Quality of Diabetes Care at Armed Forces Hospital , Southern Region , Kingdom of Saudi Arabia

Objectives: To assess the current status of care provided by the Diabetes Center at Armed Forces Hospital, Southern Region in the Kingdom of Saudi Arabia. Methods: A total of 260 diabetic patients were randomly selected from those attending the Diabetes Center at Armed Forces Hospital, Southern Region in the Kingdom of Saudi Arabia. Study tools comprised patients’ data sheet and patients' interview questionnaire. Results: Two thirds of patients aged 50 years or more. Half of patients had their disease for less than 10 years. Diet therapy alone was followed by 2.3% of diabetic patients. More than half of patients (56.5%) received insulin. Most patients were tested for HbA 1 c at least once per year (88.1%), and 71.5% received their lipid profile at least once within two years. Low indicators included receiving a dilated eye examination (35.4%), assessment for nephropathy (28.8%) and receiving a well-documented foot examination (12.7%). Highest risk HbA 1 c level (>9.5%) was reached by 38.8% of patients, 48.8% had a low density lipoprotein level of <130mg/dL and 36.5% had controlled blood pressure ( !9 130/80mmHg). Most patients were satisfied with their interaction with the treating doctor, 41.5% were satisfied with access to treatment. Hypertension was the most frequent comorbidity (38.5%). Conclusions: The quality of services as regard process and outcome is low at the Diabetes Center. The overall diabetic patients' satisfaction is high while their satisfaction with access to treatment or health professionals is low.


Introduction
RESULTS obtained from clinical trials over the past decade have led to guidelines that advocate aggressive management of hyperglycemia, hypertension, and hyperlipidemia for patients with dia-Correspondence to: Dr. Ibrahim S. Al-Arfaj, The Department of Family Medicine, Armed Forces Hospital, Southern Region, KSA.
In 2001, the Diabetes Quality Improvement Project (DQIP) was initiated in USA to define a comprehensive set of measures for evaluation of the quality of diabetes care [13] .The DQIP measures are indicators or tools to assess the level of care provided within systems of care to populations of patients with diabetes [14] .
In the Kingdom of Saudi Arabia (KSA), a diabetes center was established in June 2004, at the Armed Forces Hospital, Southern Region (AFHSR) to improve the diabetes services by providing a comprehensive, continuous, and evidence-based medical care.Since that time, there was no internal or external assessment carried out to evaluate the quality of service provided by the diabetes center.This study intends to provide information that will help in internal quality improvement, and provide comparison measurements with other diabetes health care services elsewhere in KSA or internationally for the purpose of accountability.So, the aim of this study is to assess the current status of care provided by the AFHSR Diabetes Center in KSA.

Material and Methods
This is a cross sectional study, that was conducted at the Armed Forces Hospital in Khamis Mushate, Southern Province, during June 2006.In the Diabetes Center (DC), clinics provide both primary and specialty care for about 3500 diabetic 261 patients.There are two internal medicine specialists who cover the primary health care clinics.In addition, there are two endocrinologists who cover the specialty clinics.There are also two nurses, two female dietitians, one female health educator and one podiatrician.
During the month of June 2006, there were 673 pre-arranged bookings with primary and specialty clinics.From them, a total of 260 diabetic patients and their medical records were studied in the DC in three or more visits.They were randomly selected according to a simple random sampling technique, using the random table on the booking list.Patients' records were reviewed by using the checklists.Selected patients were interviewed by the researcher using questionnaire designed by the DQIP [17] .It includes patient's identification data in addition to self-management, health and nutrition education, inter-personal care from provider, satisfaction with, and access to care, health status, and smoking cessation counseling.Five-grade scaling system (very satisfied, moderately satisfied, satisfied, poorly satisfied, unsatisfied) was developed by the researcher and was used to assess the previous satisfaction indicators.The researcher filled the questionnaire during interview with the diabetic patients attending the DC, or the accompanied relatives for dependant patients.
According to the DQIP initial measure set [14] , the process and outcome indicators were used to evaluate the process and outcome of services provided by the DC.

Process indicators:
1-Percentage of patients receiving >_ 1 HbA 1c test/year 2-Percentage of patients assessed for nephropathy 3-Percentage of patients receiving a lipid profile once in 2 years 4-Percentage of patients receiving a dilated eye exam 5-Proportion of patients receiving a well-documented foot exam to include a risk assessment
All the necessary official permissions were fully secured before data collection.Collected data were verified prior to computerized data analysis.The Statistical Package for Social Sciences (SPSS ver.13.0) was used for that purpose.Descriptive statistics (e.g., frequency and percentage) were calculated.

