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 Table of Contents  
Year : 2018  |  Volume : 4  |  Issue : 1  |  Page : 26-29

An observational study for assessment of point-of-care management received by diabetic patients before referral to a tertiary care hospital

Department of Medicine, Midnapore Medical College, Medinipur, West Bengal, India

Date of Submission17-Nov-2017
Date of Acceptance23-Dec-2017
Date of Web Publication25-May-2018

Correspondence Address:
Gouranga Santra
Block - P, Flat No. 306, Binayak Enclave, 59 Kalicharan Ghosh Road, Kolkata - 700 050, West Bengal
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrsm.jcrsm_65_17

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Introduction: Quality of diabetes care is suboptimal worldwide and it varies in rural and urban areas. Indian studies assessing the quality of diabetic care are few. We conducted a study to identify the gap in diabetes management as rural patients received before referral to a tertiary care hospital.
Methods: The study was conducted over 2 years in our institution. Rural patients managed previously outside our institution were included in the study. Patients were interviewed for treatment history. Prescriptions and related documents were evaluated for basic examinations, investigations, proper advices, and management processes.
Results: A total of 352 diabetic patients were evaluated. Blood pressure (BP) checkup was more regular than blood sugar monitoring (91% vs. 58%). Glycosylated hemoglobin was monitored rarely (2%). Eye checkup (2%), screening of neuropathies (7%), autonomic features (3%), electrocardiography (11%), and lipid screening (9%) were infrequent. Urine microalbumin-creatinine ratio was checked rarely (1%). Advice on diet (62%), exercise (56%), smoking cessation (15%), and foot care (2%) were suboptimal. Usages of insulin, oral hypoglycemic agents (OHA), and antihypertensive agents were suboptimal. Only 86 cases (29%) out of 295 with indications of OHA got adequate dose of OHAs and only 5 cases (9%) out of 57 cases with indications of insulin got adequate dose of insulin. Among diabetic hypertensives (115 cases), only 19% got adequate dose of antihypertensives.
Conclusion: Diabetic patients were managed inadequately. The study provides data for developing interventions for improving the quality of diabetes care of rural patients outside the tertiary care setup.

Keywords: Blood pressure, eye examination, glycosylated hemoglobin, insulin, microalbumin-creatinine ratio, neuropathy

How to cite this article:
Santra G. An observational study for assessment of point-of-care management received by diabetic patients before referral to a tertiary care hospital. J Curr Res Sci Med 2018;4:26-9

How to cite this URL:
Santra G. An observational study for assessment of point-of-care management received by diabetic patients before referral to a tertiary care hospital. J Curr Res Sci Med [serial online] 2018 [cited 2022 Nov 29];4:26-9. Available from: https://www.jcrsmed.org/text.asp?2018/4/1/26/233202

  Introduction Top

Quality of diabetic care is suboptimal worldwide. Quality of care varies in rural and urban areas. It may vary even in different rural areas depending on the local health-care facilities and prevailing barriers.[1] Assessment of the quality of diabetic care in an area can help to draw attention to the need for improving diabetes management in the specific area. Indian studies assessing the quality of diabetic care are very few.[2],[3],[4] We conducted a study to identify the gap in diabetes management of rural patients before attending the outpatient clinic of a medical teaching institution.

  Methods Top

We conducted the study in outpatient clinic of our institution over 2 years. Our institution is situated amid the rural area of the western part of West Bengal. A majority of patients come from the surrounding rural areas. Type 2 diabetes mellitus (T2DM) patients coming from rural areas and managed previously outside our institution were included in the study. Newly detected T2DM patients at our clinic were excluded from the study. Patients with type 1 diabetes mellitus and gestational diabetes mellitus were excluded from the study. The purpose of the study was explained to the patients and informed consent was taken.

