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Contents lists available at ScienceDirect

Primary Care Diabetes

journal homepage: http://www.elsevier.com/locate/pcd

Original research

Assessing variability in compliance with

recommendations given by the International

Diabetes (IDF) for patients with type 2

diabetes in primary care using electronic records.

The APNA study

a,∗ a b

Antonio Brugos-Larumbe , Pablo Aldaz-Herce , Francisco Guillen-Grima

a a

, Francisco Javier Garjón-Parra , Francisco Javier Bartolomé-Resano ,

a a

María Teresa Arizaleta-Beloqui , Ignacio Pérez-Ciordia , Ana María

a a c

Fernández-Navascués , María José Lerena-Rivas , Jesús Berjón-Reyero ,

a d

Luisa Jusué-Rípodas , Ines Aguinaga-Ontoso

a

Primary , Navarra Health Service, , Navarra,

b

Dept. of Health Sciences, Public , Preventive Medicine University of Navarra Clinic, IdiSNA

(Navarra Institute for Health Research), Pamplona, Navarra, Spain

c

Hospital Complex of Navarra, Navarra Health Service, Pamplona, Navarra, Spain

d

Dept. of Health Sciences, Public University of Navarra, Pamplona, Navarra, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Assess compliance with the IDF recommendations for patients with Diabetes

Received 4 May 2016 Type2 (DM2), and its variability, by groups of doctors and nurses who provide primary care

Received in revised form services in Navarre (Spain).

1 February 2017 Materials and methodologies: A cross-sectional study of a population of 462,568 inhabitants,

Accepted 15 June 2017 aged ≥18 years in 2013, attended by 381 units of doctor/nurse (quota). Clinical data were

Available online xxx collected retrospectively through electronic records.

Using cluster analysis, we identified two groups of units according to the score for each

Keywords: indicator. We calculated the Odds Ratio, adjusted for age sex, BMI, socioeconomic status

Diabetes mellitus and smoking, for complying with each recommendation whether a patient was treated by

Type 2 one of the quota from the highest score to the lowest.

∗

Corresponding author at: Centro de Salud de Villava. Plaza Miguel Indurain s/n, 31610 – Villava/Atarrabia, Navarra, Spain.

E-mail addresses: [email protected], [email protected] (A. Brugos-Larumbe), [email protected] (P. Aldaz-Herce),

[email protected] (F. Guillen-Grima), javier.garjon.parra@.es (F.J. Garjón-Parra), [email protected]

(F.J. Bartolomé-Resano), [email protected] (M.T. Arizaleta-Beloqui), [email protected] (I. Pérez-

Ciordia), [email protected] (A.M. Fernández-Navascués), [email protected] (M.J. Lerena-Rivas),

[email protected] (J. Berjón-Reyero), [email protected] (L. Jusué-Rípodas), [email protected]

(I. Aguinaga-Ontoso).

http://dx.doi.org/10.1016/j.pcd.2017.06.008

1751-9918/© 2017 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: A. Brugos-Larumbe, et al., Assessing variability in compliance with recommendations given by the International

Diabetes Federation (IDF) for patients with type 2 diabetes in primary care using electronic records. The APNA study, Prim. Care Diab. (2017), http://dx.doi.org/10.1016/j.pcd.2017.06.008

PCD-628; No. of Pages 11 ARTICLE IN PRESS

2 p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 7 ) xxx–xxx

Primary health care 30,312 patients with DM2 were identified: prevalence: 6.39%; coefficient of variation between

Variability in clinical practice UDN: 22.8%; biggest cluster 7.7% and smallest 5.3%; OR = 1.54 (1.50–1.58).

≤

Small-area analysis The HbA1c control at 8% was 82.8% (82.2–83.3) and >9% was 7.6% (7.3–8.0), with OR 1.79

(1.69–1.89) and 2.62 (2.36–2.91) respectively. Control of BP and LDL-C show significant differ-

ences between the clusters.

Conclusions: An important variability was identified according to the doctor treating patients.

The average HbA1c control is acceptable being limited in BP and LDL-C.

© 2017 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.

