Are primary care practitioners in Barbados following diabetes guidelines? - a chart audit with comparison between public and private care sectors

BACKGROUND: Over 19% of the population ≥ 40 years of age in Barbados are diabetic. The quality of diabetes primary care is uncertain. FINDINGS: Charts of diabetic and hypertensive patients were randomly sampled at all public and 20 private sector primary care clinics. Charts of all diabetic patients ≥ 40 years of age were then selected. Processes of care, and quality targets for blood pressure (BP), fasting blood glucose (FBG) and glycosylated haemoglobin (HbA1c) were documented. 252 charts of diabetic patients (125 public and 127 private) were audited. Patients had the following characteristics: mean age 64 years, female gender 61%, mean duration of diagnosis 9 years, and hypertension diagnosed 78%. Patients had an average of 4.7 clinic visits per year, 66% were prescribed metformin, 68% a sulphonylurea, 25% a statin, 21% insulin, 15% aspirin and 12% a glucosidase inhibitor. Public patients compared to private patients were more likely to be female (77% vs. 46%, p < 0.01); have a longer duration of diagnosis (11.4 vs. 6.6 years, p < 0.01), have more clinic visits per year (5.2 vs. 4.3, p < 0.01), and to be using insulin (28 vs. 15% p = 0.01). Over a 2 year period, the proportion of charts with the following recorded at least once was: BP 98%, weight 80%, FBG 76%, total cholesterol 72%, urine tested for albumin 66%, serum creatinine 62%, dietary advice 61%, exercise advice 49%, lipid profile 48%, foot examination 41%, HbA1c 33%, dietician referral 23%, retinal examination 18%, tobacco use 17%, body mass index 0%, and waist circumference 0%. Public patients were more likely to have recorded: weight (92% vs. 68%, p = < 0.01); tests for total cholesterol (78% vs. 65%, p = 0.02), albuminuria (72% vs. 59%, p = 0.03), serum creatinine (79% vs. 44%, p < 0.01), and foot examination (50% vs. 32%, p = < 0.01); dietician referral (37% vs. 8%, p < 0.01), and tobacco use (26% vs. 8%, p < 0.01). For those tested, the most recent BP was < 140/90 for 43%, HBA1c was < 7% for 28%, and FBG was < 6.7 mmol/L for 27%. CONCLUSIONS: Interventions such as body mass assessment, lifestyle advice, screening for retinopathy, monitoring blood glucose control, and achieving BP and glycaemic targets need improvement.