| Abstract|| |
Although there are numerous studies on diabetes mellitus in Saudi Arabia, data on the extent to which American Diabetic Association (ADA) standards of diabetic care are met, is scarce. We studied the computerized records of adult diabetic patients followed-up in outpatient internal medicine clinics at our tertiary care center in Riyadh, Saudi Arabia to find out how many of them met the ADA standards of diabetic care regarding fasting blood glucose, HbA1c, LDL-C, hypertension, proteinuria screening and use of anti-platelet, lipid lowering or recommended antihypertensive medications. Out of 1,188 type-2 diabetic patients studied, blood pressure readings were available in 1180 (99%) while results of fasting blood glucose, HbA1c, LDL-C and albuminuria screening were available for 1123 (95%), 968 (81%), 1037 (87%) and 307 patients, (26%) respectively. Patients achieving the ADA targets for overall, systolic and diastolic blood pressure, fasting blood glucose, HbA1c, LDL-C and albuminuria screening were 39.0%, 40.6%, 74.6%, 25.0%, 21.8%, 55.5% and 34.9%, respectively. For prevention of cardiovascular events, 61.0%, were using angiotensin converting enzyme inhibitors (ACE-I) or angiotensin-2 receptor blockers (ARBs) or both, while 71.5% and 72.3% of our patients were on anti-platelet and statin medications, respectively. In conclusion, as reported in most other studies, we also found that ADA standards of diabetic care are not met in most of our diabetic patients, indicating that these standards are easy to preach than to practice. There is need for further research to investigate the reasons for this failure and to adopt better multi-disciplinary approach and realistic targets in the future.
|How to cite this article:|
Kharal M, Al-Hajjaj A, Al-Ammri M, Al-Mardawi G, Tamim HM, Salih SB, Yousuf M. Meeting the American diabetic association standards of diabetic care. Saudi J Kidney Dis Transpl 2010;21:678-85
|How to cite this URL:|
Kharal M, Al-Hajjaj A, Al-Ammri M, Al-Mardawi G, Tamim HM, Salih SB, Yousuf M. Meeting the American diabetic association standards of diabetic care. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2020 Aug 13];21:678-85. Available from: http://www.sjkdt.org/text.asp?2010/21/4/678/64644
| Introduction|| |
The number of patients with diabetes mellitus (DM) is predicted to increase from 135 million in 1995 to 300 million in 2025, worldwide.  Most of this increase will be in developing countries with prevalence of DM in the Middle East likely to escalate by 163% by year 2030.  Diabetes mellitus in Saudi Arabian adults is rapidly increasing with a prevalence of 23.7% in the period between 1995 and 2000. 
Diabetes Mellitus in adults is associated with an annual death rate of about 5%, which is approximately double the rate for age and gender-matched control subjects without diabetes. Most of this excess mortality risk is attributable to macrovascular atherosclerotic disease.  Thus, it has been recommended that medical management to decrease cardiovascular risk should start when type-2 DM is diagnosed. 
Results from clinical trials over the past decade have led to national and international guidelines that advocate aggressive management of hyperglycemia, hypertension, and dyslipidemia for patients with DM. ,,,,
Despite many guidelines, patients with diabetes continue to suffer from high rates of cardiovascular and microvascular complications and can expect a lifespan reduction of 10-15 years. , This inability to effectively and widely translate clinical evidence into usual practice represents a major barrier to reducing the burden of diabetes and its complications.
Although there is extensive data on various aspects of DM in Saudi Arabia, knowledge about meeting the American Diabetes Association (ADA) targets in management of diabetic patients is scarce. Thus, this study was undertaken with a view to determine the extent of achieving ADA targets in type-2 DM by the internists in a tertiary care outpatient setting.
| Patients and Methods|| |
This observational, cross-sectional, retrospective study was conducted on adult patients followed-up at the outpatient internal medicine clinics in The King Fahad National Guard Hospital, King Abdulaziz Medical City, Riyadh, Saudi Arabia. This tertiary care center is responsible for treatment of Saudi National Guards and their dependents. All patient data are computerized. The study was approved by the institutional research committee. The diabetic patients seen and followed-up in this hospital are usually referred to us when it is difficult to manage them at primary care clinics or family medicine clinics and often, have one or more of the diabetic complications.
A list of patients of either gender, aged 30years or above, who had visited the internal medicine clinics during the period between August 2005 and January 2006 was generated from the Information Service Department (ISD) in the hospital. Out of these, patients who fulfilled the criteria for DM according to ADA guidelines , were included in the study. Data retrieved on computerized Misys CPR system on these diabetic patients included age, gender, presence and control of hypertension, fasting blood glucose, HbA1c, serum low density lipoprotein cholesterol (LDL-C) levels and microalbuminuria. Medication profile was reviewed through computerized Pharmacy Legacy System and specifically noted the use of antiplatelet medications (aspirin or clopidogrel or both), anti-diabetic medications (oral hypoglycemics, insulin or both), ADA recommended anti-hypertensive medications [angiotensin converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARBs) or both) and statins].
