This clinical audit assessed the quality of care for diabetic patients at the North Al-Khuwair Health Center in Oman in 2017. The audit reviewed records for 100 randomly selected diabetic patients. Key findings included: 1) Only 12% of patients had a healthy BMI, while most were overweight or obese; 2) 67% of patients were hypertensive but only 40% had their blood pressure well controlled; 3) 48% of patients had good blood sugar control as measured by HbA1c levels but 10% had poor control. The audit identified areas for improvement in lipid screening, nephropathy screening, foot examinations, and referrals to dieticians. Factors like patient non-compliance and incomplete physician

1. Clinical audit of diabetic clinic in
North Al-Khuwair Health Center 2017
Conducted By:
Dr.Omar AL-Suhai
Dr.Mahmood AL-Haddabi
Supervisor:
Dr.Najah AL-Noobi
Dr.Rahma AL-Hadrami

2. Background:
The prevalence of diabetes mellitus (DM) continues to increase worldwide both in
developing and developed countries [1]. The total number of people with DM is
projected to rise from 171million in 2000 to 366 million in 2030 [1]. Studies have
shown that diabetes and pre-diabetes are highly prevalent among the population in the
Middle East [2]. Among these countries is Oman were it ranks among the top ten
countries worldwide in the prevalence of DM [3]. Two surveys that were conducted a
decade apart indicated how rapidly is the rise of diabetes among Omani adults aged
30–64 years (12.2% in 1991 versus16.1% in 2000) [2,3].
Medical care of diabetic patients in developing countries,similar to the developed
countries, is primarily done at primary health care facilities.
In Oman, most of DM patients are followed-up at diabetic clinics that are run by
general practitioners and/or internist at primary health care centers that are spread
across the country. Therefore, the results of biochemical tests performed for DM
patients in these centers should reflect the level of primary care management of
Omani diabetic patients.
Aim:
To train family medicine residents on how to conduct successful clinical audit.
Objectives:
To improve family medicine residents knowledge and skills on conducting successful
clinical audit activity.
To assess the quality of care delivered to diabetic patients attending PHCs in
comparison to international approved standards.
To propose feedback for improving the quality of care.
To find out system weakness in order to improve it.
[1] S. Wild, G. Roglic, A. Green, R. Sicree, H. King, Global prevalence of diabetes: estimates for the year 2000 and projections for 2030,
Diab. Care 27 (2004) 1047–1053.
[2] J.A. Al-Lawati, A.M. Al-Riyami, A.J. Mohammed, P. Jousilahti,Increasing prevalence of diabetes mellitus in Oman, Diab.Med. 19
(2002) 954–957.
[3] M.G. Asfour, A. Lambourne, A. Soliman, S. Al-Behlani, D.Al-Asfoor, A. Bold, H. Mahtab, H. King, High prevalence ofdiabetes mellitus
and impaired glucose tolerance in theSultanate of Oman: results of the 1991 national survey, Diab.Med. 12 (1995) 1122–1125.

3. Methodology:
Auditing was conducted during the period from 18/3/2018 to 5/4/2018.
The Target population was: all diabetic patients following up during the
year 2017 in North Al-Khuwair Health Center.
.The total number of diabetic patients registered in the diabetic
registration was 359 patients.
The sample size was 100 patients.
Patients were assigned in two teams A and B, randomly selected 50
patients from each team .
We used Quasi randomization sampling method to choosethe patients
by including every fourth patient in the registry, with exclusion of:
defaulters, dead, patient who are registered but has no documented visit
in the diabetic clinic in 2017.
The collected data was entered and analyzed via SPSS version 19
program.

4. Results:
Standard 1: Gender and Age distribute
The sample included 52% males and 48% females.

5. 56% of the sampled patients aged 60 years old and above , 27% were
between 50-59 yrs old , 11% were between 40-49 yrs old , 3% between
30-39 yrs old and 3% were between 18-29 yrs old as well.

6. Standard 2: BMI

7. 95 % of included patients had their BMI checked in at least once and 5%
were not checked during 2017.
Only 12% of them their BMI was within the target (18-24.9%). 43%
were overweight , 18% were class I obesity ,14% were class II and 8%
were class III obesity.
Standard 3: blood pressure:
67% of the diabetic patients in our audit were also hypertensive and 33%
were not hypertensive.

