Our study found that with regard to process measures, these were generally well met in the study period 2008–2010, and the adherence rate for process measures was exceptional, as reflected by the high NWPOC score.
Our findings on the proportion of people with T2DM having their measurements performed at least once annually within one year of follow-up for the study period are comparable if not higher with other studies carried out in the Gulf region,16,22–24
and Western countries.6
The management agreement signed in 2006 with Johns Hopkins Medicine International and Health Authority Abu-Dhabi (HAAD) and the increment in the number of departmental audits might be some of the reasons helped in improving the process of diabetes care in the centre.
Despite the high rate of testing in this study, sub-optimal management of glucose and SBP was present; more than 50% of the study population did not achieve the desirable targets for the HbA1c and SBP in the following years: 2008, 2009 and 2010. For instance, in 2010, only 41% achieved the target of HbA1c and 47% meet the target of SBP. This finding reveals that excellent performance on process of diabetes care does not essentially translate into good metabolic control.6
In 2010, however, high rates of achievements of the DBP and LDL goals were found (73% versus 72%, respectively).
We noted that for outcomes of glycaemic and SBP control, similar results are reported for other countries in the region, such as the Co-operation Council for the Arab States of the Gulf (GCC),16,22–24,26–28
Nevertheless, comparing our findings with some studies carried out in other GCC countries (e.g. for glycaemic control23,28
and BP control29
) the control of glucose and BP in this setting tends to be better. Still, high rate of blood pressure target achievement was attained in 83% of the sample of Afandi et al.
the small sample (30 subjects) could be one of the reasons for this high achievement rate.
Comparing the findings with studies carried out in developed countries at various levels of healthcare, our results were consistent with a number of their findings. For instance, only 37% of the people with diabetes that participated in the NHANES 1999–2000 survey achieved the required target of HbA1c (<7%), and only 35.8% of participants reached the target of systolic blood pressure ≤130/80 mmHg.30
In the UK, the target of HbA1c (≤7.5%) was achieved only in 43–48%, and the target of blood pressure (<140/85 mmHg) was achieved in 36–59%. In addition in the Netherlands, the goal of blood pressure 135/85 mmHg was achieved only among 20% of participants.31
Notably, lipid control findings were equivalent with studies carried out elsewhere.16,24
Also noteworthy was that participants in this study attained the target of LDL more successfully compared with people with diabetes in other Arab countries.10,16,23,24,32
Our findings revealed variation in diabetes outcomes of care between younger and older patients. Compared with older individuals, younger (<40 years old) patients do not have as good HbA1c profiles, and hence better glycaemic control was more common among people aged 40 and above. Although there were no significant differences of blood pressure level across age groups, during the three years, the proportion of those that reached the target was consistently higher in the younger age group than that of the older age group. Our findings concur with previous research that addressed the association between ageing and improved glycaemic control,33–35
but an increment in the hypertension rate.36
In summary we found that glycaemic and lipid control tend to be similar between sexes, in line with studies carried out elsewhere;13,33
still in this study, men had a slightly higher proportion of reaching the ADA targets. Unlike some other studies8,37
that found women less successful in achieving the target goal for blood pressure, women performed better than men in this study on reaching the target of blood pressure, especially for the SBP in 2009 and 2010.
