|ISSN No. 1606-7754 Vol.12 No.1&2 April-August 2004|
A study of risk factors and complications in newly referred patients to diabetes clinic
S. Rajpara and K. Imtiaz
Department of Medicine, Lancashire Teaching Hospital NHS Trust, Chorley and South Ribble Hospital, Preston Road, Lancashire, PR7 1PP, United Kingdom
This study investigated the presence of risk factors and complications in the newly referred patients to our diabetes clinic. It also looked into how these risk factors and complications were being managed as compared to existing guidelines and evidence. In the present study 58 diabetic patients were included, 24 % (14/58) were smokers, 55% (32/58) were obese and 27 % (15/58) were overweight. Mean total cholesterol/HDL ratio was 4.52 and mean HbA1c was 8.29. Out of 49 type 2 diabetic patients 57.1% (28/49) patients were hypertensive and 50% (14/28) patients were on 3 or more antihypertensive drugs. Twenty of forty nine (40.8%) type 2 diabetic patients had high microalbumin/creatinine ratio and 55% (11/20) of them were on ACE inhibitors. In the type 2 diabetic group 85.7 % (42/49) were either overweight or obese and 40.4% (17/42) of these patients were on metformin. Thirteen of fifty eight patients (22 %) had ischaemic heart disease; and 22% (13/58) had total cholesterol/HDL ratio > 3.9 out of whom 31% (4/13) were on statins. All patients who were smokers received advice on stopping smoking and were offered counseling services and nicotine patches/bupropion by their General Practitioners.
Keywords : risk factors, diabetes, complications, patients
Chronic macrovascular (ischaemic heart disease, cerebro-vascular disease, peripheral vascular disease and hypertension) and microvascular complications (retinopathy, nephropathy and peripheral and autonomic neuropathy) are often present in patients at the time of diagnosis of diabetes and with increasing duration these become more frequent.1 Many of these complications can be delayed or prevented with better glycaemic and blood pressure control.2 In addition, early identification and management of these complications can retard the progression of these complications.2 In the UK the majority of type 2 and a small number of type 1 diabetic patients are managed by the primary care physician (GP) and referred to hospital either because there is a problem with metabolic control or there is a development of complications which cannot be managed at their local practice. Our aim was to study the prevalence of cardiovascular risk factors and chronic macro- and micro- vascular complications in newly referred patients to the hospital diabetes clinic. We also aimed to find out the management of these complications in the primary care centre according to pre-existing guidelines.
Materials and Methods
All patients seen in the hospital diabetes clinic between the periods of 1st August 2001 to 31st July 2002 as new referrals from primary care physicians were identified using the hospital electronic database. There were 58 diabetic patients (37 males, 21 females) referred to the Chorley Hospital outpatient diabetes clinic during that period. Chorley hospital is a district general hospital; a part of Lancashire Teaching Hospitals NHS Trust and provides health care for a population of 201,547. It has a dedicated outpatients department for diabetes and 3 consultant diabetologists. Data were collected from case notes and were analysed with the help of the audit department. All patients were Caucasians except for one who was a South Asian. All patients were referred from general practitioners because of their poor diabetes control. Many of the complications were already known to the GPs and were included in the referral letter and when necessary further tests were done to confirm them.
The patients had body mass index (BMI) measured at the time of the first appointment and those with BMI 25-29.9 were included in the overweight group and patients with BMI greater than 30 were included in the obese group. HbA1c was also measured in all patients. Patients with blood pressure greater than 140/80 mm Hg were considered hypertensive. Patients with documented evidence of myocardial infarction or angina with ECG changes/ positive exercise tolerance test/ positive coronary angiography were considered to have ischaemic heart disease. Peripheral neuropathy was diagnosed by clinical examination of the feet using 10 gram monofilament and neurotip with use of nerve conduction studies when needed. Urinary albumin/creatinine ratio was measured in the early morning urine sample of the patients and the patient was considered to have microalbuminuria if it was greater or equal to 2.5g/24h in males and 3.5g/24h in females. Fasting blood sample was collected to measure total cholesterol and total cholesterol/HDL ratio. Retinopathy was diagnosed by slit lamp examination of fundus by ophthalmologists or accredited opticians.