8. <140/90 mmHg is the target BP in diabetic patients according to ADA
guideline.
Among the 67% of the hypertensive patients 40% had well control BP
readings, while 27% had BP reading above the mentioned target.
From 33% patients who were not known to have HTN ,28 % had BP
readings <140/90 mmHg and 5% found to have BP >= 140/90 mmHg .

9. Standared 4:HbA1c:
According to ADA guideline HbA1c should be measured at least twice a
year in patients who are meeting the treatment goals and who have stable
glycemic control. For patients who are not meeting the glycemic goals or
whose therapy has changed, HbA1c should be checked 4 times a year.
In our audit we found 45% of patients their HbA1C checked once, 51%
checked twice or more, while 3% no HbA1c done for them and 1%
requested but not done.

10. 48% of the sampled diabetic patient had good control (HbA1c <7),
While 38% had HbA1c between 7-9.
10% of patients had HbA1c >9 which means poorcontrol of their blood
sugar levels.
According to ADA 2017, goal of HbA1c in non-pregnant adults is < 7,
but the target should be individualized according to the patient co-
morbidities and age.

12. As diabetic patients get older their HbA1c attain the target.

13. Standard 5: lipid screening and statin
33% of patients had their latest LDL equal or above 2.6 , while 58 % had
LDL below 2.6.
7 % of patients' LDL not done during 2017 and 2% done not reported.
According to ADA guideline the goal of LDL cholesterol <2.6 mmol/L.
79.17 % of patients with LDL >= 2.6 had been started on statin, whereas
18.75% of patients were not started on statin despite high LDL which is
highly significant indicators that need to be evaluated and improved.
2.08 % were not indicated .
79.17 % of patients with LDL >= 2.6 had been started on statin, whereas
18.75% of patients were not started on statin despite high LDL which is
highly significant indicators that need to be evaluated and improved.
2.08 % were not indicated .

14. 87% of the patients in our sample were on statin, while 4 % were not.
In 7% statin was not indicated for them and 2% refused to take statin.

15. 15 % of the patients required statin doseto be titrated up, while 12% of
the patients their statin dosestill below the ideal dosein order to reach the
target lipid profile.
72% of the patients did not require any changes in statin dose.

16. Standard 6: Nephropathy screening :
As per ADA guideline serum creatinine should be done at least annually
in all adult with diabetes regardless of degree of urine albumin excretion.
In our sample 88 % of diabetic patients had their serum creatinine done in
2017 and in 10 % patients not done, while 2% had creatinine requested
but not done.

18. We found that 57 % of patients had normal ACR values, 17 % had
microalbuminurea, 7% of patients had macroalbuminurea, on the other
hand 17% of the patients the ACR was not done for them.

19. According to ADA guidelines in the treatment of non-pregnant patients
with moderately elevated (microalbuminurea Male 2.5/Female 3.5-29.9
mg/day ) or higher level (macroalbuminurea >=30.0 mg /day ) and
(overt proteinurea >300 mg/day) of urinary albumin excretion , either
ACEI /ARBs are recommended .
In this audit 20% of patients with abnormal ACR value were on
ACE/ARBs , while 4% were not .
33% of patients with normal ACR were on either ACE or ARBs for other
reasons like hypertension.

20. Nephropathy among diabetic patients
32% of diabetic patients in our sample had no evidence of nephropathy,
while 50% of the patients were diagnosed with various stages of
nephropathy as per ADA guideline.

21. -Among 43% of Patients who have been diagnosed with diabetes for >10
yrs, 26% of them had evidence of diabetes nephropathy.
-11% had diabetic nephropathy in patients who have been diagnosed with
diabetes 5-10 yrs, compared to 13% who had diabetic nephropathy in
patients diagnosed with diabetes < 5 years.
-33.68% pt at duration 5-10% had the disease.
-only 16.84% with durartion <5 yrs has DN.

22. Standard 8: starting aspirin as primary prevention
We found 63% of the patients were on aspirin, 14 % were not on aspirin
and 23% of the patients were not indicated to be on aspirin.

