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A Clinical Audit on Diabetes Care in Two Urban Public

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Article in Malaysian Journal of Medicine and Health Sciences · January 2010

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Malaysian JournalAofClinical
MedicineAudit
andon Diabetes
Health Care Vol.
Sciences in Two
6(1)Urban Public
January Primary
2010: Care Clinics
101–109 101

A Clinical Audit on Diabetes Care in Two Urban Public Primary

Care Clinics in Malaysia
1
SG Sazlina, 2AH Zailinawati, 1A Zaiton & 3I Ong
1
Department of Family Medicine, Faculty of Medicine and Health Sciences,
Universiti Putra Malaysia, Serdang, Malaysia
2
Klinik Keluarga, Kuala Lumpur, Malaysia
3
Klinik Ian Ong, Jalan Ampang, Kuala Lumpur, Malaysia

ABSTRACT
Introduction: The incidence of diabetes mellitus (DM) is increasing globally and it is
associated with significant morbidity and mortality. The importance of a better quality of
diabetes care is increasingly acknowledged. Objective: This clinical audit was conducted
to assess the quality of care given to type 2 DM patients in public primary care clinics.
Methods: A clinical audit was conducted in two selected urban public primary care clinics,
between April and June of 2005. The indicators and criteria of quality care were based on
the current Malaysian clinical practice guidelines for type 2 DM. A structured pro forma
was used to collect data. Results: A total of 396 medical records of patients with type 2
DM were included in this audit. Most of the patients had measurements of fasting blood
glucose and blood pressure recorded in more than 90% of the visits over the previous one
year. Twenty-seven percent of the patients had glycosylated haemoglobin (HbA1c) done
every 6 months with a mean of 8.3%. Only 15.6% had HbA1c values less than 6.5 %. Fifty
percent had blood pressure controlled at 130/80 mmHg and below; and 13.0% had low
density lipoprotein cholesterol values of 2.6 mmol/L or less. The majority of the patients
were overweight or obese. Conclusions: The quality of diabetes care in this study was
found to be suboptimal. There is a gap between guidelines and clinical practice. Certain
measures to improve the quality of diabetes care need to be implemented with more rigour.

Keywords: Clinical audit, primary health care, quality indicators, type 2 diabetes
mellitus, Malaysia

INTRODUCTION
Diabetes mellitus (DM) is one of the common chronic illnesses worldwide. In recent years,
there has been a global increase in the incidence of type 2 DM. In year 2000, 171 million
people suffered from diabetes globally.[1] It is estimated that the number would double by
the year 2030. The greatest increase is expected to occur in Asia and Africa. The increase in
incidence of DM in developing countries follows the trend of population growth, aging,
urbanisation and lifestyle changes.
Diabetes mellitus has become one of the major public health issues worldwide. [2] It is
associated with significant morbidity such as coronary heart disease, stroke and nephropathy
leading to increased mortality and healthcare cost to the patient and the community.[2,3,4]
There is increasing evidence that good glycaemic control and control of cardiovascular risk

*Corresponding author: Dr Zaiton Ahmad; Email: [email protected]

Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010
102 SG Sazlina, AH Zailinawati, A Zaiton & I Ong

factors prevent or delay complications of DM. [5, 6] This in turn would restore quality of
life.[7]
In Malaysia, the overall prevalence of DM has increased to 14.9% in 2006 from 6.3% in
1986, and 8.3% in 1996 among adults of age 30 years old and more. [8] In the year 2000,
diabetes mellitus was estimated to be the seventh leading cause of burden of disease in
Malaysia, accounting for 3.7% of total disability adjusted life years. [9] In addition, admission
to public hospitals due to DM has increased from 33,187 in 2002 to 39,358 in 2004. [10]
Some local studies conducted in both the tertiary and primary care level have
demonstrated that glycaemic control and the management of the associated cardiovascular
risk factors among patients with type 2 DM are poor.[11, 12, 13, 14, 15] Hence, there is a need to
evaluate the current practice on diabetes care especially in community based primary care
clinics. One of the methods to assess the management is through a clinical audit.
Clinical audit is a strategy that allows for gauging the quality of care on current
practice of a particular medical condition.[16] The quality of care is assessed against a
standard set of criteria recommended by clinical guidelines. It is a quality improvement
process that seeks to improve patient care and outcomes through systematic review of care
against explicit criteria and the review of change.
A clinical audit can be evaluated in the aspects of the structure of care (includes
quantity and the types of services available), process of care (what is done to the patient)
and outcome of care (the eventual results on an intervention or management).[17] These
indicators of care are selected and evaluated against overt criteria. Changes are implemented
when indicated and further monitoring is conducted to confirm improvement in the healthcare
delivery.
Primary care doctors have an important and challenging task in providing quality
management to patients with type 2 DM.[18] Therefore, a clinical audit was conducted to
assess the quality of care on type 2 diabetes mellitus patients attending community-based
public primary care clinics.