Patients selected for the study were interviewed. Interview included basic demographic data. Patients were asked regarding their treatment history. Prescriptions and related documents were evaluated. Evaluation was done for basic examinations, investigations, proper advice, and management processes. Patients were asked regarding their participation in any patient education program.

Parameters evaluated were regularity of testing of blood sugar and glycosylated hemoglobin (HbA1c) levels; regular blood pressure (BP) measurements; dilated eye examination; screening for neuropathy and autonomic features; urine routine and microscopic examinations; urine microalbumin-creatinine ratio (ACR); serum urea and creatinine levels; lipid screening; electrocardiography (ECG); advice regarding diet, exercise, smoking cessation and foot care; antihypertensive, oral hypoglycemic agent (OHA); and insulin usages.

Screening for neuropathies included loss of joint position and vibration senses, proximal neuropathies, or cranial nerve palsies. Screening of autonomic features included postural fall of BP, heart rate variability on maneuvers (deep breathing and standing), and presence of impotence. Blood sugar testing was considered regular if it was done at least once in a month, and for HbA1c, it was once in 6 months.

For OHA, insulin and antihypertensive medication, assessment was done for no usages despite indications, inadequate doses, or improper uses. For this purpose, BP and blood sugar levels (fasting and postprandial) of the patients were checked during our study. Patients were asked regarding sites and methods of insulin injection.

All procedures followed were in accordance with the ethical standards of responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2010.

Statistical analysis

Percentages, mean values, and standard deviations are used to describe data. GraphPad QuickCalcs online statistical calculator (GraphPad Software Inc., La Jolla, California, USA) was used for data analysis (http://www.graphpad.com/quickcalcs).

  Results Top

[Table 1] shows the demographic profile of the study patients. A total of 352 patients of T2DM were included in the study. Majority were from lower socioeconomic class (248 patients [70.45%]). Education was below graduation in the majority (246 patients [70%]). Agriculture was the major occupation (296 patients [84%]). The mean duration of diabetes after detection was 5.35 ± 2.86 years.
Table 1: Demographic profile of the patients

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[Table 2] shows the frequency of patients (both numbers and percentages) with proper clinical checkups, investigations, and advice given to them. BP checkup was more regular than blood sugar monitoring (91% vs. 58%). HbA1c level was monitored very rarely (2%). Eye checkup for retinopathy (2%), screening for neuropathies (7%) and autonomic features (3%), ECG (11%), and blood lipid screening (9%) were infrequent. Although urine routine examination was done in >20% patients, urine ACR was checked very rarely (1%). Advice regarding diet and exercise were given in more than 50% cases. However, advice on smoking cessation was rare (15%). Foot care was neglected (2%). Participation in health education programmes was nil.
Table 2: Frequency of patients with proper clinical checkup, investigations, and advices (n=352)

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Among diabetic hypertensives (n = 115), 39 patients (34%) were not getting any antihypertensive treatment, 54 patients (47%) were getting a lower dose, and only 22 patients (19%) got adequate dose. In patients with indications for OHA (n = 295), 83 patients (28%) were getting no treatment, 127 patients (43%) were getting inadequate doses, and 85 patients (29%) got adequate doses. Out of 57 patients with indications for insulin, 45 patients (79%) were getting no insulin, 7 patients (12%) were on an inadequate dose, 5 patients (9%) were getting an adequate dose, and 18 patients (32%) followed improper methods of insulin injection. Out of 32 cases with lipid screening, 9 cases (28%) showed hyperlipidemia (raised low-density lipoprotein [LDL] and/or triglyceride levels), but only four cases (12.5%) were on hypolipidemic drugs. Out of 39 cases with ECG screening, ischemic changes were reported in 7 cases (18%), but only 3 cases (8%) were on antiplatelet therapy (aspirin).

