Original research
Trends in chronic complications of type 2 diabetic patients from Spanish primary health care centres (GEDAPS study): Ten year-implementation of St. Vincent recommendations

https://doi.org/10.1016/j.pcd.2011.06.005Get rights and content

Abstract

Aims

To assess the implementation of St. Vincent recommendations in Catalonia (Spain) between 1993 and 2003 following a program of Continuous Quality Improvement.

Methods

65 health centres (433 health professionals) took part in the study. From 1993 to 2003, 34 workshops on consensus guidelines and feedback referring to the variables that needed to be improved were carried out. Data collection was obtained concerning, socio-demographic information, and disease characteristics and complications from patients with type 2 diabetes mellitus (DM).

Results

Most cardiovascular risk factors improved: glycosilated haemoglobin (HbA1c) was reduced by 0.7% (95% CI: −0.49:−0.90); total cholesterol by 0.54 mmol/L (95% CI: −0.53:−0.55); non-high density lipoprotein cholesterol by 0.81 mmol/L (95% CI: −0.80:−0.82); systolic blood pressure (SBP) by 6.02 mmHg (95% CI: −5.79:−6.25), and diastolic blood pressure (DBP) by 2.65 mmHg (95% CI: −2.4:−2.9), with the exception of smoking and obesity, which increased by 2.1% and 5.9%, respectively.

Retinopathy and albuminuria decreased by 40.7% and 46% (p < 0.001), respectively. The incidence of diabetic foot lesions and amputations decreased by 65.7% and 61.1% (p < 0.001), respectively. The prevalence of macrovascular complications showed a slight reduction (p = 0.037). Ischemic cardiomyopathy and cerebrovascular accidents decreased by 7.7% and 17.6%, respectively.

Conclusions

Our Continuous Quality Improvement program based on St. Vincent recommendations, had a positive impact on cardiovascular risk factors. We observed a reduction of chronic complications in type 2 DM patients.

Introduction

In 1992 the St. Vincent Declaration recommended both national and local programs of Continuous Quality Improvement (CQI) in primary care for the reduction of chronic complications [1]. Some long-term studies have shown that a proper control of cardiovascular risk factors (CVRF) in the type 2 diabetic patient decreases the incidence and severity of chronic complications [2], [3], [4], [5]. The majority of these studies are, however, clinical trials and consequently the conditions are not the same as in everyday clinical practice.

Primary health care (PHC) professionals, responsible for the follow-up of most of these patients, must be aware of the control objectives recommended in the clinical guidelines [6], [7] in order to optimally control CVRF in the diabetic population. Unfortunately, the passive distribution of these recommendations has resulted in an insufficient improvement of these indicators [8], [9].

As several studies have shown, a CQI programme [10], [11], [12], [13], [14], [15], [16], [17] or an incentive payment (Quality and Outcome Framework) [18] in primary care, can achieve a better CVRF control and an improved risk profile of the diabetic patient. There is, however, an insufficient number of studies that assess the improvement of CVRF and their repercussion on the prevalence of chronic complications after the implementation of a CQI in large populations [19], [20].

To assess how the St. Vincent recommendations were implemented in Catalonia (Spain) during the 1990s we designed a CQI program with the aim of reducing cardiovascular risk factor profile and the prevalence of type 2 diabetes mellitus (DM) chronic complications.

Section snippets

Methods

Catalonia has a public health system for the entire population, most of which (70%) is concentrated in urban areas. According to the 1993 Catalan Health Survey the prevalence of known diabetes was 4.7% in the population aged over 14 [21].

In 1993 the GEDAPS group (Group of Study of Diabetes in Primary Care) was established with the objective of implementing the St. Vincent Declaration [22] in Catalonia and reducing retinopathy by one third and the number of amputations by half. The group

Sample and study population characteristics

During the study period, 1993–2003, the recorded prevalence of type 2 DM increased from 3.26% to 5.44%. The number of diabetic patients studied was 2592 in 1993 and 4298 in 2003. These figures represented 11.4% and 12.8%, respectively, of the total diabetic patients controlled in the 65 PHC. The characteristics of the patients included in the assessments have undergone minor changes, such as a slight age increase (65.3, SD: 10.1 in 1993 and 67.4, SD: 10.8 in 2003), time since onset of diabetes

Discussion

The aim of the study was to assess how the St. Vincent recommendations were followed in our population 10 years after the conference. By applying these objectives in the PHC we hoped to improve the process indicators of the diabetic patient (blood pressure, HbA1c, and cholesterol. Our hypothesis was that an improvement in these variables would reflect in a decrease in chronic complications for the patient [10].

We designed a CQI strategy, based on voluntary audits, information feedback to

Conclusions

During the 1990s St. Vincent recommendations were implemented in Catalonia (Spain). We observed an improvement in the clinical outcome indicators (glycemic control and CVRF which may have contributed to the decrease in the prevalence of microvascular complications. Macrovascular complications had a slight reduction throughout the study period, without clinical relevance.

Conflict of interest statement

The authors state that they have no conflict of interest.

Acknowledgements

To Dr. José Luis del Val and Dr. Josemi Baena for their assistance in the statistical analyses and the final manuscript.

To the IDIAP Jordi Gol for its contribution to the editing and translation of the English version of the manuscript.

And to all doctors and nurses that have contributed follow-up data of the patients throughout this 10 years: ARBUCIES-ST.HILARI: Pelegri M.; AGRAMUNT: Vendrell JM.; BONAVISTA: Policarpo M., Grive M.; BADIA DEL VALLES: Mayordomo L.; BORDETA-MAGORIA: Madrid M.,

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