Open Medicine Journal




ISSN: 1874-2203 ― Volume 6, 2019
RESEARCH ARTICLE

Guideline Adherence and the Factors Associated with Better Care for Type 2 Diabetes Mellitus Patients in Lithuanian PHC: Diabetes Mellitus Guideline Adherence in Lithuania PHC



Raila Gediminas1, *, Liseckienė Ida1, Jarusevičienė Lina1, Leonas Valius1
1 Department of Family Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania

Abstract

Background:

Type 2 diabetes mellitus is one of the most common chronic conditions, which requires appropriate management and care at PHC level, which is described in guidelines. However, guideline adherence at the international arena is insufficient and little is known about the reasons for guideline non-adherence.

Objective:

The aim of the survey was to analyse to what extent the Lithuanian family practitioners adhere to diabetes guidelines in order to compare to international data and to discover the factors associated with better diabetes care.

Methods:

The present study is a part of EUPRIMECARE Project, which sets out to develop a framework aiming at the analysis of PHC across Europe. The sample strategy was based on an unequal probability sampling design. An audit of 4 public and 6 private PHC medical records of the year 2011 was carried out in Kaunas region, clinical records of 382 diabetes type 2 patients were reviewed. Demography, diseases and diabetes performance indicators data were collected using a uniform template. Binary and multivariable logistic regression analyses were used in the investigation of the factors related to better diabetes guideline adherence.

Results:

Three guideline adherence levels were identified: high performance (performed in more than 90% cases) - BP measurement and HbA1c exam; good performance (performed in more than 50% cases) - ECG examination and serum creatinine check; insufficient performance (performed in less than 50% of cases) - annual endocrinologist consultation, eye fundus and foot examinations, LDL check and BMI calculation. Insufficient glycaemic control was positive associated with increased endocrinologist consultation and foot exam rates, elevated BP demonstrated the positive effect to creatinine check rate, multimorbidity had positive association to the annual eye, ECG, creatinine check rates; frequent FP attendance showed no positive effect on process indicators. Rural patients have a negative association to foot and ECG exam rates compared to urban patients. In a stepwise logistic regression model, 3 dependent variables had statistically significant impact on overall diabetes care indicator performance: negative - rural location of patients (OR 0.4, 95% CI 0.2-0.8), elevated mean BP (OR 0.6, 95% CI 0.4-0.9); positive - multimorbidity (OR 2.0, 95% CI 1.2-3.4).

Conclusion:

Guideline adherence for T2DM is not optimal in Lithuanian PHC. The best are BP and HbA1c checks. Suboptimal are BMI and LDL annual checks. The situation with these is almost the same as in other European countries. The better guideline adherence has been observed in urban (foot exam, ECG exam), multimorbidity (eye, ECG, creatinine exams), controlled by means of BP patients (serum creatinine test).

Keywords: Primary health care, Family physicians, Diabetes mellitus type 2, Guideline adherence, ECG, BMI.


Article Information


Identifiers and Pagination:

Year: 2019
Volume: 6
First Page: 50
Last Page: 57
Publisher Id: MEDJ-6-50
DOI: 10.2174/1874220301906010050

Article History:

Received Date: 20/02/2019
Revision Received Date: 24/06/2019
Acceptance Date: 12/07/2019
Electronic publication date: 30/08/2019
Collection year: 2019

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© 2019 Raila et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: (https://creativecommons.org/licenses/by/4.0/legalcode). This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at Department of Family Medicine, Lithuanian University of Health Sciences, Mickevičiaus g. 9, LT 44307 Kaunas, Lithuania; Tel: +37037327032, +37060199885; Fax: +37037703438; E-mail: railag@gmail.com





1. INTRODUCTION

Diabetes care is a complex process requiring ongoing patient self-management, education and support with multifactorial risk reduction strategies to prevent acute complications and to reduce the risk of long-term complications [1Care D, Suppl S S. Introduction: Standards of medical care in diabetes. Diabetes Care 2019; 421: S1-2.]. Diabetes type 2 (T2DM) is one of the most common chronic conditions at primary health care (PHC) level, which requires good organisation and coordination in PHC practices [2Provost S, et al. Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes? Heal Promot chronic Dis Prev Canada Res policy Pract 2017 Apr; 37(4): 105-15.
[http://dx.doi.org/10.24095/hpcdp.37.4.01]
]. Results of the research indicate that good guideline adherence may prevent T2DM complication progression, improve patient quality of life and limit health expenditure [3Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318(7182): 527-30.
[http://dx.doi.org/10.1136/bmj.318.7182.527] [PMID: 10024268]
, 4Chen Y, Sloan FA, Yashkin AP. Adherence to diabetes guidelines for screening, physical activity and medication and onset of complications and death. J Diabetes Complications 2015; 29(8): 1228-33.
[http://dx.doi.org/10.1016/j.jdiacomp.2015.07.005] [PMID: 26316423]
].

