Treating 4,000 diabetic patients in Cambodia, a high-prevalence but resource-limited setting: a 5-year study

Abstract

BackgroundDespite the worldwide increasing burden of diabetes, there has been no corresponding scale-up of treatment in developing countries and limited evidence of program effectiveness. In 2002, in collaboration with the Ministry of Health of Cambodia, Médecins Sans Frontières initiated an outpatient program of subsidized diabetic care in two hospital-based chronic disease clinics in rural settings. We aimed to describe the outcomes of newly and previously diagnosed diabetic patients enrolled from 2002 to 2008.MethodsWe calculated the mean and proportion of patients who met the recommended treatment targets, and the drop from baseline values for random blood glucose (RBG), hemoglobin A1c (HbA1c), blood pressure (BP), and body mass index (BMI) at regular intervals. Analysis was restricted to patients not lost to follow-up. We used the t test to compare baseline and subsequent paired values.ResultsOf 4404 patients enrolled, 2,872 (65%) were still in care at the time of the study, 24 (0.5%) had died, and 1,508 (34%) were lost tofollow-up. Median age was 53 years, 2,905 (66%) were female and 4,350 (99%) had type 2 diabetes. Median (interquartile range (IQR)) follow-up was 20 months (5 to 39.5 months). A total of 24% (51/210) of patients had a HbA1c concentration of <7% and 35% (709/1,995) had a RBG <145 mg/dl within 1 year. There was a significant drop of 109 mg/dl (95% confidence interval (CI) 103.1 to 114.3) in mean RBG (P < 0.001) and a drop of 2.7% (95% CI 2.3 to 3.0) in mean HbA1c (P < 0.001) between baseline and month 6. In all, 45% (327/723) and 62% (373/605) of patients with systolic or diastolic hypertension at baseline, respectively, reached = 130/80 mm Hg within 1 year. There was a drop of 13.5 mm Hg (95% CI 12.1 to 14.9) in mean systolic blood pressure (SBP) (P < 0.001), and a drop of 11.7 mm Hg (95% CI 10.8 to 12.6) in mean diastolic blood pressure (DBP) (P < 0.001) between baseline and month 6. Only 22% (90/401) patients with obesity at baseline lowered their BMI <27.5 kg/m2 after 1 year. Factors associated with loss to follow-up were male sex, age >60 years, living outside the province, normal BMI on admission, high RBG on last visit, and coming late for the last consultation.ConclusionSignificant and clinically important improvements in glycemia and BP were observed, but a relatively low proportion of diabetic patients reached treatment targets. These results and the high loss to follow-up rate highlight the challenges of delivering diabetic care in rural, resource-limited settings.

General practice and social service partnership for better clinical outcomes, patient self efficacy and lifestyle behaviours of diabetic care: randomised control trial of a chronic care model

“…The real world practice might not have given strong consideration to interventions that would improve patient empowerment and lifestyle modifications, with greater support in patient self management resulting in a suboptimal proportion of diabetic patients reaching their desirable targets. Diabetic programmes in Cambodia consisting of outpatient clinics with GPs, nurses, drug educators, and adherence counsellors showed significant clinical improvements in glycaemic control, but only a relatively low proportion of patients reached their treatment targets 37. A study on African-American adults has shown the importance of incorporating the empowerment principles in supporting DM patient self management in ‘real world’ settings 38.…”

Content, participants and outcomes of three diabetes care programmes in three low and middle income countries

“…While the number of persons with diabetes in need for care increases, inadequate supply of diagnostics and medicines, lack of staff, poor quality of care and high out-of-pocket payment hamper the delivery of continuous care for people with lifelong conditions [2][3][4]. Improvements in access mostly relate to decentralisation of care to the primary care level [5][6][7][8] or in special outpatient clinics [9]. Task-shifting to Community Health Workers (CHWs) or expert patients is less frequent [10,11].…”

Caseload, management and treatment outcomes of patients with hypertension and/or diabetes mellitus in a primary health care programme in an informal setting

“…Two prospective studies conducted in hospital‐based chronic disease clinics in rural Cambodia showed encouraging results in blood pressure and glycaemic control, but high losses to follow‐up remained a challenge (Raguenaud et al . ; Isaakidis et al . ).…”