An Audit of Cardiovascular Risk Management in Type 2 Diabetes Mellitus at Kenyatta National Hospital.

Abstract

Background: Type-2-diabetes-mellitus (T2DM) is the commonest form of DM worldwide and is associated with long-term complications. Adequate control of cardiovascular (CV) risk factors in T2DM is associated with up to a 50% decrease in risk of cardiovascular and microvascular events. Local studies show that specific CV risk factors in T2DM are prevalent but inadequately controlled. Objectives: To determine the adequacy of management of cardiovascular risk and healthcare practitioner’s knowledge of management of cardiovascular risk among T2DM patients at Kenyatta National Hospital. Materials and Methods: A cross-sectional study with a retrospective and a prospective component was done at Kenyatta National Hospital (KNH). The study areas were the diabetes outpatient clinic, its decentralized records department, and the medical wards. The study involved 74 healthcare practitioners chosen by non-probability purposive sampling and 362 T2DM patient files chosen by systematic random sampling. Results: Of the 362 study subjects: 68% were female, the median age was 59.0 (IQR 50.0 – 67.0) years, the median duration of diabetes was 9 (IQR 4-14) years, and the majority (47.8%) had had two clinic visits during the period of study. Risk-stratification indicated high risk in 57.7% of the study group. Eighty-one (81.5%) had hypertension, and 87.8% of these were on a RAAS blockade-based regimen. Two-thirds (67.5%) of these had off-target BP readings. Only 43.6% of patients with T2DM had documented HbA1c results, and only 34.8% were within the target range as per guidelines. About half (56.9%) of the study group had lipid profiles requested within the previous 12 months; none had documented specified targets for LDL control. The use of an antiplatelet agent for appropriate primary and secondary prevention of atherosclerotic cardiovascular disease (ASCVD) was at 14.6% and 66.7% respectively. Assessment of healthcare practitioners' knowledge on CV risk management in T2DM revealed a below-average level. The internal-medicine-residents’ mean score was 39%, the clinical-officers score was 36.4% and the medical-officers' mean was the lowest at 27%. Conclusion: There was an overall low performance across most aspects of CV risk management as shown by both audit arms. We, therefore, concluded that CV risk factor management was inadequate, likely due to insufficient knowledge on current guideline-directed management.