Pattern of diabetes management for patients in outpatient department of a tertiary hospital of Bangladesh

Background: Glycemic control is the key to preventing acute and chronic complications of diabetes mellitus. Change in life style and medication are the way to achieve control and prevent complications. Numbers of drug including insulin developed till date. These drugs are effective when lifestyle is changed. Numerous guidelines developed for judicial use of these drugs based on evidence in clinical trials. Both physician`s and patient’s factors found to be responsible for overall poor control of diabetes. Objective: In this study, we intend to find out the pattern of diabetes management in outpatient department in a specialized diabetic center and to identify the factors associated with poor glycemic control. Material and Method: This retrospective cohort study was done at outpatient Department of BIRDEM, during the period of March 2015 to April 2016. Among the diabetic patients attending the outpatient department, adult subjects were selected by random sampling. Socio-demographic, clinical and biochemical data were collected from these patients. Statistical analysis was done with SPSS version 22.0. Result: Among 522 patients, 53% were male. Mean age 47.33±13.98 years, 90% were Muslim. Most (73%) of them were from urban area, 80% were educated up to SSC or more and 65% were sedentary. Their knowledge about diet plan, exercise, SMBG, foot care, and sick day management were present in 89%, 76%, 35%, 17%, and 10% respectively but their practice of this knowledge was 68% in diet plan, 63% in exercise. Most of them had type-2 diabetes and presented asymptomatic(73%). Hypertension was present in 52% patient and complications related to diabetes in 43%. Most (66%) were overweight or obese. Positive smoking history in 27% of patients, either current or ex-smoker. Among microvascular complications retinopathy and macrovascular complications, IHD were most frequent both at diagnosis and follow up. Most common (46.5%) treatment modality was combination of oral anti-diabetic drug especially Metformin with secretagogues. Most common pattern of insulin use was premixed or split-mixed regimen. Only 18% of cases HbA1c target achieved but treatment regimen escalated only in 20.5% cases. HbA1c is infrequently used in follow up (35%). We observed the glycemic burden for prolong period of time with treatment modalities. We found, average HbA1c%, average FBS and average duration of changing regimen were 8.37±0.76%, 8.9±0.98 mmol/L for 20.45±7.48 months; 9.4±0.61%, 9.76 ± 1.25 mmol/L for 39.22±12.04 months, 9.67± 0.91%, 10.48 ± 0.70 mmol/L for 46.0±15.22 months in lifestyle change only, monotherapy with OAD and combination oral drug regimen respectively, in escalating to higher regimens. Conclusion: The present study identifies that patient inadequate knowledge regarding diabetes self-management reluctance in practice of knowledge are important factors in poor control of diabetes. Clinical inertia to change the regimen or use of insulin on patient`s request or physician`s reluctance is responsible.