Adherence to Canadian Diabetes Association Clinical Practice Guidelines: DISCUSSION part 2

1 Dec
2010

The CDA’s 2003 CPGs recommend use of acetyl- salicylic acid (unless contraindicated) for all patients with evidence of cardiovascular disease, as well as those with atherosclerotic risk factors. Some consider people with diabetes to have the same high risk of myocardial infarction as people without diabetes who have had a previous myocardial infarction.23,24 This study used a conservative definition of patients eligible for treatment with acetylsalicylic acid, whereby atherosclerotic risk was defined as a

Framingham 10-year risk score of 10% or greater. In fact, the Framingham risk score is not meant to be used for patients with diabetes, as it tends to underestimate the risk of coronary heart disease in these patients.26 In addition, this risk score should only be used to calculate the risk for primary prevention, not secondary prevention. Because the current study was retrospective and because medical history was self-reported, it was impossible to distinguish patients requiring primary prevention of cardiovascular disease from those requiring secondary prevention. Despite these limitations, we chose to define atherosclerotic risk using the Framingham risk score because it has been used to guide therapy with acetylsalicylic acid in other guidelines. buy levitra 20 mg

The suboptimal achievement of target parameters in this study may be multifactorial. Poor adherence to treatment regimens by patients, lack of response to suboptimal laboratory results by health care professionals, and patients’ lack of timely follow-up with their physicians may contribute to decreased monitoring frequency and poor achievement of metabolic targets as outlined in the CDA’s CPGs. Unfortunately, because of its retrospective design, this study did not reveal the reasons for poor achievement of laboratory targets or failure to receive indicated medications in this patient population. Another design limitation was the lack of a comparator group, which would have allowed exploration of the true impact of the program on achievement of the recommendations. Other limitations included incomplete access to laboratory results, which probably resulted in underestimation of reported frequencies of laboratory monitoring. Self-reporting of medications could have led to underestimation of their use. In particular, use of acetylsalicylic acid may have been underreported, as patients may not consider this drug a “medication” (because of its nonprescription status). The medication histories in the health records often lacked detail, and the indications, doses, start and stop dates, and contraindications were not consistently recorded. Therefore, it was impossible to determine a cause-and-effect relation between laboratory results and medication changes. Finally, the 2003 CPGs were published just 1 month before the start of the data collection period, so the recommendations might not have been fully implemented at that time.

The main strength of this study was its compre­hensive assessment of a broad selection of quality indicators, including monitoring frequencies, laboratory targets, and medication use. It is also, to the authors’ knowledge, the only study to date assessing adherence to the 2003 CPGs of the CDA. Cialis Jelly

The findings of this study have had an impact on the activities of the Diabetes Education Centre. A more detailed medication history will be solicited from patients, which will be facilitated by a revised documentation form. Also, there have been preliminary discussions between the Diabetes Education Centre and the Pharmacy Department with a view to increasing the pharmacist’s role within the clinic. Specifically, in addition to the current role of teaching patients about their medications, the pharmacist could play an important role in making recommendations about medications to physicians. Appropriate and timely initiation and adjustment of medications could bridge the gap between monitoring and achieving treatment outcomes. The findings reported here indicate that an emphasis on the management of cardiovascular risk factors may have the greatest impact. Finally, future presentations of these results to local general practitioners and endocrinologists may help to improve outcomes by increasing awareness of gaps in treatment.

In conclusion, the results reported here demonstrate that adherence to the 2003 CPGs of the CDA could be improved for patients attending the outpatient Diabetes Education Centre of the Lions Gate Hospital. Although recommendations for initial monitoring were met for most patients, far fewer achieved laboratory targets or received medications when eligible. An ideal focus for future interventions would be to improve initiation of medications and adjustment of doses, with an emphasis on management of cardiovascular risk factors.
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