Management of diabetes in pregnancy in primary care.

Diabetes in pregnancy is associated with risks to the woman and her developing fetus. Management of the condition at the primary care level includes pre-conception care, screening, diagnosis, as well as antenatal and postpartum care. A multidisciplinary approach is essential in ensuring its holistic management.

Comparing the disease profiles of adult patients with type 2 diabetes mellitus attending four public health care facilities in Malaysia.

AIM: We examined disease profiles of patients with type 2 diabetes mellitus (T2D) at four different public health facilities in Malaysia to determine which site would be the most suitable for early and intensive diabetes care against diabetes-related complications. METHODS: This study analysed 57,780 T2D patients in the Adult Diabetes Control and Management registry database in the year 2009. The four public health facilities were hospital with specialists (HS), hospital without specialists (HNS), health clinics with family medicine specialists (CS) and health clinic without doctors (CND). Descriptive analyses were used to examine age, duration of diseases, intervals from the onset of diabetes to co-morbidities (hypertension and dyslipidaemia) and complication of T2D patients at the four public health facilities. RESULTS: Patients were significantly older in HS. Patients with T2D at HS had significantly longer duration of diabetes, hypertension and dyslipidaemia. Health clinics, both the CS and the CND, were seeing T2D patients with shorter duration of macrovascular and microvascular complications. CONCLUSION: Public health clinics in this country managed T2D patients who were younger and at the early stage of diabetes, hypertension, dyslipidaemia and complications. Thus, primary care physicians are best positioned to provide early and intensive diabetes care for this group of T2D patients to prevent the development of diabetes-related complications.

Type 2 Diabetes Mellitus Patient Profiles, Diseases Control and Complications at Four Public Health Facilities- A Cross-sectional Study based on the Adult Diabetes Control and Management (ADCM) Registry 2009.

INTRODUCTION: Diabetes care at different healthcare facilities varied from significantly better at one setting to no difference amongst them. We examined type 2 diabetes patient profiles, disease control and complication rates at four public health facilities in Malaysia. MATERIALS AND METHODS: This study analyzed data from diabetes registry database, the Adult Diabetes Control and Management (ADCM). The four public health facilities were hospital with specialist (HS), hospital without specialist (HNS), health clinics with family physicians (CS) and health clinic without doctor (CND). Independent risk factors were identified using multivariate regression analyses. RESULTS: The means age and duration of diabetes in years were significantly older and longer in HS (ANOVA, p< 0.0001). There were significantly more patients on insulin (31.2%), anti-hypertensives (80.1%), statins (68.1%) and antiplatelets (51.2%) in HS. Patients at HS had significantly lower means BMI, HbA1c, LDL-C and higher mean HDL-C. A significant larger proportion of type 2 diabetes patients at HS had diabetes-related complications (2-5 times). Compared to the HS, the CS was more likely to achieve HbA1c ≤ 6.5% (adjusted OR 1.2) and BP target < 130/80 mmHg (adjusted OR 1.4), the HNS was 3.4 times more likely not achieving LDL-C target < 2.6 mmol/L. CONCLUSION: Public hospitals with specialists in Malaysia were treating older male Chinese type 2 diabetes patients with more complications, and prescribed more medications. Patients attending these hospitals achieved better LDL-C target but poorer in attaining BP and lower HbA1c targets as compared to public health clinics with doctors and family physicians.

Ethnic differences in glycaemic control and complications: the adult diabetes control and management (ADCM), Malaysia.

INTRODUCTION: Ethnicity is an important factor in diabetes care. The understanding of its effect in this country may help to improve diabetes care, glycaemic control and diabetic complication rates. This study was to determine the diabetes control profile in relation to complication rates between the three main ethnics group in Malaysia. METHODS: This nested cross-sectional study was part of the Audit of Diabetes Control and Management (ADCM), an ongoing cohort patient registry focused on diabetes control and management in the primary care setting in Malaysia. This registry registers all diabetes patients aged 18 years old and above. Demographic data, diabetes duration, treatment modalities, as well as various risk factors and diabetes complications are reported. Data was handled by statisticians using STATA version 9. RESULTS: A total of 20330 patients from 54 health centers were registered at the time of this report. The majority were type 2 diabetics (99.1%) of whom 56.6% were female. The mean age was 57.9 years (SD 11.58). Malay accounted for 56.3%, Chinese 19.5% and Indian 22.5%. There were 30.3% who attained HbA1c < 7%. Among three main races more Chinese had HbA1c < 6.5% (Chi-square: X2 = 71.64, p < 0.001), but did not show less complications of nephropathy (Indian suffered significantly more nephropathy, Chi-square: X2 = 168.76, p < 0.001), ischaemic heart disease (Chi-square: X2 = 5.67, p = 0.532) and stroke (Chi-square: X2 =15.38, p = 0.078). CONCLUSION: This study has again emphasized the existence of ethnic differences in glycaemic control and complication profiles. The Chinese diabetics suffer as many diabetes-related complications despite better glycaemic control. Further studies will need to look into other socio-genetic factors in order to provide a more personalized effective diabetes care.