  Discussion Top

The status of diabetes control in India is far from ideal.[2],[5] Frequency of uncontrolled and undiagnosed diabetes is very high in different parts of India.[6],[7]

Quality of diabetic care in rural West Bengal was found to be worrisome. BP was monitored more frequently than other parameters as seen in other studies.[8],[9] Initial changes in the retina have no bearing on vision, so ophthalmology consultation was neglected. ECG and lipid screening were performed infrequently despite the high risk of lipid abnormalities and cardiac disorders in diabetic patients. Doctors relied very rarely on HbA1c for dose adjustment. For assessing nephrological complications, routine urine examination (20%) was performed uncommonly; however, it was more frequent than serum urea and creatinine level assessment (12%). Urine ACR as a marker of early renal involvement was assessed infrequently (<1%). Blood sugar monitoring was not regular in more than 40% patients advice regarding diet and exercise were given more importance than smoking cessation though smoking is a major cardiovascular risk factor, especially in diabetic patients, and like diet and exercise, smoking also needs more attention. Usages of antihypertensive, OHA, and insulin were suboptimal. Usages of hypolipidemic drugs and antiplatelets were also suboptimal. Foot infection and amputation rates are higher among rural than urban patients.[10] However, foot care was neglected in our study patients. Eye examination and foot care advice were much lower than other Indian studies.[2],[4],[8],[9] Frequency of ECG testing was also low in comparison to other studies.[2],[4] Comparable data are not available for neurological screening investigations and advice of lifestyle and medicines from the Indian studies.[2],[7],[8],[9]

Nagpal and Bhartia in a Delhi-based study among urban diabetics from middle- and high-income groups found that only 13%, 16.2%, 32.1%, and 3.1% of patients had undergone HbA1c estimation, eye examination, serum cholesterol testing, and foot examination, respectively, in the last year.[4] In another study, diagnostic tests for complications were requested in 17.6% patients for eye examination, 5.6% for kidney function tests, and 4.2% for lipid tests. BP was checked in only 43.4% at the time of diagnosis.[8] A study from Bangalore revealed that BP was the only parameter regularly monitored in majority (93%) of the diabetics. Hb1AC, LDL cholesterol, and eye examination were less common and done in 40%, 52.6%, and 56.8% of diabetics, respectively.[9] Indicators of diabetic care in our study are worse than above studies possibly because of poverty and rural location.

The DiabCare Asia-India study conducted over 1 year in the late 1990s among urban Indian diabetics from 26 participating centers provided information of patient characteristics and quality of care provided to them. Approximately half of the diabetic population had poor glycemic control (HbA1c >2% above upper limit of normal and fasting blood glucose >139 mg/dl) and lipid control was suboptimal. Frequency of self-monitoring was low. Only 4% of patients were on diet therapy.[2] While this was mainly an outcome-based study, ours is a process evaluation study. However, both indicate suboptimal quality of diabetic care.

A large part of diabetic care lies with patients. Hence, patient education programmes are important. The Chennai Urban Rural Epidemiology Study-9 showed that awareness and knowledge regarding diabetes and its complications are grossly inadequate in Chennai.[11] In our study, patients' participation in patient education programmes was nil. Patient education programmes were not arranged in the area at all.

Different Indian studies assessed the barriers of diabetic management and strategies to remove the barriers. Rao et al. in a multistage cluster sample survey throughout India in 2004 found that self-reported diabetes at lower socioeconomic groups is very low due to unawareness of the disease and lack of access to medical care.[12] Knowledge of diabetes is lower among rural people.[13] Low awareness leads to delayed recognition of complications.[14],[15] The need for lifelong medication, limited availability of antidiabetic medications in the public sector, and higher cost in private sector are responsible for treatment noncompliance.[14] Lack of financial affordability, health insurance, and poor public health-care infrastructure in rural India are important factors.[16] Barriers to insulin therapy are prevalent in Indian population. The IMPROVE Control India study revealed that in most diabetics, insulin therapy is delayed until it was absolutely necessary or when the HbA1c levels reached approximately 9%.[17] Poor awareness among physicians, and western guidelines being not applicable to Indian patients are also important barriers to diabetes management.[18] As the barriers are well known, identifying the gaps in diabetic care in an area will help to prevent and control diabetes and its complications.

