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Title: Pharmaceutical care in management of type-2 diabetes and primary prevention of cardiovascular disease with risk analysis of developing cardiovascular events
Author: Diab, Mohammad Issam
Awarding Body: University of Strathclyde
Current Institution: University of Strathclyde
Date of Award: 2012
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Aim: To identify the needs for improved levels of care provided to patients with type-2 diabetes in Qatar with a special focus on cardiovascular disease (CVD) prevention. Subjects and Settings: 305 patients attending the diabetes clinic in Hamad General Hospital, Qatar, from 2010-2011, all having type-2 diabetes and no history of CVD. Patients' medical records accessed from medical files manually and electronically. Methods: a) 38 criteria medication assessment tool (MAT) designed from recommendations on the management of type-2 diabetes and combined with recommendations relevant to primary prevention of CVD. The MAT was validated by a group of researchers and practitioners and field tested. Levels of applicability and adherence to each criterion and for each patient were calculated individually and the overall adherence determined. Areas needing improvement were identified and patients' clinical factors associated with prescribing adherence were studied b) Patients' 10 year risk estimates of developing any coronary heart disease (CHD), fatal CHD, any stroke and fatal stroke obtained using the type-2 specific CVD risk calculator from the UK Prospective Diabetes Study (UKPDS risk engine). Patients were defined to be at 'high' risk if estimates were 15%. The association between each risk factor within the risk calculator and being at a higher risk of developing CVD was studied and used to target patients for a designed pharmaceutical care plan. Levels of care provided to patients at higher risk of developing CVD were also assessed and used to address care issues to achieve effective CVD risk reduction in clinical practice. Results a)- The MAT was applied to the whole study sample (11590 assessed criteria in 305 patients). Application of the MAT identified 18/38 criteria with high levels of adherence (80%), 10/38 criteria with intermediate levels of adherence (50%; <80%) and 10/38 criteria with low levels of adherence (<50%). The over patients was 68.1% (95% CI: 67, 69; n= 6657 applicable criteria). Insufficient documentation to assess care was found in 1.1% (95% CI: 0.9, 1.4; n=74) of the applicable criteria. Total non-adherences were found in 30.7% (95% CI: 30, 32; n=2049) of the applicable criteria in which only 5.8% (95% CI: 5, 7; n=118) had a documented justification. Consequently 94.2% (95% CI: 93, 95; n=1931) had unjustified non-adherence and indicated a need for inclusion in a treatment review through an appropriate pharmaceutical care plan. Adherence using the individual patient as the unit of analysis (MAT adherence per patient) revealed that prescribers adhered to < 70% of the applicable criteria in 50.5% (95% CI: 45, 56; n=154) of patients. Only blood pressure status and total cholesterol levels were found to be associated with prescribing adherence levels. ( b) Overall, in the following patient groups: any CHD (n= 282 eligible), fatal CHD (n=278 eligible), any stroke (n=274 eligible) and fatal stroke (n=305 eligible) there were 46.1% (95% CI: 40.3, 51.9, n=130), 29.5% (95% CI: 24.4, 35.1, n=82), 12.8% (95% CI: 9.3, 17.3, n=35) and 0% (95% CI: 0, 0) high risk patie nts identified respectively. A high risk of developing any CHD was significantly associated with increased means ± [standard deviation (SD)] of age (60.0±[8.7] vs 47.0±[9.7], p<0.0001), diabetes duration in years (13.6±[6.9] vs 7.5±[4.5], p<0.0001), systolic blood pressure, SBP (144±[16.9] vs 136±[17.5], p<0.0001), HbA1c level (9.0±[1.7] vs 8.1±[1.9], p<0.0001), and reduced high density lipoprotein (1.07±[0.3] vs 1.2±[0.42], p=0.002). Significantly more males than females were at high risk of developing CHD (64.6% vs. 35.4%, respectively, p<0.0001). In addition to total cholesterol (4.9±[1.1] vs 4.6±[1.0], p=0.04), similar associations and trends were also observed when these above variables were compared with the risk of developing fatal CHD. High risk of developing any stroke was significantly associated with increased means of age (69.4±[5.4] vs 49.5±[9.2], p<0.0001), diabetes duration in years (18.4±[7.2] vs 8.6±[5.0], p<0.0001) and SBP (145±[19.8] vs ). Targeted HbA1c and blood pressure values were not achieved in the majority of patients (84% and 75%, respectively) who are at higher risk of developing CVD. Conclusion: The study identified levels of adherence to guideline recommendations, the need for additional documentation and criteria with low adherence that might be a focus for a possible change at individual or organisational levels (changes in policies or structures) as well as educational interventions and a starting point for targeted pharmaceutical care. The risk of developing any CHD in patients with type-2 diabetes was significantly higher than the risk of developing fatal CHD, any stroke or fatal stroke. Risk calculators can be used to target patients for pharmaceutical care according to their CVD risk factors.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available