METHODS
A clinical audit was conducted in two selected community-based urban public primary care
clinics in the Klang Valley region, Malaysia between April and June of 2005. The public
primary care clinics served a minimum of 20,000 population each. [10] Patients with diabetes
were seen at the outpatient clinics. These clinics did not have designated days for follow-
up for patients with type 2 DM nor a diabetes care team to manage their patients. The
attending doctors reviewed the patients on the day of their follow-up. The staff in the
outpatient clinic comprises a family medicine specialist, approximately four medical and
health officers, two nurses and three medical assistants. The clinics had basic in-house
laboratory facilities required for the surveillance of glycaemic control and monitoring of
diabetic complications.
The indicators of quality care were determined after a discussion with the clinics’
doctors which were based on the current Malaysian clinical practice guidelines on the
management of type 2 DM.[19] The target level of performance for each of the indicators was
agreed at 80% as good performance, in accordance to the Primary Healthcare Quality
Assurance programme’s recommendation.[20]

Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010
 A Clinical Audit on Diabetes Care in Two Urban Public Primary Care Clinics 103

The indicators selected, represented the process and outcome measures of diabetes
care. The process measures of clinical care were defined as measuring fasting blood glucose
(FBG), blood pressure (BP) and calculation of body mass index (BMI) at every visit over
the previous one year. It was agreed that the glycosylated haemoglobin (HbA1c) levels
should be measured every six months and screening of lipid profile, fundoscopic and foot
examinations, and urine protein or microalbuminuria should be done annually. The clinical
outcome of diabetes care were defined as good control if the documented values were; FBG
< 6.1 mmol/L, HbA1c < 6.5 %, low density lipoprotein cholesterol (LDL-C) < 2.6 mmol/L, BP
< 130/80 mmHg and BMI < 23 kg/m2.
The records of patients with type 2 DM who visited the primary care clinics over the 3-
month period were reviewed using a systematic random sampling method. The records
were obtained from the respective clinic’s database. All patients diagnosed with type 2 DM
aged 18 years and above, treated and followed up regularly for at least a year with the clinic
were included in this audit. Patients with type 1 DM, newly diagnosed Type 2 DM (less than
6-month duration) and gestational DM were excluded from this audit.
A standard structured pro forma was used to document the secondary data of the
patients. The pro forma comprised the socio-demographic profile, duration of diabetes,
smoking status, past medical history including presence of comorbid illness (defined as the
presence of medical conditions such as hypertension, hyperlipidaemia, coronary artery
disease and others) and treatment history for diabetes. In addition, it also consisted of the
checklist for both process measures for diabetes care and the outcome of care.
Both verbal and written informed consents were obtained from the participating clinic
doctors and relevant authorities. Ethical approval was obtained from Universiti Putra
Malaysia Medical Research Ethics Committee. The data were analysed using the Statistical
Package for Social Science (SPSS) version 14.0. Kolmogorov-Smirnov test was done to test
the distribution of the data. Mean ± SD is used to describe normally distributed data; while
median ± IQR is used for data not normally distributed.

RESULTS
A total of 396 medical records of patients with type 2 DM which fulfilled the criteria were
reviewed. The demographic and clinical characteristics are presented in Table 1. The mean
age of the patients’ was 58.7 ± SD 10.6 years, ranging between 25 to 95 years of age. The
majority (57.6%) of the patients were females and 37.1% were of Chinese ethnicity.
Approximately 40.0% of the patients had concurrent hypertension. Most (95.2%) of the
patients were on oral hypoglycaemic agents, either on monotherapy or on combination
therapy.
The process measures of diabetes care are summarised in Table 2. FBG and BP
measurements were noted to be recorded in more than 90% of the visits over the previous
one year. However, only 109 (27.5%) of the diabetic patients had HbA1c done at six monthly
intervals.
Among those who had HbA1c done at six monthly intervals, the mean HbA1c was 8.3
± SD 1.9 % (95% CI between 7.9– 8.6); with 17 of 109 (15.6%) having HbA1c less than 6.5%.
The median fasting blood glucose was 8.3 ± IQR 4.3; 32.7% had FBG of 6.1 mmol/L and less.
One hundred and ninety nine of the 393 patients (50.6%) had BP of 130/80mmHg and less;

Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010
104 SG Sazlina, AH Zailinawati, A Zaiton & I Ong

Table 1. Demographic and clinical characteristics of patients with type 2 DM

(N= 396)

Variables Frequency (%) or

Mean/median ± SD/IQR

Age
Mean ± SD years 58.7 ± 10.6
< 50 years old 74 (18.7)
> 50 years old 322 (81.3)
Sex
Male 168 (42.4)
Female 228 (57.6)
Race
Malay 119 (30.1)
Chinese 147 (37.1)
Indians 126 (31.8)
Others 4 (1.0)
Smoking status
Current smoke 45 (11.4)
Ex-smoker 8 (0.2)
Never smoked 227 (57.3)
Not documented 116 (29.3)
Duration of diabetes (N = 396)
Median ± IQR, years 5.0 ± 7.0
< 10 years 284 (71.7)
> 10 years 112 (28.3)
Medical history (N = 396)
History of hypertension 150 (37.9)
History of hyperlipidaemia 28 (7.1)
History of comorbid illness
None 241 (60.9)
Presence of co morbid illness 155 (39.1)
Treatment received
Treatment for diabetes:
Lifestyle modifications alone 3 (0.8)
Oral hypoglycaemic agents (OHA) 374 (95.2)
OHA and insulin 19 (4.8)
Antihypertensive agents 161 (40.7)
Aspirin 31 (7.8)
Lipid lowering agents 30 (7.6)

Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010
 A Clinical Audit on Diabetes Care in Two Urban Public Primary Care Clinics 105

Table 2. Process measures of diabetes care (N= 396)

Indicators Frequency Percentage

Fasting blood glucose recorded at every visit 385 97.2

Blood pressure recorded at every visit 393 99.2
Body mass index recorded at every visit 195 49.2
HbA1c recorded every 6 months 109 27.5
Fasting lipid profile recorded annually 123 31.1
Urine protein/microalbuminuria recorded annually 34 8.6
Fundoscopic examination recorded annually 218 55.1
Foot examination recorded annually 219 55.3

Table 3. Clinical outcome of diabetes care

Variables Frequency (%) or

Mean/median ± SD/IQR

HbA1c (N = 109)
Mean ± SD, % 8.3 ± 1.9
HbA1c < 6.5% 17 (15.6)
HbA1c > 6.5% 92 (84.4)
FBG (N = 385)
Median ± IQR, mmol/L 8.3 ± 4.3
FBG < 6.1 mmol/L 126 (32.7)
FBG > 6.1 mmol/L 259 (67.3)
BP (N = 393)
Systolic BP, Median ± IQR , mmHg 130 ± 20
Diastolic BP, Median ± IQR, mmHg 80 ± 12
BP < 130/80 mmHg 199 (50.6)
BP > 130/80 mmHg 194 (49.4)
LDL-C (N = 123)
Median ± IQR, mmol/L 3.8 ± 1.2
LDL-C < 2.6 mmol/L 16 (13.0)
LDL-C > 2.6 mmol/L 107 (87.0)
Body mass index (N = 195)
Median ± IQR, kg/m2 26.9 ± 6.2
Normal (18.5 – 22.99 kg/m2) 35 (17.9)
Preobese (23 – 27.49 kg/m2) 75 (38.5)
Obese (more than 27.5 kg/m2) 85 (43.6.)

NB. SD = Standard deviation

IQR = Interquartile range

Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010
106 SG Sazlina, AH Zailinawati, A Zaiton & I Ong

while only 16 of 123 (13.0%) had LDL-C of 2.6 mmol/L and less. Among the 195 patients with
recorded weight and height, 160 (82.1%) had a body mass index (BMI) of 23 kg/m2 and more.
The clinical outcome of diabetes care is shown in Table 3.