Diabetic hypertensive control and treatment: a descriptive report from the audit diabetes control and management (adcm) registry.

INTRODUCTION: Hypertension is a common co-morbidity in diabetes mellitus (DM) that may lead to serious complications if not adequately controlled. METHOD: This is a descriptive study based on data from the Audit of Diabetes Control and Management (ADCM) registry. This audit assessed the treatment and standard of control of hypertension in diabetic patients aged 18 years and above. Data were analysed using STATA version 9. RESULTS: From a total of 20 646 cases, about two third of them, 13 417 (65%) were reported to have hypertension. 19 484 (94.4%) had their blood pressure (BP) recorded and out of these, 11 414 (58.5%) were found to have BP >130/80 mmHg. 13 601 cases (65.9%) of the total sample were on antihypertensive drugs. 64.1% of those on antihypertensive drugs were prescribed angiotensin-converting enzyme inhibitors (ACEI) or angiotensin II receptor blockers. 14.2% were on more than two types of antihypertensive drugs. Older patients and those with longer duration of DM were less likely to achieve the target BP of ≤130/80. In general, about 40% of diabetic cases registered in the ADCM project had their hypertension well controlled.

The effect of "group detailing" on drug prescribing in primary care.

The quality of physician prescribing is suboptimal. Patients are at risk of potentially adverse reaction because of inappropriate or writing error in the drug prescriptions. We assess the effect of "group academic detailing" to reduce writing drug name using brand name and short form in the drug prescriptions in a controlled study at two primary health care clinics in Negeri Sembilan. Five medical officers in Ampangan Health Clinic received an educational intervention consisting of group academic detailing from the resident Family Medicine Specialist, as well as a drug summary list using generic names. The academic detailing focused on appropriate prescribing habit and emphasized on using the full generic drug name when writing the drug prescription. Analyses were based on 3371 prescriptions that were taken from two clinics. The other health clinic was for comparison. The prescribing rates were assessed by reviewing the prescriptions (two months each for pre- and post-intervention phase). Statistically significant reduction in writing prescription using brand name and using short form were observed after the educational intervention. Writing prescription using brand name for pre- and postintervention phase were 33.9% and 19.0% (postintervention vs pre-intervention RR 0.56, 95% CI 0.48 to 0.66) in the intervention clinic. Prescription writing using any short form for pre- and post-intervention phase were 49.2% and 29.2% (post-intervention vs pre-intervention RR 0.59, 95% CI 0.53 to 0.67). This low cost educational intervention focusing on prescribing habit produced an important reduction in writing prescription using brand name and short form. Group detailing appears to be feasible in the public health care system in Malaysia and possibly can be used for other prescribing issues in primary care.

An Audit of Diabetes Control and Management (ADCM).

Diabetes is a chronic condition that is one of the major causes of illness, disability, and death in Malaysia. Cost in managing diabetes plus indirect cost of lost work, pain, and suffering have all increased. The optimal management of patients with diabetes require the tracking of patients over time to monitor the progression of the disease, compliance with treatment, and preventive care. Diabetes care can be improved by standardizing access to, and improving the use of, clinical information. Access to timely, accurate and well-organized electronic data will improve the quality of care for patients with diabetes. Clinical Research Center convened an expert workshop to forecast how physicians, hospitals and clinics will employ clinical information technology (IT) applications to diabetes care over the next year. Workshop participants included experts from research organizations, government, and the IT vendor. This is a summary of the workshop organised for the purpose of the Audit of Diabetes Control and Management (ADCM) project. We hope to identify the gaps, if any, that exists in delivering diabetes care and to improve the quality of care. In future, we hope to develop an expansion of this project for the Adult Diabetes Registry that will be implemented for the whole country.

Leadership in the ministry of health.

Leadership in a huge and complex organisation like the Ministry of Health is important. The importance of leadership lies in the role it plays in defining the character, values and direction of an organization; and it's relation to organizational performance. Leadership is a quality that must be embedded within an organization for the organization to be successful and meet its objectives. Good leaders can be developed through a continuous process of self-study, education, training and experience. This concept of leadership also highlights the importance of seeking people with leadership talent, developing their potential and providing opportunities for them to lead.

