1 year of DM care were not included in the audit.
Patients were not informed of the audit examinations in advance. Patients were asked about the engagement of clinical audit, including HbA1C testing, and only those who were willing to participate and provide written consent were engaged in the audit. Patients were interviewed and examined according to a standardized data collection sheet that was jointly developed by UNRWA and WDF. The sheet included questions on past medical history, current findings, laboratory tests, clinical management and diabetes complications. Comprehensive clinical examination, patient interview and record review were used to complete the questionnaire and these were carried out by the experienced UNRWA experts.. Blood samples were collected and tested for HbA1c at the internationally recognized laboratory at the Augusta Victoria Hospital in East Jerusalem. Data was entered and analyzed with Epi-info 2000. Patients provided informed written consent
The knowledge of UNRWA medical officers working for diabetes patients at NCD clinics was also assessed. To this effect, a questionnaire was developed and distributed to 66 medical officers before the start of the clinical audit in each health centre. The questionnaire analysed the medical officers’ knowledge on the different aspects of diabetes care such as the demographic characteristics of patients, the prevalence of risk factors, and the correct clinical management and follow up of diabetic patients.
Results A total of 1,600 patients were enrolled in the audit. Of them, 68 (4.3%) were affected by type 1 diabetes and 1,532 (95.7%) by type 2 diabetes. A considerably high proportion of them (1,102 or 68.5%) have co-morbidity with hypertension. 1,109 (63.7%) were female: this high proportion of female patients is probably the reflection of general attendance pattern of patients in UNRWA health centers. In regards to risk factors, one significant finding was the very high proportion of obese and overweight patients: 1,024 (64.0%) and 421 (26.3%), respectively. The number of smokers was 313 (19.6%). Clinical management of diabetes is largely in line with the UNRWA’s technical instructions on diabetes care. Of 1,600 patients, 63 (3.9%) receive lifestyle support alone while 1,529 (95.6%) receive diabetes medicines and 8 (0.5%) receive treatment from non-UNRWA health facilities. Of those receiving medicines, the most commonly used was oral hypoglycemic agents (OHA). 1,192 patients (68. 2%) were with OHA alone, followed by combined therapy of OHA and insulin (231, or 14.4%), and Insulin therapy alone (207, or 12.9%). Monitoring examinations for diabetes are also done regularly. Postprandial glucose, cholesterol, creatinine and urine protein tests were regularly done for almost all patients (94.7%, 96.4%, 91.4% and 87.5%, respectively).
The findings from the knowledge, attitude, and practice assessment among 66 medical officers at the health centers involved in the clinical audit also revealed their good knowledge on diabetes care and proper follow up of technical instructions. Almost 80 to 90% of them have correct knowledge on frequency of patients’ follow up visits, laboratory tests on cholesterol and creatinine. More than 70% of medical officers have a correct understanding of the proportion of insulin therapy.
The main shortcomings identified in the clinical audit is that the control rate for diabetes based on the HbA1c tests is much lower than that measured using PPG. While 44.8% of patients have PPG ≤ 180mg/dl, only 452 (28.3%) have HbA1c < 7%. For patients with type 2 diabetes only, 42.6% vs. 25.1%, and for patients with type 2 diabetes and hypertension, 45.7% vs. 30.8%, respectively.
Another shortcoming is the failure of lifestyle support activities. More than 90% of patients are either obese (64.0%) or overweight (26.3%). Among female patients, the proportion is much higher at almost 95% of which 73.4% are obese.
Conclusion The availability of competent health staff and of updated, scientifically documented protocols (named Technical Instructions) is one of the main strengths of the diabetes care programme in UNRWA health centres. The clinical audit confirmed that UNRWA doctors and nurses, working in diabetes care, follow the Technical Instructions rather rigorously. The doctors’ knowledge on diabetes and its care is therefore considered appropriate in principle, as well as their capacity to correctly prescribe lifestyle and drug based treatments. Follow up blood and urine examinations are also conducted regularly as indicated in the UNRWA protocols.
At the same time, the audit demonstrated the poor sensitivity of two-hour PPG testing in measuring diabetes control compared with HbA1c. This could mean that UNRWA has systematically over-estimated control rates of its patients. More than 90% of patients are either obese or overweight. Without addressing such lifestyle issues, UNRWA may not achieve sensible results in diabetes care.
UNRWA’s extensive experience in diabetes care in primary health care settings and the capacity, experience and rigour of UNRWA’s doctors and nurses are a solid foundation on which to improve the performance of diabetes care. A comprehensive and strategic response that goes beyond the activities of the NCD care programme alone is needed to address such fundamental issues and the recently applied person & family centred family health team reform offers an ideal reference framework.

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