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British Journal of Healthcare and Medical Research - Vol. 11, No. 5
Publication Date: October 25, 2024
DOI:10.14738/bjhmr.115.17745.
Jowi, S. O., Otieno, C. F., & Ogola, E. N. (2024). An Audit of Cardiovascular Risk Management of A1c, Blood Pressure and Cholesterol
(ABC) in a Diabetic Clinic: Identifying Gaps and Quality Improvement Implications. British Journal of Healthcare and Medical
Research, Vol - 11(5). 206-219.
Services for Science and Education – United Kingdom
An Audit of Cardiovascular Risk Management of A1c,
Blood Pressure and Cholesterol (ABC) in a Diabetic Clinic:
Identifying Gaps and Quality Improvement Implications
Jowi, Simeon O.
Department of Clinical Medicine and Therapeutics,
College of Health Sciences, University of Nairobi, Nairobi, Kenya
Otieno, C. F.
ORCID: 0000-0002-6906-0517
Department of Clinical Medicine and Therapeutics,
College of Health Sciences, University of Nairobi, Nairobi, Kenya
Ogola, E. N.
Department of Clinical Medicine and Therapeutics,
College of Health Sciences, University of Nairobi, Nairobi, Kenya
ABSTRACT
Background: Type 2 diabetes increases cardiovascular disease (CVD) risk. Optimal
management requires controlling blood sugar (A1c), blood pressure (BP), and LDL
cholesterol (LDL-C). Quality improvement (QI) initiatives to track these factors are
essential; however, resource limitations hinder optimal care in low- and middle- income countries (LMICs). Care audits aid in identifying gaps and guide QI
initiatives. Methods: A retrospective cross-sectional audit (2019 data) of 362 type 2
diabetes patients’ files at Kenyatta National Hospital (Nairobi) was done using
systematic random sampling. Data on demographics, diabetes duration,
comorbidities, and CVD risk factors (A1c, BP, LDL-C) were extracted comparing
them to Kenyan, European, and American Diabetes Association guidelines, to assess
adherence and data use for decision-making. Results: Most participants (68%) were
female, aged 50-59, with diabetes duration under 10 years. CVD risk stratification
was not documented. We categorized patients into cardiovascular risk strata: very
high (28.7%), high (57.7%), and moderate (13.5%). Only 50.6% had one risk factor
controlled, and none had all three controlled, with 42.3% missing documentation
for these factors. BP was the most frequently recorded parameter (99%). Clinic visit
frequency was low, with 47.8% attending twice and 26.2% attending once in the
year under consideration. Conclusion: We revealed deficiencies in documentation
and suboptimal control of CVD risk factors. Absence of CVD risk stratification during
care highlights the need for QI initiatives to improve documentation and translate
guidelines into effective management practices. Addressing socioeconomic factors
influencing follow-up visits and access to necessary tests is crucial for optimizing
care in LMIC settings.
Keywords: Type 2 diabetes, CVD risk factors, Quality improvement (QI) initiatives,
Clinical practice guidelines, Risk stratification, LMICs.
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Jowi, S. O., Otieno, C. F., & Ogola, E. N. (2024). An Audit of Cardiovascular Risk Management of A1c, Blood Pressure and Cholesterol (ABC) in a
Diabetic Clinic: Identifying Gaps and Quality Improvement Implications. British Journal of Healthcare and Medical Research, Vol - 11(5). 206-219.
URL: http://dx.doi.org/10.14738/bjhmr.115.17745.
BACKGROUND
Among individuals living with type 2 diabetes, up to two-thirds will develop atherosclerotic
cardiovascular disease (ASCVD) throughout their lifetime [1-3]. In such individuals with
diabetes who develop ASCVD, the vascular disease is more extensive, less amenable to
treatment, and tends to have worse outcomes than in the general population [1,4-6]. However,
intensive glycaemic, blood pressure (BP), and LDL cholesterol (LDL-C) control in accordance to
recommended evidence-based treatment targets has been shown to reduce cardiovascular
outcomes and death [7, 8, 9]. The ability to measure and track clinical performance and
outcomes, linked to a quality improvement (QI) program, is essential for ensuring the provision
of the best level of care desired. Approximately 80% of adults living with diabetes worldwide
live in low-income and middle-income countries (LMICs) [10]. The health systems in LMICs are
limited in their capacity to deliver optimal care for non-communicable diseases (NCDs), of
which diabetes is one, and this has resulted in substantial excess mortality [11,12]. The
recommended comprehensive approach to clinical care of type 2 diabetes consists of
pharmacological and non-pharmacological treatment and treatment targets for glycaemic
control and other key cardiovascular disease (CVD) risk factors, namely, hypertension, elevated
cholesterol, and obesity [3,4,13,14]. High-quality cohort studies have demonstrated the benefit
of multiple risk factor reduction among people with type 2 diabetes mellitus (T2DM) [13].
