Official Journal Of The Trinidad & Tobago Medical - the Trinidad and ...

Caribbean Medical Journal
Development of a Nationwide T&T Diabetes Outreach Program
Part 2: Specific Programs
Immediately after a patient has anthropometrics entered and
POC testing performed, the data, collected and now stored in
TTDEMS, is printed out onto a “Stoplight Form” by a color
printer; one copy is given to the healthcare provider, and another
copy is given to the patient. The purpose of this form is twofold-
- to provide POC results for the healthcare provider to act upon
during the clinic visit that same day, and to alert patients to their
level of control for each parameter. Ten parameters indicated
on each Stoplight Form: body mass index, blood pressure,
HbA1c, glucose, urinary microalbumin:creatinine ratio, total
cholesterol, triglycerides, LDL cholesterol, HDL cholesterol
and foot exam. The TTDEMS system flags individual patient
results with a red light, yellow light, or green light, based on
ranges consistent with those recommended by CHRC, PAHO,
and the American Diabetes Association. A red light indicates
“poor; take action”; a yellow light indicates “needs improvement”;
and a green light indicates “good”. The reverse side of the
Stoplight Form contains suggestions for providers on diabetes
care pathway guidelines. See attached sample of a Stoplight
Form given to a patient who participated in our Diabetes Outreach
Program (Figure 1 of Stoplight Form).
TTDEMS not only prints out immediate results on the individual
patient, but can aggregate data. The aggregate group data stored
in the TTDEMS database can be used for a variety of purposes:
To assess prevalent risk status (such as HbA1c, dyslipidemia,
and hypertension); to assess prevalent complication status (such
as microalbuminuria); and to assess the prevalence of provider
adherence to CHRC/PAHO guidelines for management of
diabetes.
A number of health care research questions could be evaluated
using aggregate data, such as: What is the status of diabetes
care in each clinic? What characteristics affect the health status
observed – access to or utilization of services? Medications
prescribed? Medications taken? Does POC testing improve a
clinic’s achievement of guideline adherence (such as regularity
of HbA1c, lipid, or microalbumin testing), and does it change
provider adherence to established guidelines? Studies have
suggested that having access to immediate test results through
POC testing is associated with the same or better medication
adherence compared with having test results provided by a
pathology laboratory 6 .
In 2009, we conducted pilot assessments on 51 patients (55%
female and 45% male) using the equipment described above at
the Couva District Health Facility, the Princes Town District
Health Facility, and the Point Fortin Health Centre. 39% of
patients had HbA1c > 10% (Figure 2), indicating poorly
controlled diabetes, at high risk for complications. 91% of
patients had blood pressures that were not at goal, i.e. systolic
BP > 130, and/or diastolic BP > 80. 49% of patients had LDL
cholesterol levels > 100 mg/dL. These are only pilot data, of
course, not necessarily representative of larger populations.
Figure 2: Pilot Study – Hemoglobin A1c distribution
In the remaining years of the Diabetes Outreach Program of
the TTHSI project, the goal is to assist in the transfer of this
technology into individual health centers for continued use.
The potential is to have in place, in these Regional Health
Authorities and local health care sites, the equipment for
improving individual patient care while collecting computerized
data that can help in public health analyses and resource
allocation.
Diabetes Eye Screening Program
Two landmark studies, the Diabetic Retinopathy Study 7 and the
Early Treatment Diabetic Retinopathy Study 8 , proved that early
treatment of diabetic retinopathy with laser photocoagulation
can reduce the risk of severe vision loss by at least 57%. The
key treatment, however, is to have it done at the right time,
when ophthalmologic examination finds high risk nonproliferative
retinopathy, proliferative retinopathy, or macular
edema. With the exception of macular edema, which may cause
blurring of vision, the other stages of retinopathy can initially
be asymptomatic. Thus, the general recommendation is that
people with diabetes have an ophthalmologic examination
annually. In T&T, as in most countries in the world, an annual
ophthalmologic examination is not practically possible for most
people with diabetes.
The National Health Service (NHS) in the United Kingdom has
successfully addressed this problem of resources by instituting
a nationwide retinal photography program. People with diabetes
are not routinely examined by an ophthalmologist, but instead
have retinal photographs taken. The pictures are digitally
transmitted to a central reading center that evaluates which
people require further examination for treatment by an
ophthalmologist, and which do not.
The TTHSI Diabetes Outreach Program’s Retinal Screening
Program is patterned after the UK model as described above.
Retinal photographs will be captured in regional health clinics
by trained photographers using the Canon CR-1 non-mydriatic
digital retinal camera (Canon Medical Systems, Irvine, California,
USA). Photographers need not have medical backgrounds, but
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