We note an encouraging progress with regard to intermediate outcomes of diabetes control including glycaemic and lipid between 2008 and 2010. This finding is in line with the progress in the developed countries such as UK and USA.3–5
The UAE is following several objectives of the national strategy for the control of diabetes. Actions proceeding to implement two of these objectives are: (1) support continuous monitoring and evaluation of diabetes care and (2) improving and promoting the quality of diabetes care at three levels of healthcare system might help in improving both the process and outcomes of diabetes care in healthcare providing centres in the UAE.38
The multilevel model showed that there is an increment in the levels of SBP/DBP in individuals who had been prescribed pharmacological medications to regulate blood pressure. Similar results were found by Youssef et al
in Egypt, as patients who were prescribed antihypertensive drugs had about 11 and 3 mmHg higher points in their S/DBP than those non-prescribed. Several reasons can contribute to the poor S/DBP control among this group, and might be related to the disease process itself39
and to ‘reverse causation’ (i.e. patients on medication had higher blood pressure measurements to start with). There is also evidence which supports the important role of patient's related factors such as understanding of hypertension and its complications, and the importance of adherence to treatment.40
Complete investigation for the association between these variables was not performed in this study; however, non-adherence to the treatment is proposed to be one of the causes. Non-adherence is a common problem in all chronic conditions; principally it is problematic in T2DM and blood pressure due to the complexity of treatment regimens, including the use of combined drugs and the life-long duration of the disease.41
The Canadian Coalition for Blood Pressure Control documented a non-compliance rate of 50% in its report.42
As evidence showed that non-adherence to hypertension medications in T2DM is common; identifying variables that influence people with T2DM adherence to medications is essential.
‘Clinical inertia’, an issue associated with healthcare professionals, was also suggested to be another reason not only for this paradox, but also for the sub-optimal control of HbA1c and blood pressure in this study. Phillips et al.43
have defined clinical inertia in the comprehensive review they carried out as a failure of the healthcare professionals to initiate or optimize therapy when indicated. Therefore, for people with uncontrolled blood pressure who are already on pharmacological treatment, regular review for the drugs prescribed is essential. More research should focus on clinical inertia and the pattern of drug usage and their correlation with metabolic control in the UAE.
Implications of the study
This study provides useful baseline data about the quality of T2DM care in a diabetes centre, at a tertiary healthcare setting in Al-Ain. Results from this study are comparable with other studies elsewhere; however, there is still scope for further improvement.
Identifying differences in diabetes care provided to different age groups and gender demonstrated in the study would assist healthcare professionals, and policy planners and makers in addressing the problem and planning for quality improvement enterprises. It is worrying that younger Emirates with T2DM had worse glycaemic control than older patients; given that the risk for both micro and macrovascular complications over a long period of time would increase. Hence, further investigation for the sub-optimal outcome of care among this group is needed to optimize the care provided.
As diabetes management relies on great extent on the patient's lifestyle, the use of interventions that are multifaceted and holistic in approach would be helpful in addressing the underlying causes of unhealthy lifestyle among people with diabetes.44
For instance, educational interventions targeting the young population should be realistic, non-judgemental and focus on coping strategies.44
At the diabetes centre level, supporting, monitoring and evaluation of the diabetes care are highly recommended to tackle any difference in care and to improve and promote the quality of diabetes. As more than 70% of the UAE population is composed of expatriates that come from all over the world, future research should target this group as well, to investigate the quality of diabetes care and optimize its management.
There are limitations to our study, principally that the analysis was performed at a single centre in the Al-Ain. The results of this study, however, are likely to be representative of care provided in other diabetes centres in Al-Ain, given the similarity in organizational structure, followed guidelines, physician training and similar patient characteristics. Another caveat is the use of medical records to assess the care provided to people with T2DM that depend on the quality of documentation and might not necessarily reflect the actual care delivered or outcomes.
Data on body mass index (BMI), patient's experience of their care and quality of life was not possible to collect in this study; therefore, they were not included in the statistical analysis. Studying the association between variables such as BMI and outcome of T2DM care is essential; hence we recommend future studies to consider investigating this association.
Our results also stated that there was worse blood pressure control among people with T2DM, who had been prescribed both anti-blood pressure drugs, were limited by lack of detailed information on: individual drugs, the cumulative doses and duration of treatment of each drug as they can interact with other factors influencing blood pressure control. Meanwhile, for people with T2DM with poor metabolic control, there is a call for reviewing the drugs profile and putting emphasis on improving the patients’ adherence on drug use in the centre.