Although clinical guideline adherence theoretically may improve health outcomes [3Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. BMJ 1999; 318(7182): 527-30.
[http://dx.doi.org/10.1136/bmj.318.7182.527] [PMID: 10024268]
], this has more theoretical approach as the evidence from empirical studies is mixed [5Oude Wesselink SF, Lingsma HF, Robben PBM, Mackenbach JP. Guideline adherence and health outcomes in diabetes mellitus type 2 patients: a cross-sectional study. BMC Health Serv Res 2015; 15(1): 22.
[http://dx.doi.org/10.1186/s12913-014-0669-z] [PMID: 25608447]
]. Therefore, it was concluded that up to 2/3 of the guideline recommendations were not adhered despite different specialties, countries and health systems [6Mickan S, Burls A, Glasziou P. Patterns of ‘leakage’ in the utilisation of clinical guidelines: A systematic review. Postgrad Med J 2011; 87(1032): 670-9.
[http://dx.doi.org/10.1136/pgmj.2010.116012] [PMID: 21715571]
]. Some of the barriers were associated with patient factors (expectations, motivation, compliance) as well as with organisation-related factors (high costs for practice, lack of time and logistical support) [6Mickan S, Burls A, Glasziou P. Patterns of ‘leakage’ in the utilisation of clinical guidelines: A systematic review. Postgrad Med J 2011; 87(1032): 670-9.
[http://dx.doi.org/10.1136/pgmj.2010.116012] [PMID: 21715571]
]. Results of the studies carried out demonstrated a range of factors positively associated with higher guideline adherence - practice characteristics, computerisation, nurse employment [7O’Connor R, Houghton F, Saunders J, Dobbs F. Diabetes mellitus in Irish general practice: Level of care as reflected by HbA1c values. Eur J Gen Pract 2006; 12(2): 58-65.
[http://dx.doi.org/10.1080/13814780600780858] [PMID: 16945878]
], managed care (centralised organisation, coordination, responsibility and centralised annual assessment) [8van der Heijden AAWA, de Bruijne MC, Feenstra TL, et al. Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: A controlled clinical trial. BMC Health Serv Res 2014; 14: 280.
[http://dx.doi.org/10.1186/1472-6963-14-280] [PMID: 24966055]
], consultation frequency, patient gender and age [9Van Doorn-Klomberg AL, Braspenning JC, Atsma F, et al. Patient characteristics associated with measurement of routine diabetes care: An observational study. PLoS One 2015; 10(3)e0121845
[http://dx.doi.org/10.1371/journal.pone.0121845] [PMID: 25822978]
]. Despite some debates on the guideline adherence associated to better patient health outcomes [8van der Heijden AAWA, de Bruijne MC, Feenstra TL, et al. Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: A controlled clinical trial. BMC Health Serv Res 2014; 14: 280.
[http://dx.doi.org/10.1186/1472-6963-14-280] [PMID: 24966055]
, 10de Belvis AG, Pelone F, Biasco A, Ricciardi W, Volpe M. Can primary care professionals’ adherence to Evidence Based Medicine tools improve quality of care in type 2 diabetes mellitus? A systematic review. Diabetes Res Clin Pract 2009; 85(2): 119-31.
[http://dx.doi.org/10.1016/j.diabres.2009.05.007] [PMID: 19539391]
] and the correctness of their application for patients with multimorbidity [11Spencer-Bonilla G, Quiñones AR, Montori VM. International Minimally Disruptive Medicine Workgroup. Assessing the burden of treatment. J Gen Intern Med 2017; 32(10): 1141-5.
[http://dx.doi.org/10.1007/s11606-017-4117-8] [PMID: 28699060]
], there is a need to follow the guidelines as they are in line with the best available evidence of clinical practice and cost-effectiveness.