Blood pressure was recorded by electronic blood pressure apparatus Dinamap (Datascope Accutore-plus, US) with the patient sitting after a rest of ten minutes. This apparatus was periodically calibrated for accuracy by comparison with a mercury syphgmomanometer. In case the initial blood pressure was high, a second reading was taken ten minutes after the first reading for the purpose of the study. Hypertension was diagnosed if the patient had blood pressure equal to, or more than 140/90 mmHg or the patient was on anti-hypertensive treatment. Fasting blood glucose (FBG) was measured on serum using Architect c 8000 7M system in mmol/dL. HbA1C was determined on whole blood by ion-exchange high-performance liquid chromatography using Bio-Rad variant II hemoglobin testing system (US). LDL-C was measured after a 12-hours fast by multiagent LDL assay using direct, quantitative method (Architect c 8000 7M system, US). Proteinuria was checked either on first voided, random, morning urine sample by albumin to creatinine ratio or by 24-hour urinary protein by spectrophotometry using Abbott analyzer.
All the data obtained was analyzed by a biomedical statistician using SPSS program version 13 to find out the number and percentage of patients meeting the 2005 ADA recommended targets  regarding overall, systolic and diastolic blood pressure, fasting blood glucose, HbA1c and LDL-C levels. For the purpose of analysis, only the last blood pressure and the laboratory values were used to best reflect the effect of long-term treatment. Categorical data was calculated by number and percentage (%), while continuous data was calculated as mean and standard deviation (SD).
| Results|| |
The total number of patients visiting the medical outpatient during the study period was 2110. Out of these, 1188 (56.3%) fulfilled the criteria for type-2 DM and were included in the study. Of these diabetic patients, 458 (38.5%) were males and 730 (61.5%) were females, with a male to female ratio of 1:1.6. Hypertension was present in 655 (55.1%) of the study patients.
ADA Screening Tests
Out of the 1188 diabetic patients, blood pressure readings were available in 1180 patients (99%) while results for FPG, HbA1c, LDL-C and albuminuria screening were available for 1129 (95%), 968 (81%), 1037 (87%) and 307 (26%) cases, respectively. These data with mean values and standard deviations are given in [Table 1].
The number and percentage of our study patients on anti-diabetic, recommended antihypertensive, anti-platelet and statin medications were 1120 (94.3%), 706 (59.5%), 849 (71.5%) and 859 (72.3%) respectively, as shown in [Table 2]. The different types of anti-diabetic therapy used are shown in [Figure 1]. Patients on ACEI and/or ARB are shown in [Figure 2], while the use of different anti-platelet medications is shown in [Figure 3].
ADA cardiovascular risk target achievement
The percentage of the study patients achieving the overall, systolic and diastolic BP, HbA1c and LDL-C targets, as prescribed by the ADA, was 39.1%. 41.3%, 74.9%, 21.8% and 55.5%, respectively [Figure 4].
| Discussion|| |
Despite strong evidence that intensive control of cardiovascular risk factors reduces morbidity and mortality in diabetes, our study revealed that a large number of patients were not achieving recommended ADA targets of care.
Most of the published studies of adherence of physicians to the recommended standard of diabetes care have been at different levels of care with differences in the guidelines followed, with only two studies previously reported from the Middle East, one from Saudi Arabia,  and the other from Lebanon.  To our knowledge, our study is the second from Saudi Arabia to report on how the internists in a single tertiary care center adhere to the guidelines for the management of type-2 DM. In a previously reported study from different centers of Eastern and Western regions of Saudi Arabia, the same treatment targets of overall BP and HbA1c were achieved in 32 and 24% of the patients with type-2 diabetes mellitus, respectively.  However, in that study there was no information about how many of the patients were using various anti-diabetic, antihypertensive, anti-platelet and statin medications. In a study from a university health center at Lebanon  involving 204 diabetic patients, parameters such as systolic and diastolic blood pressure, fasting blood glucose and HbA1c were met in 55.4%, 65.7%, 17.8% and 28.4% of their patients compared to 47.6%, 74.6%, 25.0% and 21.8% of the patients respectively, in our study. However, in that study all the diabetic patients were mainly followed-up by family physicians with optimal BP target of 135/85 mmHg.
A comparison of achievement of HBA1c and blood pressure targets in our study with other Studies ,,,,,,, is given in [Table 3], which high lights that these targets are increasingly difficult to achieve. While interpreting the results of our study, it is important to note that most of the patients in our study were already having diabetic complications with multiple associated co-morbidities, a group with inherent difficulties to achieve the targets of standards of care in any setting. Therefore, these patients are not representative of most of the diabetic patients in primary care settings in Saudi Arabia, where the level of care may be much less.