Our study has some limitations. Assessment was done only in patients who attended the clinic. It is a hospital-based study and does not represent the community as a whole. To maintain simplicity of the study, it was not possible to include all the parameters of diabetic evaluation and management in the study. Our study is a small one. A larger study will give more information.


Inadequate management of chronic diseases is called “clinical inertia.” It is common in diabetic patients. Our patients were also evaluated and managed inadequately. However, the study provides benchmark data for developing interventions targeted at patients, health-care workers, and health-care infrastructure providers for improving the quality of diabetes care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Baruah MP, Pathak A, Kalra S, Das AK, Zargar AH, Bajaj S, et al. A revisit to prevailing care and challenges of managing diabetes in India: Focus on regional disparities. Indian J Endocrinol Metab 2014;18:254-63.  Back to cited text no. 1
Raheja BS, Kapur A, Bhoraskar A, Sathe SR, Jorgensen LN, Moorthi SR, et al. DiabCare Asia – India study: Diabetes care in India – Current status. J Assoc Physicians India 2001;49:717-22.  Back to cited text no. 2
Ramachandran A, Mary S, Sathish CK, Selvam S, Catherin Seeli A, Muruganandam M, et al. Population based study of quality of diabetes care in Southern India. J Assoc Physicians India 2008;56:513-6.  Back to cited text no. 3
Nagpal J, Bhartia A. Quality of diabetes care in the middle- and high-income group populace: The Delhi Diabetes Community (DEDICOM) survey. Diabetes Care 2006;29:2341-8.  Back to cited text no. 4
Joshi SR, Das AK, Vijay VJ, Mohan V. Challenges in diabetes care in India: Sheer numbers, lack of awareness and inadequate control. J Assoc Physicians India 2008;56:443-50.  Back to cited text no. 5
Kanungo S, Mahapatra T, Bhowmik K, Mahapatra S, Saha J, Pal D, et al. Diabetes scenario in a backward rural district population of India and need for restructuring of health care delivery services. Epidemiol 2016;6:224.  Back to cited text no. 6
Menon VU, Kumar KV, Gilchrist A, Sugathan TN, Sundaram KR, Nair V, et al. Prevalence of known and undetected diabetes and associated risk factors in central Kerala – ADEPS. Diabetes Res Clin Pract 2006;74:289-94.  Back to cited text no. 7
Bjork S, Kapur A, King H, Nair J, Ramachandran A. Global policy: Aspects of diabetes in India. Health Policy 2003;66:61-72.  Back to cited text no. 8
George CE, Mathew S, Norman G, Mukherjee D. Quality of diabetic care among patients in a tertiary care hospital in Bangalore, South India: A Cross-sectional study. J Clin Diagn Res 2015;9:LC07-10.  Back to cited text no. 9
Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R. Urban-rural differences in the prevalence of foot complications in South-Indian diabetic patients. Diabetes Care 2006;29:701-3.  Back to cited text no. 10
Mohan D, Raj D, Shanthirani CS, Datta M, Unwin NC, Kapur A, et al. Awareness and knowledge of diabetes in Chennai – The Chennai urban rural epidemiology study [CURES-9]. J Assoc Physicians India 2005;53:283-7.  Back to cited text no. 11
Rao KD, Bhatnagar A, Murphy A. Socio-economic inequalities in the financing of cardiovascular & diabetes inpatient treatment in India. Indian J Med Res 2011;133:57-63.  Back to cited text no. 12
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Venkataraman K, Kannan AT, Mohan V. Challenges in diabetes management with particular reference to India. Int J Diabetes Dev Ctries 2009;29:103-9.  Back to cited text no. 14
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  [Table 1], [Table 2]


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