Tight glucose, blood pressure and lipid control in patients with diabetes
can reduce morbidity and mortality from macro- and micro-vascular
complications. However, treatment targets are not being met in a large
proportion of patients. Clinical audit involves cycles of evaluation of
current activity against standards. It allows problems to be identified and
action to be taken to address them.
Annual retrospective audits over 3 years of random samples of up to 20
patient medical records from 13 general practitioners in the midwest region
of Western Australia (n=807). Statistical tests compared the second and
third audits with the first in regard to completeness of screening, health
indicators, and the proportion of patients within The Royal Australian
College of General Practitioners and Diabetes Australia guidelines targets.
While there was a significant improvement in lipid monitoring over the
study period (p<0.001), monitoring of HbA1c and blood pressure (BP)
remained unchanged. Between the first and third audits, a reduction
in mean HbA1c (p<0.001), mean total cholesterol (p=0.017), mean LDL
cholesterol (p=0.014) and mean systolic BP (p=0.002) was seen. There
was an improvement in the proportion of patients achieving cholesterol
goals (measured by LDL and reaching a target of HbA1c <7%) between
the first and third audits; however the proportion with BP within target
declined. In the third audit, 11% of patients on diet alone, 36% on an oral
hypoglycaemic agent, 90% on three oral hypoglycaemic agents and 84%
of those on insulin were outside the target HbA1c. In the same audit, of
those outside target BP, 53% were on no treatment and 65% were only on
one type of medication. Eighty-seven percent of patients outside target
cholesterol levels had not been prescribed a statin.
Many of the audited GPs in our study undertreated BP, HbA1c and
cholesterol. Improvement in some areas was seen over the study period,
which may have been due to the quality assurance activities undertaken.
These results reveal a therapeutic opportunity for reducing cardiovascular
events in patients with diabetes. More aggressive management of BP and
lipids by GPs may see rewards in terms of reducing cardiovascular events
in patients with diabetes.
In the management of type 1 and 2 diabetes, it is clear that tight glucose, blood pressure (BP) and lipid control can reduce morbidity and mortality from macro- and microvascular complications.1–6 Best practice recommended biological targets are constantly under re-evaluation and change. Current consensus guidelines suggest the following:7
- glycated haemoglobin (HbA1c <7%)
- BP (<130/80 mmHg), and
- total cholesterol (<4.0 mmol/L).
Despite the known benefits of managing these parameters appropriately, targets are not being met in a large proportion of patients with type 2 diabetes mellitus (T2DM).8,9 Better screening alone does not improve health outcomes;10 however there is evidence of improved lipid levels with active clinical management.6
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