Quality of Prescribing In Type 2 Diabetes Ambulatory Care at Webuye District Hospital
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ABSTRACT

Background: Registration of measurements and clinical outcomes has often been relied upon as existing performance indicators to assess quality of care in type 2 diabetes mellitus. It is recommended that quality of diabetic care, including quality of prescribing, should be closely monitored. This results in greater improvement in glycaemic control, blood pressure and lipid management.

Objective: The main objective of this study was to describe quality of prescribing in type 2 diabetes mellitus ambulatory care at Webuye District Hospital.

Methods: This was a retrospective review of patient medical records at Webuye District Hospital, Kenya. The target population was type 2 diabetes mellitus patients who visited the diabetic clinic in the year 2013. Fisher’s formula for descriptive studies was used to calculate a sample of 369 patients.  Sequential sampling of patient attendance lists was applied to retrieve 880 patient records. The first 369 fitting the inclusion criteria were picked for this study. A data collection form was designed, pre-tested and validated. Data collected were coded and analysed with Microsoft Office Excel 2007 and STATA® software version 10.1.

Results: Of the total 369 type 2 diabetes mellitus patients, 57.2 % were female and 14.9 % were newly diagnosed. The main co-morbidity was hypertension in 70.5 % of the patients. The main drugs prescribed for hyperglycemia were metformin (84.9 %), glibenclamide (47.7 %) and insulin (32.0 %) while those prescribed for cardiovascular risk were hydrochlorothiazide (52.8 %) and enalapril (51.8 %). Potential cases of drug-drug interactions were found in 4 % (95 % CI, 2-6) of patient medical records.

Age, weight and systolic blood pressure were recorded for all 369 patients while body mass index and albuminuria were recorded for 56 % and none of the patients respectively. Outcome measures for 10 of the 12 selected prescribing quality indicators varied from 6 % for prescribing a statin in patients with high cardiovascular risk to 99 % for prescribing of any antihyperglycaemic or antihypertensive medication. Outcome measures for the remaining 2 prescribing indicators could not be calculated due to absence of eligible patients.  

The use of insulin was influenced by glycated haemoglobin level [Odds ratio (OR) 1.1, p = < 0.01] and duration of diabetes (OR 1.07, p = < 0.01) while the use of losartan or enalapril was influenced by hypertension co-morbidity (OR 19.3, p = < 0.01). Additionally, use of acetyl salicylic acid was influenced by hypertension (OR 4.1, p = < 0.01) and age (OR 4.1, p = < 0.01).

Conclusion: This study established that adherence to treatment guidelines on choice of drugs for management of hyperglycemia and cardiovascular risk was good. However, there were deficiencies in adequate control of hyperglycemia, hypertension and dyslipidaemia.  Six (6) prescribing quality indicators with outcomes of ≥ 70 % represented good quality prescribing, while 4 others with outcomes of 6-56 % represented poor quality prescribing. There were also deficiencies in quality of prescribing in elderly patients, where nearly half were prescribed glibenclamide; while only one third were prescribed acetyl salicylic acid for primary prevention of cardiovascular disease. Cases of potential drug-drug interactions were found in ˂ 5 % of the records reviewed, which represented quality prescribing. Duration of diabetes and glycated hemoglobin level significantly influenced use of insulin for management of hyperglycemia while hypertension significantly influenced use of enalapril, losartan and acetyl salicylic acid. Age also significantly influenced use of acetyl salicylic acid.

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