Type 2 diabetes care in family medicine

Abstract

The effectiveness of type 2 diabetes (DM2) care depends greatly on the collaboration of the physician and the patient as well their contribution to the treatment process. The present study assessed the obstacles in patient adherence to diabetes management, the patients’ quality of life and the accordance of clinical outcomes with the recommendations in the clinical practice guidelines. The study also evaluated the family doctors’ (FD) knowldge with the DM2 clinical practice guidelines, the correspondence of self-reported care of DM2 patients to the recommendations of clinical practice guidelines and analysed which factors influence the adherence to the guidelines. The qualitative study of the patients revealed that the course of the disease is imperceptible for the patients; the information about DM2 is unclear or insufficient; the coping with the disease is complicated in different life situations; and the relationship with the healthcare provider is important. The assessment of patient quality of life disclosed that that the patients assigned the lowest scores to their general health and role-physical. Better awareness of diabetes was the factor which had a negative effect on the assessment given on all eight scales of quality of life. Excessive weight is a risk factor which could be modified to improve patients’ wellbeing as overweight patients had especially low ratings in the physical functioning, role physical and role emotional scales. In general, the clinical outcomes of DM2 patients did not meet the requirements set in the guidelines, but were at the same time comparable with the results of DM2 patients’ worldwide. Glycaemic control – an important clinical outcome of the disease – was better (HbA1c<6.5%) in patients who were aware of the HbA1c test whereas the diabetes duration for more than 5 years had a negative impact on glycaemic control. DM2 clinical practice guidelines were available and used in daily practice by most FDs. However, the correspondence of self-reported behaviour to the guidelines varied to a great extent. Pharmacological treatment was usually started later than suggested in the guidelines and in follow-up of the patient the performance of recommended tests and examinations varied from overuse to underuse. Among the factors which hinder the FD’s adherence to the guidelines the most, the majority of FD’s highlighted patient-related factors, such as the patients’ low awareness of diabetes complications, their lack of motivation to change their lifestyle and the non-adherence to the medical regimen.Teist tüüpi diabeedi ravi tulemuslikkus sõltub suurel määral arsti ja patsiendi koostööst ning nende mõlema panusest raviprotsessi. Käesolevas uurimuses analüüsiti teist tüüpi diabeediga patsientide ravisoostumisega seonduvaid takistusi, nende hinnanguid elukvaliteedile ning kliiniliste tulemuste vastavust ravijuhendi soovitustele. Samuti hinnati uurimuses perearstide teadlikkust teist tüüpi diabeedi ravijuhendist, patsiente jälgimise vastavust ravijuhendile ning analüüsiti, millised tegurid mõjutavad ravijuhendist kinnipidamist. Patsientide kvalitatiivse uuringu tulemusena selgus, et diabeedi kulg on haigele tunnetamatu, diabeedi kohta saadav informatsioon on ebaselge või puudulik, haigusega toimetulek erinevates olukordades on keeruline ning suhtlemisviis meditsiinitöötajatega on oluline. Elukvaliteedi uuringust selgus, et diabeedihaigete hinnangud on kõige madalamad üldtervislikule seisundile ning igapäevaelu kehalistele piirangutele. Patsientide teadlikkus oma haigusest ja selle tüsistustest mõjutas negatiivselt hinnanguid kõigil kaheksal elukvaliteedi skaalal. Liigne kehakaal on riskitegur, mida mõjutades saaks patsientide elukvaliteeti parandada, sest ülekaalulised hindasid negatiivsemalt kehalist seisundit, kehalisi piiranguid ja emotsionaalset toimetulekut igapäevaelus. Üldiselt ei vastanud diabeediga patsientide kliinilised tulemused ravijuhendis soovitatule, kuid samas on tulemused võrreldavad teistes maades saavutatuga. Glükohemoglobiini sisaldus (HbA1c<6,5%) , kui oluline kliiniline tulemus, vastab ravijuhendis soovitatule suurema tõenäosusega patsientidel, kes on glükohemoglobiini analüüsist teadlikud, kuid haiguse kestus üle 5 aasta halvendas tulemust. Enamikule perearstidest oli teist tüüpi diabeedi ravijuhend hästi kättesaadav ning leidis igapäevatöös kasutust. Samas oli arstide tegutsemise vastavus ravijuhendiga väga varieeruv. Medikamentoosse raviga alustatakse tavaliselt kõrgemate veresuhkruväärtuste korral, kui on soovitatud ravijuhendis ning diabeedihaige jälgimisel tehtavate analüüside määramisel esineb nii üle- kui alakasutust. Ravijuhendi järgimist kõige enam takistavatest teguritest, nimetab enamik perearste patsiendist tingitud tegureid: haigete madal teadlikkus diabeedi tüsistustest, puuduv motiveeritus muuta eluviise ning halb raviga soostumine.