For measurement of the diabetes care quality, a wide range of guideline adherence indicators were used. The most often analysed in the research are the following: body mass index (BMI) [12Vaona A, Del Zotti F, Girotto S, Marafetti C, Rigon G, Marcon A. Data collection of patients with diabetes in family medicine: A study in north-eastern Italy. BMC Health Serv Res 2017; 17(1): 565.
[http://dx.doi.org/10.1186/s12913-017-2508-5] [PMID: 28814303]
], foot and eye examinations [12Vaona A, Del Zotti F, Girotto S, Marafetti C, Rigon G, Marcon A. Data collection of patients with diabetes in family medicine: A study in north-eastern Italy. BMC Health Serv Res 2017; 17(1): 565.
[http://dx.doi.org/10.1186/s12913-017-2508-5] [PMID: 28814303]
, 13Sieng S, Hurst C. A combination of process of care and clinical target among type 2 diabetes mellitus patients in general medical clinics and specialist diabetes clinics at hospital levels. BMC Health Serv Res 2017; 17(1): 533.
[http://dx.doi.org/10.1186/s12913-017-2486-7] [PMID: 28784176]
], measurement of glycolised haemoglobin (HbA1c), low density lipoprotein (LDL), glomerular filtration rate, urine albumin, assessment of smoking status [5Oude Wesselink SF, Lingsma HF, Robben PBM, Mackenbach JP. Guideline adherence and health outcomes in diabetes mellitus type 2 patients: a cross-sectional study. BMC Health Serv Res 2015; 15(1): 22.
[http://dx.doi.org/10.1186/s12913-014-0669-z] [PMID: 25608447]
, 9Van Doorn-Klomberg AL, Braspenning JC, Atsma F, et al. Patient characteristics associated with measurement of routine diabetes care: An observational study. PLoS One 2015; 10(3)e0121845
[http://dx.doi.org/10.1371/journal.pone.0121845] [PMID: 25822978]
, 14Halladay JR, DeWalt DA, Wise A, et al. More extensive implementation of the chronic care model is associated with better lipid control in diabetes. J Am Board Fam Med 2014; 27(1): 34-41.
[http://dx.doi.org/10.3122/jabfm.2014.01.130070] [PMID: 24390884]
]. There is evidence showing that the achievement of specific goals for each of these indicators leads to better diabetes outcomes, and strong evidence demonstrates that major complications are reduced if these goals are achieved [15American Diabetes Association, “Standards of Medical Care in Diabetes. Diabetes Care 2017; 401: S33-43.]. In Lithuania, a few studies were carried out indicating not optimal diabetes care in the country [16Visockienė Ž, Šiaulienė L, Puronaitė R, Šapoka V, Kasiulevičius V. Quality of diabetes care at the largest outpatient clinics in Vilnius. Acta Med Litu 2016; 23(2): 126-34.
[http://dx.doi.org/10.6001/actamedica.v23i2.3329] [PMID: 28356799]
, 17Domeikienė A, Vaivadaitė J, Ivanauskienė R, Padaiga Ž. Direct cost of patients with type 2 diabetes mellitus healthcare and its complications in Lithuania. Medicina (Kaunas) 2014; 50(1): 54-60.
[http://dx.doi.org/10.1016/j.medici.2014.05.007] [PMID: 25060205]
] however, the guideline adherence on diabetes care is not addressed in a systematic way [18Suija K, Kivisto K, Sarria-Santamera A, et al. Challenges of audit of care on clinical quality indicators for hypertension and type 2 diabetes across four European countries. Fam Pract 2015; 32(1): 69-74.
[http://dx.doi.org/10.1093/fampra/cmu078] [PMID: 25411423]
].

National guidelines on diabetes care of T2DM patients were firstly published in 2002 [19422 Dėl ligų diagnostikos bei ambulatorinio gydymo, kompensuojamo iš Privalomojo sveikatos draudimo f...” [Online]. Available:. https://www.e-tar.lt/portal/lt/legalAct/TAR.F420486F530B [Accessed: 03-May-2019].], then revised in 2005 [20V-152 Dėl Lietuvos Respublikos sveikatos apsaugos ministro 2002 m. rugpjūčio 14 d. įsakymo Nr. 422 "Dėl...” Available:. https://www.e-tar.lt/portal/lt/legalAct/TAR.9F375A3F37D0 [Accessed: 03-May-2019].] and later in the year 2012 [21“V-159 Dėl Cukrinio diabeto ambulatorinio gydymo kompensuojamaisiais vaistais tvarkos aprašo patvirtinimo.” [Online]. Available:. https://www.e-tar.lt/portal/legalAct.html?documentId=TAR.1657DC90A805 [Accessed: 03-May-2019].]. The guidelines were based on the annual assessment of patients and on the performance of tests and examinations rather on the decision-making process addressing how to treat the disease. Both the family physician (FP) and endocrinologist are involved in diabetes care, but their roles lack clarity with respect to functions and responsibility in diabetes care. According to the national guidelines, patients with T2DM shall be directed to an endocrinologist once a year, even it is well controlled. For the study period, the targets were the following: HbA1c ≤ 7.0%, blood pressure (BP) <130/80 mmHg; and total cholesterol <4.8 mmol/l.

The aim of the survey was to analyse to what extent the Lithuanian FP adhere to national T2DM guidelines and to assess the relationships between adherence to guidelines and patients and healthcare practice characteristics.

2. METHODS

The present study is a part of EUPRIMECARE Project [22“European Commission : CORDIS : Projects and Results : Final Report Summary - EUPRIMECARE (Quality and costs of primary care in Europe).” Available:. https://cordis.europa.eu/result/rcn/58690_en.html [Accessed: 05-Mar-2018].], which sets out to develop a framework aiming to analyse PHC across Europe, to assess and compare PHC models in terms of quality and identification of costs. The article introduces the Lithuanian data on T2DM care.