23. - 6% of the patients were on diet only and all of them were newly
diagnosed (within 2017).
- 31% of patients were on metformin alone.
- 21% were on both metformin and sulfonylurea
- 18% of the patients were on metformin and other OHA (like
sitagliptine).
- 6% were on insulin alone.
- 17% were on insulin and OHA.
- 1% of the patients were on other OHA.

24. This graph reflects the progressive nature of Diabetes Mellitus, as the
duration of the disease increased the need of combination of insulin and
other OHA become more needed to attain the target control.

25. Standard 9: Foot, Eye and Dietician assessment
86 % of the patients in our Audit had eye referral done and 91% of the
patients had their foot assessment done.
85 % of patients were not seen by Dietician which is high percentage of
patients.
91
86
149 11
85
0 3 1
FOOT ASSESSMENT EYE ASSESSMENT DIETICIAN
Foot, Eye,& Dietician assessment
Done Not done Refused

26. Standard 10: smoking status, CVD risk and Vaccination
-88% of the cases in this audit had no information about their smoking
statusm while were 5% or less who are documented to be smoking, not
smoking or ex-smoker.
- 63% of the patients had their CVD risk documented, while it was not
documented in 37%.
- 45 % of the patients received their annual influenza, while 55% did not
receive.
3
63
45
5
37
55
4 0 0
88
0 0
0
20
40
60
80
100
Smoking CVD Vaccination
Smoking, CVD and vaccination
Yes No X-smooker Knot known

27. Factors affecting the result
Patient factors:
 Medication compliance.
 Follow up Compliance:
 Missing appointment.
 Coming on different day under general medicine.
 They are not attend totally and only taking medication.
 Refusing intervention:
 Refusing medication (insulin, statin or aspirin)
 Refusing further assessment when needed like referral to
dietitian and ophthalmologist.
 Not giving the investigations that ordered by the doctors like
urine samples.
Doctor factors:
- Updating knowledge about the latest guidelines.
- Documentation of some of the information were missing like:
 Patient referral to dietician.
 Documentation of feedback from ophthalmologist.
 Documentation of the medications compliance.
 Documentation of past medical history, smoking status,
alcohol intake, and family history of CVD were deficient.
 Calculating CVD risk as it is needed for aspirin and statin.

28.  System factors:
 Lack of feedback system provided from other specialty.
 Some investigation taking time to be resulted.
 Lack of communication when the sample not good to be
analyzed.

29. Recommendation:
1. Staff (doctors, nurses and dietician) should be updated
regarding guidelines: through lectures, keeping the targets
value in the OPD, and doing clinical audit to make their
practice up to the standard.
2. Insure documentation of basic details like CVD risk,
smoking status, past medical history and FH, other
specialty input, and the management plan.
3. Doctors should be responsible for patient care and utilize
the resources available like dietician, and to assess their
follow up.
4. Extra time can be given for some patient like newly
diagnosed patient, patient with HbA1c > 9 (making
Diabetic after noon clinic for those patients).
5. Make sure that all patients follow up in their appointment
by calling them if they miss their appointment and if the
patient called to be documented in the notes.
6. In case any patient missed his appointment in diabetic
clinic and come to the general clinic should be given
medications for few days only, and to give them
appointment in diabetic clinic and encourage them to
follow up.
7. Compare the result of this audit with next audit that we
recommend to be done annually.

30. Action Plan:
Subject How to do it? Responsibility Time frame Remarks
BP and BMI
measurement
Insure that triage
was done for all
patient in each
visit
Nurse in diabetic
clinic
Immediate Closed
HbA1c
Calculated at least
twice per year for
all diabetic
patients and 4
times if not
controlled.
Diabetic focal
point
Immediate Closed
ACR
Annual
measurement
Diabetic focal
point
Immediate Closed
eGFR
Annual
calculation of
eGFR
Diabetic focal
point
3 months Open
Aspirin /statin
Start patient on
aspirin/statin as
per guidelines
Diabetic focal
point
Immediate Closed
Patient with
HbA1c > 9
not on insulin
Discuss with
patient the need
to start insulin
Diabetic focal
point
Immediate Closed
Dietician Utilize resources
Diabetic focal
point
Immediate Closed
Eye assessment Annual referral to
ophthalmologist
Diabetic focal
point
Immediate Closed
Foot
assessment
At least once Diabetic focal
point
Immediate Closed