Consequently, the pharmacological treatments that result in the most effective improvement in
diabetes outcomes include glucose-lowering medications, antihypertensive medications, and
LDL-cholesterol-lowering medications [15]. The complex requirements of diabetes care
necessitate that a health system promotes and creates long-term chronic disease management
rather than episodic care [14,16,17,18]. In LMICs, fewer than 10% of people living with diabetes
receive guideline-based comprehensive diabetes treatment. Enabling health systems to deliver
comprehensive treatment to lower glucose and address cardiovascular disease risk factors,
such as hypertension and high cholesterol, are urgent global diabetes priorities, especially in
LMICs [19].
Clinical audits have demonstrated their value in informing initiatives for improving care
processes [20]. Clinical audits also assist in the scrutiny of healthcare provision and help in
identifying any shortfalls in the care of patients [21]. Conducting audits and improvements
based on them are found to be feasible even in resource-limited settings [22]. This audit was
performed to evaluate the level of assessment and control of glycaemic, blood pressure and
cholesterol parameters in the care of patients with type 2 diabetes by the clinical team at the
outpatient clinic setting of the hospital. What was not documented was not done, as the dictum
goes! The experts have acknowledged the centrality of the main cardiovascular risk factors in
patients with T2DM and the serious morbidity and mortality attributable to CVD. Consequently,
multiple guidelines and standards of medical care for diabetes mellitus patients have been
developed. These standards of care in the form of clinical practice guidelines (CPGs) are
supported by the highest level of evidence available at the time. Different regions/countries
around the world tend to contextualize their own guidelines. However, most guidelines
surrounding cardiovascular risk management in individuals with T2DM tend to cover the key
risk factors of hypertension, dyslipidaemia, obesity/overweight, smoking cessation, lifestyle
modification (including diet, exercise and alcohol use) and the use of anti-platelets. CPGs for
cardiovascular risk management in type 2 diabetes (T2DM) are dynamically revised based on
evolving evidence and are tailored to specific contexts globally. Our audit standards are dictated
by the dynamic nature of these guidelines.
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British Journal of Healthcare and Medical Research (BJHMR) Vol 11, Issue 05, October-2024
Services for Science and Education – United Kingdom
METHODS
This was a retrospective file audit performed at the diabetes clinic at the Kenyatta National
Hospital (KNH). The KNH is a tertiary, public teaching hospital in Nairobi, Kenya’s capital city.
The study areas were the diabetes outpatient clinic (DOPC) and its decentralized records
department. The decentralized records department at the diabetic outpatient clinics stores
physical files for patients with diabetes mellitus. These physical files act as the main form of
data entry and storage of patients’ clinical information. The patient files were chosen by
systematic random sampling. The inclusion criteria for the T2DM patients was files of patients
diagnosed with T2DM on follow-up at the KNH DOPC for at least one year (the target period of
the audit was as of January 1st, 2019, to December 31st, 2019). File numbers of patients with a
diagnosis of diabetes mellitus were identified from the KNH electronic database using 2020
international codes of disease (ICD-10 codes E11-). The records officers then used the files
numbers to retrieve them physically from the records office store. Once retrieved in
manageable batches of approximately thirty to forty per day, the principal investigator (JSO)
carefully perused each file for inclusion in the study. The files were then carefully studied by
the PI and two research assistants to obtain predefined study-specific targets that were adapted
from the relevant guidelines, which were the 2018-Kenya National Clinical Guidelines for the
Management of Diabetes Mellitus[23], the European Society of Cardiology (ESC)
Guidelines/European Association for Study of Diabetes (EASD) Consensus Report on
Management of Cardiovascular Disease in Type 2 DM[24] and American Diabetes Association
(ADA) Guidelines[25,26] on the Management of Cardiovascular Risk in DM. When there was a
lack of consensus in the guidelines above, we adhered to our local guidelines. The study tool
was a questionnaire in the form of a checklist with 5 core sections covering each of the
cardiovascular risk factors whose management we sought to audit. The following data were
extracted from the files: patient study number, demographic details, duration of type 2 DM,
comorbidities and CVD risk stratification. Stored data from Excel were exported to STATA
version 14 and R version 4.3.1 for statistical analysis. The demographic and clinical
characteristics of the study population were described. For continuous variables, appropriate
measures of central tendency (mean/median/mode) were reported. Categorical variables are
summarized as percentages and proportions. Interventions not documented were considered
not done and were documented as such, and an arbitrary target score of 100% was used. This
study was carried out after presentation and approval by the Department of Clinical Medicine
and Therapeutics, University of Nairobi, KNH and the Ethical Review Committee. The data
collected from the files were kept under lock and key with access controlled by the principal
investigator.
Table 1: Guideline targets with respect to key areas of cardiovascular risk management
in T2DM patients.
Risk Factor/Standard of care Kenya Diabetic Clinical guidelines
Target
Risk stratification
*ADA and ESC have different methods of quantifying
variables while stratifying risk however treatment targets
based on risk stratification are similar
Kenya guidelines borrow aspects of risk
stratification heavily from ESC:
moderate, high, very high
Hypertension
*ESC and ADA target 130/80 for most hypertensive
diabetics.
Target <140/80 mmHg