2.1. Participants

An audit of medical records was carried out in Kaunas region that is the most central geographical location of Lithuania covering both urban and rural areas. Economic indicators (e.g. salaries) in this region are equal to the Lithuanian average. The population of Kaunas region amounts to 453,482 inhabitants making almost 15% of the total population of Lithuania.

In autumn of 2011, 49 Primary health care centres providing PHC services for the population under the contract with Sickness Funds were operating in Kaunas region. According to the Sickness Funds data, the majority of population was served in urban (85.8% vs.15.2% rural), public (60.1% vs. 39.9% private) and large (47.3% vs. 37.7% medium and 15.0% small) PHC centres (large PHC served 20,000 and more patients, medium PHC centres served 5,000 to 19,999 patients and small PHC centres served less than 5,000 patients).

The sample strategy was based on a πPS unequal probability sampling design [23Grafström A, Qualité L, Tillé Y, Matei A. Size constrained unequal probability sampling with a non-integer sum of inclusion probabilities. Electron J Stat 2012; 6: 1477-89.
[http://dx.doi.org/10.1214/12-EJS719]
] that deals with complex distribution of sampling units: size of PHC institution (large, medium, small practices), urbanisation (rural or urban), different ownership (public or private). 4 public and 6 private PHC centres were selected. As in one small urban and one medium urban centre the necessary number of patients with T2DM was not available, two additional centres (which represented the same size and urbanization) were included in the study.

Data were collected after the permission by the Ethics Committee of the Lithuanian University of Health Sciences was received in March 2012. The heads of the selected PHC centres were informed about the survey aims and procedure, and notified about the special emphasis that should be made on personal data protection during data collection - only gender and date of birth of patients should be included into the study and no information related to physicians would be collected. All heads of PHC centres signed written agreements on participation provided that they would receive the report from the research team about the performance of a particular PHC centre.

At the time of research, majority of Lithuania FP used ambulatory cards in paper form. Each FP provided the list of their patients with T2DM. Patients of all family practitioners working for the same PHC centre were merged and from this the required number of patients was selected for the audit randomly. Three trained medical staff members collected data from individual medical records (paper form) at each PHC centre.

Medical records concerning patients with a diagnosis of T2DM (E11.0 – E11.9 according to the ICD-10 classification) in the year 2011 were included. The relevant clinical data were recorded using a uniform template. Records of demography data (gender, age, residence area), medicine data (all patient diseases, medicines, reasons and number of consultations to specialists, FPs, diabetes indicator examination data (eye fundus exam, foot check, BP, ECG), laboratory data (HbA1c, serum creatinine, LDL concentration) were made. If several of the same kind checks during the year 2011 were done, they were counted separately.

2.2. Measures

The following nine good diabetes patient care indicators were analysed that should be checked or should perform in compliance with the national diabetes care protocol [20V-152 Dėl Lietuvos Respublikos sveikatos apsaugos ministro 2002 m. rugpjūčio 14 d. įsakymo Nr. 422 "Dėl...” Available:. https://www.e-tar.lt/portal/lt/legalAct/TAR.9F375A3F37D0 [Accessed: 03-May-2019].]: 1. BMI exam 2. Foot examination (for diabetic polyneuropathy and arterial blood circulation) 3. Eye fundus examination 4. ECG exam 5. HbA1c exam 6. Low-density lipoprotein (LDL) concentration 7. Serum creatinine concentration 8. Endocrinologist consultation 9. BP measurement. All the measures should be performed at least once per year, except glycated haemoglobin. According to the diabetes care protocol, glycated haemoglobin should be done 4 times per year. As logistic independent variable we set criterion – at least 2 times per year to compare to other countries. The place where the checks were performed, i.e. at PHC or at the secondary health care level (endocrinologist consultation or hospital), was not considered. An obligatory annual endocrinologist consultation was included into analysis as the Lithuanian diabetes care protocol [20V-152 Dėl Lietuvos Respublikos sveikatos apsaugos ministro 2002 m. rugpjūčio 14 d. įsakymo Nr. 422 "Dėl...” Available:. https://www.e-tar.lt/portal/lt/legalAct/TAR.9F375A3F37D0 [Accessed: 03-May-2019].] requires for it. Microalbuminuria, protein in 24 hours urine, albumin/creatinine ratio tests were not included in the further analysis as there were no possibilities to do these tests in Lithuania at PHC level in the year 2011. BP measurement was included in the study as mean systolic and diastolic blood pressure values during the year 2011.

