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DESPITE medication and guidelines to control diabetes, a majority of patients have poor control over blood pressure and cholesterol. Now, researchers at the All India Institute of Medical Sciences (AIIMS), the Public Health Foundation of India (PHFI), and the Rollins School of Public Health, Emory University, Atlanta, have found that a low-cost care, intervention treatment model can help patients double their likelihood of controlling diabetes.
For the study, published in the Annals of Internal Medicine, researchers analysed results from a trial conducted at ten clinical centres in India and Pakistan. They compared the effect of a multi-component, diabetes-focused quality improvement (QI) strategy against the usual care alternatives for heart patients with poorly controlled diabetes.
Nikhil Tandon, Professor and Head, Department of Endocrinology, AIIMS, the senior author for the publication, said the team compared the effects of multicomponent diabetes QI strategy (combining a non-physician care coordinator and decision-support electronic health record software) with the usual care in South Asia, where resources are limited and diabetes is prevalent.
Approximately 1,150 patients with diabetes and poor cardio-metabolic profiles were randomly assigned to either the multicomponent QI strategy or the usual care for two and a half years. Results suggested that patients in the QI strategy group were twice as likely to achieve combined diabetes care goals and larger reductions for each risk factor compared to the usual care.
“This was the first trial of comprehensive diabetes management in a low/middle-income country setting,” explains Tandon. “This intervention does not require new or expensive drugs, but instead it enhances a patient’s likelihood of managing their disease on their own by providing individualised support and enhancing the physician’s likelihood of being responsive.”
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Tandon explained that people with diabetes need to control blood sugar, cholesterol and blood pressure. There are medications for all three and standard guidelines to manage them; despite this, a majority patients with diabetes have poor control with blood pressure and cholesterol. It is this suboptimal standard of care which the intervention addresses — using the usual medication and a real life setting wherein the patients paid for their visits, consultations, medicine and tests. So this really targets improvement in care delivery at the clinic level. Though this study was done at tertiary care level, we have replicated it at community health centres (secondary care level) also, Dr Tandon further added.
“By better controlling their blood sugar, blood pressure, and cholesterol levels, our study offers a hope of reducing onset of diabetes complications like heart disease, eye disease, kidney failure, and amputations which are very common in people with diabetes in South Asia,” Dr D Prabhakaran, Vice President, Research and Policy, PHFI told The Indian Express.
“Since these findings are relevant to India and many other countries, further research will uncover whether this approach reduces diabetes complications such heart attacks, strokes, eye disease, kidney failure, and amputations in the long-term and to assess patients’ and providers’ views so that the intervention can be delivered more widely,” he added.
Of the 415 million people with diabetes worldwide, 75 per cent live in low/middle-income countries. India alone is home to the second highest number of people with diabetes (nearly 70 million) worldwide. Tandon quoted a DiabCare India study (2011) to state that a proportion of patients with diabetes in India are currently not able to maintain desired blood sugar profiles. The 2011 study had showed that mean HbA1c (a measure of average control over 3 months) was 8.9 per cent in the country, with less than 20 per cent of people meeting the glucose target of 7 per cent.
A similar study conducted a decade earlier had shown that about 75 per cent of people attending diabetes clinics had an HbA1c at 7 per cent, a clear indication that glucose control is poor and that there have been no major improvement over the last 10-15 years.
He further reiterated that it was a quality improvement strategy in which the intervention is a composite of a non-physician care coordinator (akin to a community health worker – but stationed in a clinic and a decision support software which is embedded on a platform provided by an electronic health record.