Europe and other countries. The extended use of computer-

1. Introduction

ized clinical records allows selected multivariate analyses of

both epidemiological data and quality of care or outcome of

Diabetes is a major public health problem because of its high

patients in charge of the local primary care system. Despite

morbidity and high prevalence. The International Diabetes

some limitations that may persist in the quality of data, the

Federation (IDF) estimated that in 2015 the European region

use of electronic records to evaluate the quality of care of type

had about 60 million diabetics aged between 20 and 79 years

2 diabetes is an increasingly accepted practice [18–21].

old, a prevalence of 9.1% (6.8–13.0), predicting an increase

In Spain the use of primary health care record for the detec-

to 10.7% (8.2–14.9) for 2040 [1]. The estimated prevalence for

tion of the prevalence of DM and cardiovascular diseases has

Spain in 2015 was 10.4% (8.2–14.7).

been validated [22].

People with diabetes have twice the cardiovascular risk

Our study is part of the Navarre Primary Care study (APNA

non-diabetics do [2] and in addition diabetes is associated

study) that uses electronic records of PC medical history files

with a significant premature mortality [3]. Although there is

and we intend to assess compliance by PC givers with the

evidence that early diagnosis and metabolic control reduce

recommendations proposed by the IDF for DM2 patients as

microvascular complications [4,5], it is not yet certain that

well as evaluate the variability among the health care centres

intensive control compared to standard control can have

providing the service.

a positive effect on macrovascular complications; it could

also be associated with an increased risk of vascular mor-

tality and severe hypoglycemia [6–8]. Identifying the basal

glycemia under fasting conditions as well as the glycosylated 2. Methods

hemoglobin are considered adequate tests for diagnosis [9].

The level of glycemic control in diabetic patients in Spain This study was conducted in Navarre, a community located

is acceptable [10], although controlling for cardiovascular risk in northern Spain, with a population, in December 2013, aged

≥

factors is low, especially in patients at high risk [11]. 18 years-old of 462,568 inhabitants (50.67% women). A pop-

More than 40 years since Wennberg and Gittelsohn [12] ulation group called “cupo” (quota) was assigned to a family

highlighted the significant variability in clinical practice not doctor and a nurse in PC. We analysed 381 quotas with an

±

justified by the health problems of the population, several average population of 1214 339.

studies have found that this variability can be seen regardless We analysed the 2013 electronic records showing clini-

of the country or health system being studied and occurs both cal variables that doctors or nurses registered in code during

in diagnostic, therapeutic or preventive services [13–15]. A sys- the consultation. Likewise, the analytical results electronically

tematic programme for preventive activities in primary care included in the medical history from laboratories were also

(PC) is available in Spain which is evaluated regularly, identi- collected. Variables related to diet, exercise or retinopathy or

fying variabilities between health centres [16]. However it is feet assessments were not included as they were not avail-

not known whether there is variability in the identification able in encoded form. The data were anonymized, and the

and control of diabetes. requirement for informed consent was therefore waived.

In the US, the National Health and Nutrition Examination

Survey (NHANES) assessed the degree of control of diabetes

and cardiovascular risk factors, and found that 30–50% of 2.1. Study variables

patients did not comply with the individualised objectives of

glycemic, blood pressure (BP) or lipid control, and more than Age, sex, health centre, quota, socioecomonic status, smoking,

20% continued to smoke [17]. Likewise in Spain the ENRICA type 2 diabetes diagnosis, weight (kilograms), height (metres),

2

study reported that 70.9% of DM2 have HbA1c at <7%, but only body mass index (BMI: weight/height ), waist circumfer-

21.9% maintain BP control of <130/80 mmHg [10]. ence (cm), systolic and diastolic blood pressure (mmHg),

The IDF proposes assessment indicators for the quality of basal glycemia (mg/dl), glycated hemoglobin (HbA1c: %),

care given to these people based on the best available evidence total cholesterol (mg/dl), HDL cholesterol (HDL-C: mg/dl), LDL

[9]. cholesterol (LDL-C: mg/dl), triglycerides (TG: mg/dl).

Cross-sectional studies of Social Security/NHS populations We assessed a selection of indicators proposed by the IDF

in Primary Care settings are common and widespread all over that were possible with the available coded variables [9].

Please cite this article in press as: A. Brugos-Larumbe, et al., Assessing variability in compliance with recommendations given by the International

Diabetes Federation (IDF) for patients with type 2 diabetes in primary care using electronic records. The APNA study, Prim. Care Diab. (2017), http://dx.doi.org/10.1016/j.pcd.2017.06.008