2.3. Definitions

Variables selected for the study were the following: I. Demographic characteristics of patients: 1. gender (male or female) 2. age (under 65 years or 65 years and older) 3. place of residence (rural or urban location). II. Variables reflecting the patient’s health status: 1. high BP (mean blood pressure >=130/80 mmHg vs <130/80 mmHg) 2. insufficient glycaemic control (HbA1c ≥7%, vs HbA1c <7%) 3. multimorbidity (number of diagnoses ≤2 vs >2) 4. polypharmacy (number of medicines taken ≥5 vs. less than 5). III. Variables related to the frequency: 1. frequent GP attender (13 or more GP consultations per year vs less than 13 consultations) 2. HbA1c making frequency (>2 times per year vs ≤2. Frequent GP attender was named according to literature data [24Morriss R, Kai J, Atha C, et al. Persistent frequent attenders in primary care: costs, reasons for attendance, organisation of care and potential for cognitive behavioural therapeutic intervention. BMC Fam Pract 2012; 13(1): 39.
[http://dx.doi.org/10.1186/1471-2296-13-39] [PMID: 22607525]
], multimorbidity and polypharmacy was set according to literature data [25Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017; 17(1): 230.
[http://dx.doi.org/10.1186/s12877-017-0621-2] [PMID: 29017448]
]. Finally count of all ‘must done’ according to diabetic care protocol measures and procedures (9 indicators: HbA1c measurement >2 times a year; blood pressure measuring, ECG examination, serum creatinine, endocrinologist consultation, eye fundus examination, leg examination for pulse and neuropathy, LDL, BMI - at least one time a year) were split into two groups according to the dataset median preparing them to logistic regression (better guideline adherence, ≥5 procedures vs poor, < 5 measures done).

2.4. Statistical Analysis

Descriptive statistics of patients was generated. Characteristics of the population are presented as means, standard deviations or proportions according to a diabetes care group. Finally, we carried out univariate and stepwise multivariate logistic regression analysis and calculated odds ratios in order to verify the differences between the reference group and each of other variables setting the statistical significant level at 0.05. Logistic regression method was chosen as it requires no linear relationship between dependent variables and does not need residuals normal distributed, also it deals good with a binary ordinal dependent variables. The variables were checked by means of collinearity and significant collinear variables were dropped out from calculations.

All the analyses were carried out on IBM SPSS (software package for statistical analysis) Statistics Package Ver. 21.0 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.).

3. RESULTS

382 patient records were reviewed retrospectively. The study population contained statistically significant more female patients (Table 1). The average patient age was 66.2±10.4 years, whereas 60.5% of persons were above 65 years old. Majority of patients lived in urban area (84.8%). The mean glycated haemoglobin of the entire study population was 7.3±1.2%. Proportions of patients with the mean glycated haemoglobin above 7% and less than 7% were approximately the same (47.4 and 43.2% respectively). Polypharmacy was found in 34.3% of study patients. Most of the patients have more than 2 diagnoses, included T2DM (83.2%).

Performance of T2DM indicators varied from 19.4% (BMI calculation) to 100% (BP measurement) (Table 2). The following three performance levels could be identified: high performance (performed in more than 90% cases) - BP measurement and HbA1c exam; good performance (performed in more than 50% cases) - ECG examination and serum creatinine check; and insufficient performance (performed in less than 50% of cases) - annual endocrinologist consultation, eye fundus and foot examinations, LDL check and BMI calculation. Fig. (1) illustrates the HbA1c measurement frequency during the 12 months study period. HbA1c was measured 2 times per year for 54.2% and 4 times (per diabetic care protocol) only in 7.9% of patients respectively, so HbA1c checks are considered to be done not as often as required per diabetes protocol.

Table 1
Demographic and baseline characteristics of the studied sample.


Table 2
T2DM guideline adherence: investigations performance*.


Fig. (1)
Glycated hemoglobin measuring frequency,time per year,%.


Table 3
Associations between guideline adherence indicators and patient criteria*.


A logistic regression model revealed the relationship between a range of dependent variables and the performance of indicators (Table 3). Insufficient glycaemic control (HbA1c≥7%) was positive associated with increased endocrinologist consultation and foot exam rates (OR 2.0, 95% CI 1.2-3.1 and OR 2.1 95% CI 1.2-3.6 respectively) but also on the poorer HbA1c measure frequency (OR 0.5, 95% CI 0.4-0.9); multimorbidity had positive association to the annual check of eye exam (OR 2.2, 95% CI 1.3-3.8), ECG (OR 2.8, 95% CI 1.6-5.1), creatinine (OR 2.3, 95% CI 1.3-3.9) rates; frequent FP attendance showed no positive effect on process indicators, but had inverse association to ECG indicator rate (OR 0.6, 95% CI 0.4-0.9). Elevated mean BP had a positive association to creatinine test rate (OR 2.4, 95 CI% 1.3-4.5). Patient demographic factor analysis revealed older patient age (≥65 years age) had positive association on eye exam (OR 1.5 95% CI 1.1-2.4), ECG (OR 2.1 95% CI 1.3-3.5), serum creatinine (OR 1.7, 95% CI 1.1-2.7), but negative to LDL (OR 0.2, 95% CI 0.1-0.3) to be checked. Rural patients have a negative association to foot exam and ECG exam rates (OR 0.3, 95% CI 0.1-0.7 and OR 0.3 95% CI 0.2-0.5 respectively) compared to urban patients.