Results
A total of 260 diabetic patients participated in this study.Table (1) shows their characteristics.HbA 1 c was tested once per year at least in 88.1% of diabetic patients and only 8.1% of them attained HbA 1 c level less than 7%.Only 36.5% of patients attained the targeted blood pressure (<130/ 80mmHg).
Table (2) shows the initial measure set, process and outcome indicators among diabetic patients according to DQIP.Female patients receive HbA 1 c testing, LDL-C testing, dilated eye exam and detailed foot exam significantly more than male patients (p<0.05).Highest risk HbA 1 c was significantly more frequent in male diabetes (p<0.005).There was no significant difference between male and female diabetic patients in the control of LDL-C and blood pressure.Of diabetic patients, 83.5% received health education at the DC.However, 79.6% could understand the message which was applied by 55% of the diabetic patients.Two-thirds of patients (63.5%) were involved in their health care decisions, 91.2% of patients were satisfied with their interaction with the treating doctor, 41.5% were satisfied with access to treatment or health professionals, while 89.2% expressed their overall satisfaction.

Discussion
Improved blood glucose control, regular eye examinations, and reduction in cholesterol and blood pressure are some of the practices that have been unequivocally shown to reduce complications and thereby diminish the heavy personal and financial toll attributed to diabetes [15] .This study aimed to describe the current status of care provided by the AFHSR DC.
The present study indicated that there were slightly more female diabetic patients than males, two thirds of them aged 50 years or more and half of patients had their disease for less than 10 years.This was in agreement of several national and international studies [16][17][18][19] .El-Hazmi et al., noted that the increase in prevalence in those aged 45 years and above was very significant in the Saudi population and places KSA among the countries of world classified as high prevalence countries.Differences in sex-specific prevalence rates are possibly due to a result of differences in the lifestyles of the male and female population [19] .
Results of the present study showed that only 22% of patients had normal weight.Some studies emphasized the significance of high prevalence of obesity among the Saudi population as a risk factor for diabetes.Several researchers noted that in the KSA, overweight and obesity are common in both males and females [18-21] .These findings are even higher than that reported in several studies, Grant et al. [17] conducted a retrospective study in USA and reported that obesity is highly prevalent among American diabetic patients (31.2%).
Valk et al. [22] noted that the main risk factors contributing to the increasing incidence of type 2 diabetes are the continuously rising levels of obesity and physical inactivity.
The low rate of patient on diet therapy alone was comparable to those reported by Grant et al. [17] , who reported that among patients attending the Diabetes Clinics, 2.7% were on diet therapy only, 30.2% were on hypoglycemic therapy while 67.1% received insulin therapy.In Amsterdam, Netherlands, the study of Valk et al. [22] revealed that the percentage of patients treated only with diet decreased from 31.2% in 1992 to 8.3% in 1996.This could be explained by the current recommendations of the importance of controlling blood sugar even by more aggressive approaches, lack of patient adherence to diet and exercise advice, or due to the absence of clear practice guidelines at the center that emphasizes the role of non-pharmacological interventions.
The present study revealed that the DQIP process indicators were quite low.Al-Owayyed et al., in Riyadh identified a better result of process regarding the lipid profile testing, dilated eye examination, and foot examination, which was 73.8%, 61.5%, and 53.3% respectively.Other process indicators were 60.5% for HbA 1 c testing and only 12% were tested for microalbuminurea [18] .Grant et al. [17] revealed that higher process indicators for HbA 1 c which are measured for 98.8% of American diabetic patients, lipid profile was measured for 86.9% of diabetic patients, dilated eye examination was performed for 55.4% of patients, screening for nephropathy was performed for 65.1% of patients, while documented foot examination was performed for 63.6% of diabetic patients.
There are several factors that might contribute to these findings such as: Poor patients' compliance to advice, treatment or appointments, heavy clinics' workload, absence of practice guidelines, or lack of self care and effective health education programs.However, the definite causes must be explored and managed accordingly.Furthermore, the outcome indicators were also low.The present study showed that the highest risk HbA 1 c level (>9.5%) was reached by 38.8% of diabetic patients, while only 8.1 % of diabetic patients attained HbA 1 c level less than 7%.In USA, the study of Grant et al. [17] showed that this outcome indicator (HbA 1 c level less than 7%) was much better attained by one third of diabetic patients (34%).