The arthritis and musculoskeletal quality improvement program (amquip): a breakthrough series methodology project.

The Australian government had funded the National Primary Care Collaborative (NPCC) program with funding of $14.6 million over three years. One of the pilots project was the Arthritis and Musculoskeletal Quality Improvement Program (AMQuIP).The study aims to optimize general practitioners (GPs) management of patients with osteoarthritis (OA) of the hip and knee by identifying gaps between their current practice and best practice. The Breakthrough Series Collaborative methodology with several Plan-Do-Study-Act (PDSA) cycles was employed. Participants comprises of 12 GPs/practices from two Victorian Divisions of general Practice (one rural, one metropolitan) with 10 patients per GP/practice. GPs/practices attended an orientation and three learning workshops and a videoconference. GPs/practices completed PDSA cycles between workshop and reported results at workshops. GPs/practices reported use of guidelines, change in patient management and change in practice management/systems. All recruited patients completed the SF-12v2 Health Survey and WOMAC OA Index Questionnaire twice. Follow up activities including focus groups and face-to-face interviews were held six months after the final workshop. All GPs/practices used the guidelines/key messages, introduced "new" management strategies to patients, and made positive changes to their practice management/systems. Patient reported positive changes and outcomes. By using a structured methodology and evidence-based guidelines/key messages; GPs can introduce new patient management strategies, and by identifying gaps in practice management systems, positive changes can be achieved.

Reflecting on Research: Self- Monitoring of Blood Glucose among Diabetes Patients Attending Government Health Clinics.

This article described the author's reflection on conducting research in primary care. Certainly hand-on experience will give a better learning experience for a person to explore further in research and research training will help too. Conducting a collaborative research with other institutions also help in better research outcome. Research capacity building is important as most patients are seen in primary care.

Self-monitoring of blood glucose among diabetes patients attending government health clinics.

The aims of this study were (i) to determine the prevalence of self-monitoring of blood glucose (SMBG) among Type 2 diabetes patients attending government health clinics and (ii) to ascertain the factors influencing SMBG. Five hundred and fifty-six Type 2 diabetes patients from two government health clinics in Selangor and Negeri Sembilan were interviewed using a structured questionnaire. The total subjects of the study were 556 patients. Eighty-five patients (15.3%) of patients; performed SMBG. However, 170 subjects were included in the statistical analysis, 85 patients who were not self-monitoring were randomly selected and was compared with 85 patients who were self-monitoring. Among those who performed SMBG, the majority (83.5%) monitored less than once per day and only 16.5% monitored at least once a day. One-third of patients adjusted their medications based on their SMBG results. The higher patient's level of education (p= 0.024, CI 1.29 - 35.3); the higher total family income (p= 0.041, CI 1.26 - 4.79); the longer duration of diabetes (p<0.01, CI 2.22 - 7.29); and treatment regime which includes insulin (p< 0.001, CI 2.05 -9.24) were significant predictors of SMBG practice. Although SMBG is recognised to be useful and effective in achieving diabetes control, this study has found that only a minority of patients with diabetes performed SMBG. Hence healthcare personnel must increase awareness on the importance of SMBG and strongly promote the practice among diabetic patients.

Modifying antibiotic prescribing: the effectiveness of academic detailing plus information leaflet in a Malaysian primary care setting.

We assessed the effectiveness of an educational intervention in reducing antibiotic prescribing in public primary care clinics in Malaysia. Twenty-nine medical officers in nine clinics received an educational intervention consisting of academic detailing from the resident Family Medicine Specialist, as well as an information leaflet. The antibiotic prescribing rates were assessed for six months - three months before and three months after the intervention. A total of 28,562 prescriptions were analyzed. Among participating doctors, general antibiotic prescribing rates for pre- and post-intervention phases were 14.3% and 11.0% (post-intervention vs pre-intervention RR 0.77, 95% CI 0.72 to 0.83). The URTI-specific antibiotic prescribing rates for pre- and post-intervention phases were 27.7% and 16.6%, respectively (post-intervention vs pre-intervention RR 0.60, 95% CI 0.54 to 0.66). No significant change in antibiotic prescribing rates was observed among primary care practitioners who did not participate in the study. This low cost educational intervention using both active and passive strategies focusing on URTI produced a statistically significant (and clinically important) reduction in antibiotic prescribing.