In order to identify the variables having a statistically significant impact on the performance of indicators, univariate and multivariate stepwise regression models were applied (Table 4). The results of the study demonstrated that rural location of patients (OR 0.5, 95% CI 0.3-0.8) and elevated mean blood pressure (OR 0.8, 95% CI 0.6-0.9) have a negative impact on the performance of these indicators. In stepwise logistic regression model, 3 dependent variables had statistically significant impact on performance: negative - rural location of patients (OR 0.4, 95% CI 0.2-0.8), elevated mean BP (OR 0.6, 95% CI 0.4-0.9); positive - multimorbidity (OR 2.0, 95% CI 1.2-3.4).

4. DISCUSSION

Although some efforts to investigate the performance of diabetes care in Lithuania were observed [16Visockienė Ž, Šiaulienė L, Puronaitė R, Šapoka V, Kasiulevičius V. Quality of diabetes care at the largest outpatient clinics in Vilnius. Acta Med Litu 2016; 23(2): 126-34.
[http://dx.doi.org/10.6001/actamedica.v23i2.3329] [PMID: 28356799]
], the present study is among the first ones aiming at assessment of the adherence to diabetes guidelines and at the identification of the predicting factors for greater adherence.

The findings have demonstrated a dramatic discrepancy between the performance level of different indicators ranging from 19.4% (BMI calculation) to 100% (BP measurement). Although the performance of some indicators could be related to financial (dis)interest (for HbA1c exam, GP practices get financial incentives up to 4 times per year, performance level of 90.6%; annual LDL check is not covered by national insurance, patients have to pay for the test, performance level of 23.8%), a rather great scatter of adherence to other recommended indicators forces to search for the explanations going beyond the financial issues. The results of the study carried out in Cameroon [26Jingi AM, Nansseu JRN, Noubiap JJN. Primary care physicians’ practice regarding diabetes mellitus diagnosis, evaluation and management in the West region of Cameroon. BMC Endocr Disord 2015; 15: 18.
[http://dx.doi.org/10.1186/s12902-015-0016-3] [PMID: 25881080]
] demonstrate that around 1/3 of physicians (36.4%) complete the full physical examination during the consultation of a diabetes patient. Our findings emphasise the need to take into account the importance of psychosocial, behavioural and managerial aspects while addressing the issue of guideline adherence. A large body of evidence demonstrates that T2DM care is not optimal even in the countries with a strong PHC based on teamwork and family physicians acting independently from specialists [5Oude Wesselink SF, Lingsma HF, Robben PBM, Mackenbach JP. Guideline adherence and health outcomes in diabetes mellitus type 2 patients: a cross-sectional study. BMC Health Serv Res 2015; 15(1): 22.
[http://dx.doi.org/10.1186/s12913-014-0669-z] [PMID: 25608447]
, 27Pinchevsky Y, Butkow N, Chirwa T, Raal FJ. Glycaemic, blood pressure and cholesterol control in 25 629 diabetics. Cardiovasc J Afr 2015; 26(4): 188-92.
[http://dx.doi.org/10.5830/CVJA-2015-050] [PMID: 26407221]
]. The performance level revealed by our study is 46.3% for eye examination and 43.2% for foot examination. Results similar to the outcomes of our study have been found by the studies carried out in the Netherlands [5Oude Wesselink SF, Lingsma HF, Robben PBM, Mackenbach JP. Guideline adherence and health outcomes in diabetes mellitus type 2 patients: a cross-sectional study. BMC Health Serv Res 2015; 15(1): 22.
[http://dx.doi.org/10.1186/s12913-014-0669-z] [PMID: 25608447]
] and Sweden [28Neumark A-SN, Brudin L, Neumark T. Adherence to national diabetes guidelines through monitoring quality indicators-A comparison of three types of care for the elderly with special emphasis on HbA1c. Prim Care Diabetes 2015; 9(4): 253-60.
[http://dx.doi.org/10.1016/j.pcd.2015.03.002] [PMID: 25865853]
] indicating that adherence was below 50% for foot and eye examinations, and was high (≥85%) for BP and HbA1c. However, the striking differences between Lithuania and other countries in the performance of annual assessment of BMI (19.4% in our study and 70% in the Dutch study) [5Oude Wesselink SF, Lingsma HF, Robben PBM, Mackenbach JP. Guideline adherence and health outcomes in diabetes mellitus type 2 patients: a cross-sectional study. BMC Health Serv Res 2015; 15(1): 22.
[http://dx.doi.org/10.1186/s12913-014-0669-z] [PMID: 25608447]
] suggest the low primary care team awareness of the importance of the increased body mass in diabetes care or/and non-efficient teamwork [28Neumark A-SN, Brudin L, Neumark T. Adherence to national diabetes guidelines through monitoring quality indicators-A comparison of three types of care for the elderly with special emphasis on HbA1c. Prim Care Diabetes 2015; 9(4): 253-60.
[http://dx.doi.org/10.1016/j.pcd.2015.03.002] [PMID: 25865853]
]. The guideline adherence is very likely to be linked to the interplay of a great spectrum of individual, practice and policy-related factors, whereas a better understanding of the complexity of the phenomenon could be a tool for enhancing the adherence to diabetes care guidelines in PHC of both Lithuania and other countries [29Norkus A, Ostrauskas R, Zalinkevičius R, Radzevičienė L, Sulcaite R. Adequate prescribing of medication does not necessarily translate into good control of diabetes mellitus. Patient Prefer Adherence 2013; 7: 643-52.
[http://dx.doi.org/10.2147/PPA.S45867] [PMID: 23874086]
].

