This study reports for the first time the level of control of CVD risk factors in patients with T2DM in Oman. It shows that in such patients, hyperglycaemia, hypertension, and dyslipidaemia are poorly controlled despite universally free medical care including free medication and patients seeing their local physicians almost every 2 months. Only a minute fraction (0.2%) of patients in our study attained currently recommended levels of control for hyperglycaemia and other CVD risk factors. An earlier report suggested this figure to be 2.4% [15
]. Although most patients are consulted, on average, 6 times annually, we found no significant relationship between the number of OPD visits and level of HbA1c (p
= 0.83; data not shown). This illustrates the urgent need for more emphasis on patient education, in particular including DM health educators to PHC teams.
Compared with a similar study conducted in 2005 involving 430 diabetic patients in Muscat, the capital city of Oman [15
], our study shows higher proportions of patients reaching recommended HbA1c level (30 vs
24%) and favorable lipid profile (total cholesterol 55 vs
40%; LDL-C 25 vs
15%; and HDL-C 49 vs
41%). The improved glycaemic control and lipid profile in our study could be attributed to a policy decision made in 2006, when insulin, statins and BP lowering drugs were made widely available in all PHC centers throughout Oman instead of only being prescribed by physicians in secondary and tertiary hospitals.
Hypertension is associated with DM, and may be related to underlying diabetic nephropathy or to coexisting essential hypertension [16
]. In our study only 25% of patients were at goal (<130/80 mmHg) for optimal BP control compared with 48% reported by Al-Mandhari et al
]. The difference could partially be attributed to the fact that the former study covered a larger national sample while the latter covered only 1 region in the capital, Muscat. Control of hypertension remains a challenge in both developing and developed nations. The mean BP in the United States has decreased from 138/73 mmHg in 1994 to 135/71 mmHg in 2000, and in Sweden (from 141/77 mmHg in 2005 to 136/76 mmHg in 2009) [17
]. Over the same periods, <38% of patients in the US and 54% in Sweden reached goal (<130/80 mmHg and ≤140/90 mmHg, respectively).
Microalbuminuria independently predicts traditional risk factors and CVD mortality and events in patients with DM [19
]. An earlier study of microalbuminuria of patients with DM attending a university hospital in Oman reported the prevalence of incipient nephropathy to be 27% [20
]. Our study, covering primary care centres, shows higher figure (37%) similar to rates reported from Saudi Arabia (41%) and India (36%) [21
]. Over a decade ago, the incidence of end-stage renal disease (ESRD) in Oman was reported to be ~120 per million inhabitants annually with 14.5% of cases attributed to DM [23
]. This is likely to have increased since the number of renal dialysis units and patients in Oman have more than doubled from 10 units with 345 patients in 1998 to 17 units and 872 patients in 2009 [24
]. With current prevalence rates of DM, the burden of ESRD attributable to DM in Oman is likely to have increased to rates comparable to Jordan (29%) if not more [25
]. If current trends continue, Oman could expect a costly epidemic of ESRD over the next decades.
Despite compelling evidence, over the past 2 decades, from various randomized clinical trials [3
] on the benefit of controlling hyperglycaemia and CVD risk factors in the prevention of microvascular and macrovascular complications of DM, the control of DM and associated risk factors remains poor in developed and developing countries alike. In an analysis of the National Health and Nutrition Examination Survey III (NHANES III) (1988-1998) compared to NHANES I (1999-2000) surveys, Saydah and colleagues [17
] found the proportion of people with good glycaemic control (HbA1C <7%) to have declined from 44 to 37% respectively. In Australia, HbA1c control levels varied from 38% in general practice to 57% in specialist DM clinics [26
], and in Finland, glycaemic control levels were as low as 25% [27
]. HbA1c figures comparable to ours were reported from United Arab Emirates (31%) and Lebanon (28%), while lower figures were reported from Saudi Arabia (20.6%), Kuwait (13%) and Bahrain (11.2%) [28
Based on evidence from randomized clinical trials, various clinical guidelines recommend cut-point values for optimal levels of glycaemia, BP and lipids for patients with DM in order to prevent or delay microvascular and macrovascular complications. Yet optimal control of glycaemia, BP and lipids remain under 50% at best. Several factors have been cited to influence quality of care for people with DM, and could be divided into 3 types [33
, patient-related factors include patient demographics and their lifestyle including diet, physical activity and compliance with medication. Second
, physician-related factors, including training, education and financial incentives for health professional to acquire self-confidence and overcome “clinical inertia” (the failure to initiate or advance therapy in a patient who is not at the evidence-based treatment goal) [34
]. Alberti et al
found physicians “motivation” to be significantly associated with better quality of DM care in Tunisia [33
]. However, the subjective nature of the term “motivation” makes it difficult to standardize. Third
, health system-related factors that could influence DM care. Al-Azri et al
] identified several such factors in PHC setting in Oman including shortage of Arabic language speaking nurses; unavailability of some anti-diabetic medications and educational materials; lack of continuity of care (seeing different physician over time), and unavailability of laboratory results to physicians even 2 weeks after ordering blood tests.
There have been some questions as to whether the low glycaemic control goals for patients with T2DM (such as HbA1c 6.5 to 7%) is evidence-based or warranted. For, findings from several clinical trials, regarding tight glycaemia are inconclusive, estimates of favorable effects were imprecise due to low rate of complications and at times contradictory [36
]. For example, the UKPDS trial [37
] has shown that tight glycaemic control significantly reduces all-cause and CVD mortality. In contrast, the ACCORD trial has shown that compared with standard therapy, the use of intensive therapy to target normal HbA1c levels for 3.5 years increased mortality and did not significantly reduce major cardiovascular events in patients with T2DM [38
]. Proponents of less tight control advocate for a balanced approach where risk of complications (hyperglycaemia and death) in addition to non-compliance, social and financial burdens are considered [36
]. They propose to keep HbA1c between 7 to 7.5% with estimated average glucose in the range of 8.5 to 9.5 mmol/l for most patients.
Accurate documentation of data in DM care is vital to continuity of care. Our study shows lack of documentation in medical records ranging from 11 (BP) to 64% (albumin-to-creatinine ratio). Unrecorded variables related to DM care were in the range of 19 to 50% in 3 health centers in Egypt [39
] and 20 to 70% in 52 general practices in the Netherlands [40
]. The transition from paper run to electronic health records is currently underway in all PHC centers in Oman and is expected to improve quality of care monitoring and evaluation of risk factor control for patients with T2DM as shown elsewhere [41
In conclusion, control of hyperglycaemia and other CVD risk factor appears to be suboptimal in Oman. Addressing health system components such as providing medical staff training, incentive to health professionals and better patient education may improve quality of DM care in Oman.