DISCUSSION
The measurements of FBG and BP in the present audit were recorded in more than 90% of
the times, at every visit in the two clinics. These findings were comparable to another audit
done, which noted that measurements of FBG and BP done at every visit reached 83.5% and
83.3% respectively.[14] This could be due to these measurements been easily done during a
consultation with no added cost especially for the BP measurement.
The documentation on monitoring of BMI, HbA1c, lipid profile, fundoscopic evaluation,
foot examination, and urine protein or micro-albuminuria, as recommended by guidelines,
were less than 80%. These results are similar to a study done previously.[14] The issue of
higher cost in requesting laboratory tests (such as HbA1c, lipid profile and urine micro-
albumin) in primary care clinics as compared to the tertiary care centres, could have impeded
the provision of quality care by the doctors. The under-documentation of fundoscopic and
foot examinations in this study could be due to doctors not conducting these examinations
because they are time consuming.
In addition, the public primary care clinics, the patient load has increased tremendously
over the recent years. The overall attendance in the public primary care clinics has increased
from 23.1 million in 2003 to 25.4 million in 2005 [21] Therefore, with the increasing demand to
see large number of patients in a day and time constraints with limited manpower may have
contributed to the under prescription of the laboratory tests in the surveillance of glycaemic
control and cardiovascular risk factors.
In the present audit, glycaemic control was suboptimal. Among 109 (27.5%) of the
diabetes patients who had HbA1c done every 6 months, the mean HbA1c was 8.3 ± 1.9 %
and only 17 (15.6%) had good glycaemic control. These results are comparable to other
studies.[12, 15] In these two studies conducted at primary care facilities, it was found that
approximately 20% had HbA1c level of 7.0% or less. The possible reason for this could be
due to the under prescription of insulin therapy among primary care doctors, hence,
contributing to higher HbA1c levels.[22] In addition, patients’ suboptimal compliance may
also contribute to the low percentage of good glycaemic control.[15,23] Furthermore, the
patients may be inadequately educated to manage their illnesses.
The majority of the patients in this present audit did not achieve good BP control and
the recommended LDL-C levels. Fifty percent achieved targeted BP level in this audit as
compared to 24.5% in another study.[15] Only 13.0% had LDL-C of 2.6 mmol/L and less,
which was similar to that found in a study by Eid et al.[11] In the presence of multiple
cardiovascular risk factors in patients with diabetes, achieving recommended levels as in
the guidelines may be difficult despite using multiple medications due to the course of
disease progression.[24]
In this audit, most of the process of care and the outcome of care did not achieve the
target level of performance. The possibility of polypharmacy could create a problem with
treatment adherence which would have influenced the outcome of care. There is a need to

Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010
 A Clinical Audit on Diabetes Care in Two Urban Public Primary Care Clinics 107

improve the provision of care; which should involve the healthcare team, the patient and
families.[25, 26] The health delivery system of these clinics has to be evaluated to assure
effective and efficient clinical care. A trained multidisciplinary care team (which includes the
nurses and medical assistants) should be initiated with clear defined roles and duties; as
well as updating them on evidence-based care via continuous medical education.[25]
Implementation of a multidisciplinary team combined with arrangements for follow-up and
patient education has been shown to improve the process of care and outcome
measures.[27,28]
It is important to develop a good clinical information system by establishing a
comprehensive registry for diabetes patients in the clinics.[25, 26] This will allow a proactive
review on individual patient care; by providing timely reminders for needed services such
as their annual eye or foot examination and scheduled visits.[28] In addition, a clinical
information system can aid to track and plan care; for example, a staff could be designated
to be responsible for follow up needs such as the six monthly HbA1c measurement and the
annual assessment of eye examination and lipid profile.[29] An ongoing audit should be
done to confirm improvement in healthcare delivery following any changes implemented in
the care and this will facilitate performance monitoring and quality improvement efforts.[25,26]
In the management of chronic diseases, patients make decisions and engage in
behaviours that would influence their health. This in turn would affect the control and
outcome of their disease. Therefore, patients should be supported and empowered to manage
their health care. [25,26] However, for this to be successful, the emphasis is on the patients’
central role in their care and to foster a sense of responsibility for their own health. They
should receive basic information of their disease, taught the strategies for living with
chronic disease and given ongoing support from families and health care team. The health
care team should also receive training on self-management and skill building to facilitate
patients in achieving their goals.
In this audit, the retrospective nature of data collection was limited by the accuracy of
the data obtained from medical records, with the possibility of undocumented clinical
variables. Furthermore, the values of the laboratory tests could not be standardised in view
of different laboratory facilities utilised by the clinics.
In conclusion, this audit shows there is a gap between guidelines and clinical practice
in the provision of diabetes care. The quality of care was found to be suboptimal; however,
by motivating the primary care doctors via combinations of health care professional
education, audit and peer review, the quality of diabetes care in primary care setting could
be improved.

ACKNOWLEDGEMENTS
The authors would like to extend their gratitude to all the doctors and staff of the participating
clinics for their support and assistance in conducting this audit. They would also like to
thank the Petaling District Health Office for permission to conduct this audit.

Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010
108 SG Sazlina, AH Zailinawati, A Zaiton & I Ong

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Malaysian Journal of Medicine and Health Sciences Vol. 6 (1) January 2010

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