Table 4
Possible predictors of better diabetes care*. Univariate and multivariate regression models.


Our data illustrate that the rural location of patients and not controlled BP are associated with the lack of adherence to a diabetes protocol (foot, ECG exams and creatinine test respectively). Although the data concerning the impact of rural and urban differences in the guideline adherence is controversial: the results of the study carried out in the USA have demonstrated that foot and eye examination were lower in rural areas [30Hale NL, Bennett KJ, Probst JC. Diabetes care and outcomes: Disparities across rural America. J Community Health 2010; 35(4): 365-74.
[http://dx.doi.org/10.1007/s10900-010-9259-0] [PMID: 20386968]
], the results of the Finnish study have revealed neither rural nor urban differences by means of treatment targets of diabetes (HbA1c) [31Toivakka M, Laatikainen T, Kumpula T, Tykkyläinen M. Do the classification of areas and distance matter to the assessment results of achieving the treatment targets among type 2 diabetes patients? Int J Health Geogr 2015; 14(1): 27.
[http://dx.doi.org/10.1186/s12942-015-0020-x] [PMID: 26420168]
], a distance from health care centres has been found by the Australian study [32Matthews V, Schierhout G, McBroom J, et al. Duration of participation in continuous quality improvement: A key factor explaining improved delivery of Type 2 diabetes services. BMC Health Serv Res 2014; 14: 578.
[http://dx.doi.org/10.1186/s12913-014-0578-1] [PMID: 25408165]
] as a factor associated with better guideline adherence. In our study, treatment target HbA1c performance once a year is rather good, but it is far from recommended as the optimum 4 times per year; in logistic regression, we see poorer glycaemic control is associated with rare HbA1c checks.

On the other side, in our study multimorbidity increased adherence to T2DM guidelines (eye, ECG, creatinine exams). In the case of multimorbidity, indicator performance is known to depend on whether the conditions are strongly associated with each other or not; it was found out that patients with a strongly related to T2DM condition - cardiovascular disease - were more likely to have their BP measured [9Van Doorn-Klomberg AL, Braspenning JC, Atsma F, et al. Patient characteristics associated with measurement of routine diabetes care: An observational study. PLoS One 2015; 10(3)e0121845
[http://dx.doi.org/10.1371/journal.pone.0121845] [PMID: 25822978]
].