In the United Kingdom Prospective Diabetes Study (UKPDS),  despite the intensive treatment used in that study which is not currently possible for routine care of diabetes, HbA1c of 7.0% was achieved in only 50% of patients. Thus, even with such an approach, 50% were unable to reach this target, and after nine years, fewer than 25% of obese subjects maintained this control.  Furthermore, the patients in the UKPDS, all had newly diagnosed type-2 diabetes. As the glycemic control deteriorates further with time when complications ensue, despite progressive requirements for higher doses of hypoglycemic agents,  achieving the HbA1c target of 7.0% becomes an uphill task. It is, therefore, not surprising that only 22% of patients with type-2 DM in our clinic population had an HbA1c < 7%. Our results illustrate that with currently available therapies, many patients fail to reach recommended treatment targets. Indeed, clinicians appreciate that, for many patients, individualized recommendations may be more appropriate. 
The UKPDS also demonstrated that tight blood pressure control delayed the development and progression of macrovascular and microvascular disease in type-2 DM.  It is important to note that, despite participation in a clinical trial, only 56% of patients in the tight control group and 37% in the less tight control group achieved a blood pressure < 150/85 mm Hg. Relatively recently, in the Heart Outcomes Prevention Evaluation (HOPE) study,  investigators reported that patients with diabetes and at least one other cardiovascular risk factor (not necessarily hypertension) treated with the ACE-I ramipril were less likely to develop the composite endpoint of myocardial infarction, stroke or death from cardiovascular disease, compared with those who received placebo, despite a mean reduction in blood pressure of only 3/2 mmHg. The picture looks dismal if we consider that fewer than 10% reached combined ADA recommended HbA1c, blood pressure and total cholesterol levels in the NHANES study. 
Meeting the ADA recommended target level of LDL-C in 55.5% of the patients in our study was slightly better than the 50.5% reported elsewhere from Saudi Arabia,  but less compared to 60.0% and 64.2% in Australian  and US  studies, respectively.
The use of medications recommended by the ADA for prevention of cardiovascular complications in our type-2 diabetic patients was 61.0%, 71.5% and 72.3% for ACEI or ARBs or both, anti-platelets and statins respectively. This is better than many other studies in type-2 diabetic patients. In a Canadian study of diabetics with or without atherosclerotic complications,  fewer than 25% received an antiplatelet agent or statins, and fewer than 50% received an ACEI. In a Belgian study,  only 33.1% and 39.9% were on aspirin and statins respectively, while only 36.0% were on aspirin in a Swedish study. 
In the management of a patient with type-2 DM, poly-pharmacy may be unavoidable. Given the cardiovascular risk profile of type-2 DM, up to 10% of patients could require two or three hypoglycemic agents (ultimately including insulin), at least three anti-hypertensive agents, two hypolipidemic agents, and aspirin. A high proportion will also require treatment for co-existent cardiovascular disease and coincidental unrelated chronic disease. It is difficult to see how we can realistically expect patients to comply for long with such a draconian regimen requiring so many different medications. The development of combination tablets by the pharmaceutical industry seems to be the utmost priority for effective prevention of complications of type-2 diabetes,  and should be encouraged.
Being a retrospective study, our study had inherent problems. Furthermore, as the data obtained was through electronic records, information about retinopathy screening, foot examination and neuropathy were not available. This will need either the information about these parameters to be included in the electronic record or patient file audit to get information in any future study.
In conclusion, our study indicated that the ADA guidelines regarding checking of blood pressure, blood glucose, HbA1c, the use of antiplatelet, ACEI, ARBs and lipid lowering drugs were followed in majority of the cases. However, similar to other studies, we were not faring well regarding proteinuria screening and meeting the ADA targets for HbA1c, blood pressure control and LDL-C lowering, indicating that these standards are easy to preach than to practice. Further future studies are needed in Saudi Arabia with improved methodology to find out the reasons for this gap between guidelines and practice. There is also need for primary prevention of type-2 diabetes and its complications rather than the secondary prevention of established cardiovascular complications.
| Acknowledgement|| |
We thankfully appreciate Jamila Meyer and Marla Perez, secretaries of Department of Medicine for their support in preparing the manuscript and Arvin A. Santos, Graphics Designer, Postgraduate Training Center, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia, for his help with the graphics.
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Assistant Professor of Medicine, King Saud Bin Abdulaziz University of Health Sciences; Consultant, Division of Internal Medicine, Department of Medicine, King Abdulaziz Medical City P.O. Box 22490, Riyadh 11426
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]