Previous low indicators found in this study can be explained by the presence of several factors like lack of adherence to practice guidelines by the practitioners, patients' non-compliance to advice, treatment or appointments, or simply missing records for patients' workup.Moreover the present study showed that 48.8% of diabetic patients had a low density lipoprotein (<130mg/dL).A comparable level for this indicator was reported by the study of Grant et al., on American diabetics (52.9%) [17] .
Blood pressure control ( < 130/80mmHg) among diabetic patients was attained by 36.5% of diabetic patients.This result is lower than that achieved in the American study of Grant et al., which reported controlled blood pressure among 55% of diabetic patients [17] .
This study showed that 83.5% of diabetic patients received health education.However, 79.6% could understand the message which was applied by 55% of the diabetic patients only.This discrepancy can be explained by the presence of only female health educator for diabetic patients in the DC at the AFHSR.These findings were explained by several authors.Elasy et al., emphasized that diabetes education is an essential part of diabetes care.However, problems with communication and cultural differences may hinder delivery of optimal diabetes care to ethnic groups [24] .In Turkey, Uitewaal et al., noted that the influence of gender inequality between the female educator and the male patients might explain the lack of effect in men.Male patients may feel less inclined to take advice regarding behavioral changes from women [25] .
Austin [29] stated that diabetes education is usually underutilized.Approximately 60-70% of diabetic patients do not receive training in diabetes self-management.Diabetes educators should be trained to identify and help overcome barriers to optimal diabetes care.He advised that diabetes educators must frame their intervention on the basis of the 7 Self-Care Behaviors: (1) healthful eating, (2) being active, (3) monitoring, (4) taking medication, (5) problem-solving, (6) healthful coping, and (7) reducing risks.
The present study showed that two-thirds of diabetic patients (63.5%) were involved in their health care decisions.Anderson et al., stated that substantial proportion of diabetic patients report difficulty achieving standard self-care treatment goals.They described the unmet needs for diabetes self-care knowledge and skills associated with patient outcomes.Routine monitoring of patientcentered self-care outcomes could help improve long-term outcomes of diabetes care [23] .
The overall satisfaction with the service was expressed by 89.2%, 91.2% of diabetic patients were satisfied with their interaction with the treating doctor.However, only 41.5% were satisfied with access to treatment or health professionals.This finding can be explained by the crowded appointment schedule, staff shortage, or lack of other means of communication.However, the true reasons behind that should be further explored and managed.
This study indicated that prevalence of cigarette smoking among diabetics was very low (1.2%).This finding is in agreement with that noted by Harris et al., who stated that people with diabetes who smoke have a substantially increased risk of cardiovascular disease, above and beyond that attributed to diabetes itself.Smoking cessation is the most important and effective way to reduce diabetes-related morbidity and mortality in smokers [28] .This finding was much lower than that reported by Al-Owayyed et al., which was 12.9% [18] .
In the present study, hypertension was the most frequent comorbidity among diabetic patients (38.5%).This was comparable with that reported by Al-Owayyed et al., in Riyadh, who revealed that hypertension was found in 31 % of patients, retinopathy in 17.9%, nephropathy in 13.3%, ischemic heart disease in 6.6%, and neuropathy in 4.8% [18] .
In Canada, Hanley et al., noted that the high prevalence rates of both micro-and macro-albuminuria among diabetics explain the high incidence of the renal complica-tions of diabetes.They reported a high prevalence of neuropathy among diabetics (46.3%).Followed by retinopathy (24%) [26] .
Differences in reported complications attributable to diabetes, as assessed by the DQIP process and outcome indicators may reflect differences both in duration/severity of disease in addition to differences in quality of provided health care for diabetic patients [28] .

Conclusions:
The quality of service introduced to diabetes patients in the DC is low.The outcomes are unfavorable in spite of high patients' satisfaction regarding health care team.In order to improve the quality of diabetes care in the center, intensification of health education and self care management is essential, in addition to establishing internal auditing to monitor the progress of all diabetes patients aspects of care and to overcome the barriers faced regularly.

Table ( 2
): Diabetes Quality Improvement Project (DQIP) initial measure set, process & outcome indicators among diabetic patients at Diabetes Center, Armed Forces Hospital Southern Region, KSA.