In our study, frequent FP attendance has no positive impact on guideline adherence. Frequent patient attendance has been found positively associated with better guideline adherence by the studies carried out in Australia [32Matthews V, Schierhout G, McBroom J, et al. Duration of participation in continuous quality improvement: A key factor explaining improved delivery of Type 2 diabetes services. BMC Health Serv Res 2014; 14: 578.
[http://dx.doi.org/10.1186/s12913-014-0578-1] [PMID: 25408165]
], Saudi Arabia [33Al Harbi TJ, Tourkmani AM, Al-Khashan HI, Mishriky AM, Al Qahtani H, Bakhiet A. Adherence to the American Diabetes Association standards of care among patients with type 2 diabetes in primary care in Saudi Arabia. Saudi Med J 2015; 36(2): 221-7.
[http://dx.doi.org/10.15537/smj.2015.2.9603] [PMID: 25719589]
]. The relationship between the higher performance and frequent attendance raises doubts about the efficiency of a diabetes patient management pattern. Increasing the chance of the performance of a larger set of indicators, frequent attendance increases respectively the turnover of diabetes patients thereby reducing the time allocated to a consultation and, potentially, to its efficiency. The aforesaid findings encourage the insight that in order to increase the adherence to diabetes care guidelines both the educational gaps in the knowledge of physicians and the decision-making process related to diabetes should be addressed [34Corriere MD, Minang LB, Sisson SD, Brancati FL, Kalyani RR. The use of clinical guidelines highlights ongoing educational gaps in physicians’ knowledge and decision making related to diabetes. BMC Med Educ 2014; 14: 186.
[http://dx.doi.org/10.1186/1472-6920-14-186] [PMID: 25199672]
]. Results of other studies illustrating the guideline adherence are positively associated with group practice and practice computerisation [7O’Connor R, Houghton F, Saunders J, Dobbs F. Diabetes mellitus in Irish general practice: Level of care as reflected by HbA1c values. Eur J Gen Pract 2006; 12(2): 58-65.
[http://dx.doi.org/10.1080/13814780600780858] [PMID: 16945878]
], managed care (characterised by centralised organisation, coordination, responsibility and centralised annual assessment) [8van der Heijden AAWA, de Bruijne MC, Feenstra TL, et al. Resource use and costs of type 2 diabetes patients receiving managed or protocolized primary care: A controlled clinical trial. BMC Health Serv Res 2014; 14: 280.
[http://dx.doi.org/10.1186/1472-6963-14-280] [PMID: 24966055]
], nurse employing practices [7O’Connor R, Houghton F, Saunders J, Dobbs F. Diabetes mellitus in Irish general practice: Level of care as reflected by HbA1c values. Eur J Gen Pract 2006; 12(2): 58-65.
[http://dx.doi.org/10.1080/13814780600780858] [PMID: 16945878]
], and support the idea that wider strategies are required to improve the diabetes care including the greater integration of community nurses [35Jackson GL, Lee S-YD, Edelman D, Weinberger M, Yano EM. Employment of mid-level providers in primary care and control of diabetes. Prim Care Diabetes 2011; 5(1): 25-31.
[http://dx.doi.org/10.1016/j.pcd.2010.09.005] [PMID: 20980212]
, 36Chmiel C, Giewer I, Frei A, Rosemann T. Four-year long-term follow-up of diabetes patients after implementation of the Chronic Care Model in primary care: A cross-sectional study. Swiss Med Wkly 2017; 147(4344)w14522
[PMID: 29120011]
], allocation of higher responsibility to family physicians (up to 2012 GPs were not allowed to manage diabetes patients themselves [19422 Dėl ligų diagnostikos bei ambulatorinio gydymo, kompensuojamo iš Privalomojo sveikatos draudimo f...” [Online]. Available:. https://www.e-tar.lt/portal/lt/legalAct/TAR.F420486F530B [Accessed: 03-May-2019].-21“V-159 Dėl Cukrinio diabeto ambulatorinio gydymo kompensuojamaisiais vaistais tvarkos aprašo patvirtinimo.” [Online]. Available:. https://www.e-tar.lt/portal/legalAct.html?documentId=TAR.1657DC90A805 [Accessed: 03-May-2019].], e-health solutions [37Iljaž R, Brodnik A, Zrimec T, Cukjati I. E-healthcare for diabetes mellitus type 2 patients - A randomised controlled trial in Slovenia. Zdr Varst 2017; 56(3): 150-7.
[http://dx.doi.org/10.1515/sjph-2017-0020] [PMID: 28713443]
].

Our study suggests that the adherence to diabetes care guidelines in Lithuania is challenging similarly to other countries. The results of other studies also illustrate that there is no significant difference in diabetes care of Eastern and Western Europe [38Andel M, Grzeszczak W, Michalek J, et al. DEPAC Group. A multinational, multi-centre, observational, cross-sectional survey assessing diabetes secondary care in Central and Eastern Europe (DEPAC Survey). Diabet Med 2008; 25(10): 1195-203.
[http://dx.doi.org/10.1111/j.1464-5491.2008.02570.x] [PMID: 19046198]
]. As it becomes more evident that different health systems face similar difficulties, an increasing demand to find out the generalisable solutions of these problems is observed. In the future research, the transferability of the aforesaid solutions should be assessed.

5. LIMITATIONS OF THE SURVEY

The present study has certain limitations. Firstly, the medical records of the patients have been reviewed only at primary care level (there is a possibility that the BMI, foot examination or eye fundus examination have been provided in secondary care settings) and this could impair the picture of overall T2DM care of the country. Secondly, the study has a cross-sectional design that allows no analysis of causal inference. Thirdly, there was possibility an FP writes down not everything he does. Thus, the national adherence to diabetes guidelines might be higher.

CONCLUSION

Guideline adherence for T2DM is not optimal in Lithuanian PHC. The best are BP and HbA1c checks. Suboptimal are BMI and LDL annual checks. The situation with these is almost the same as in other European countries. The better guideline adherence has been observed in urban (foot exam, ECG exam), multimorbidity (eye, ECG, creatinine exams), controlled by means of BP patients (serum creatinine test).

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Permission by the Ethics Committee of the Lithuanian University of Health Sciences was received in March 2012

HUMAN AND ANIMAL RIGHTS

No animals/humans were used for studies that are the basis of this research.

CONSENT FOR PUBLICATION

All heads of PHC centres signed written agreements on participation provided that they would receive the report from the research team about the performance of a particular PHC centre.

AVAILABILITY OF DATA AND MATERIALS

Not applicable.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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