Cohort monitoring of persons with diabetes mellitus in a primary healthcare clinic for Palestine refugees in Jordan

United Nations Relief and Works Agency for Palestine Refugees in the Near East, Amman, Jordan Field Health Programme, United Nations Relief and Works Agency, Amman, Jordan Tokyo University Medical School, Tokyo, Japan International Union Against Tuberculosis and Lung Disease, Paris, France London School of Hygiene and Tropical Medicine, London, UK Medecins Sans Frontieres, Medical Department, Operational Research Unit, Brussels Operational Center, Luxembourg, Luxembourg World Diabetes Foundation, Gentofte, Denmark.
Tropical Medicine & International Health (Impact Factor: 2.33). 10/2012; 17(12). DOI: 10.1111/j.1365-3156.2012.03097.x
Source: PubMed


To illustrate the method of cohort reporting of persons with diabetes mellitus (DM) in a primary healthcare clinic in Amman, Jordan, serving Palestine refugees with the aim of improving quality of DM care services.

A descriptive study using quarterly and cumulative case findings, as well as cumulative and 12-month analyses of cohort outcomes collected through E-Health in UNRWA Nuzha Primary Health Care Clinic.

There were 55 newly registered patients with DM in quarter 1, 2012, and a total of 2851 patients with DM ever registered on E-Health because this was established in 2009. By 31 March 2012, 70% of 2851 patients were alive in care, 18% had failed to present to a healthcare worker in the last 3 months and the remainder had died, transferred out or were lost to follow-up. Cumulative and 12-month cohort outcome analysis indicated deficiencies in several components of clinical care: measurement of blood pressure, annual assessments for foot care and blood tests for glucose, cholesterol and renal function. 10-20% of patients with DM in the different cohorts had serious late complications such as blindness, stroke, cardiovascular disease and amputations.

Cohort analysis provides data about incidence and prevalence of DM at the clinic level, clinical management performance and prevalence of serious morbidity. It needs to be more widely applied for the monitoring and management of non-communicable chronic diseases.

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    • "For example, the prevalence of diabetes mellitus (DM) among Palestinian refugees is estimated to be 12-15% and has doubled in the last 10 years. Obesity, a risk factor for type 2 diabetes, is a problem more prevalent in UNRWA refugee camps compared with original populations of the host countries.[6] "
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    ABSTRACT: Background: Palestinian refugees have been a displaced group of people since 1948, many of whom are living in refugee camps in the Middle East. They are entitled to free health care from the United Nations Relief and Work Agency (UNRWA). They show a higher prevalence of diabetes than the population in their host countries in the Middle East. This study examined the realities of care for diabetic patients in UNRWA health clinics in Damascus, Syria. The aim was three-fold: To investigate the level of diabetes care, to probe patients’ level of general understanding of their disease and its management, and to search for areas of potential improvement. Methods: Data on patient education and care was gathered over a 1 month period from August 4, 2008 to September 4, 2008 using questionnaires and direct observation of the workflow at the clinics. Clinic-led care was observed by the study team using checklists during patient visits. All of the clinic staff and sampled patients were interviewed. The main areas of care assessed were: Patient follow-up; examination of eyes and feet; availability of medications; and patient education. A total of 154 people with diabetes were sampled from three refugee camps situated around Damascus. Results: A total of 154 patients, three doctors and seven nurses composed the sample of the study. Foot examinations were almost always neglected by health staff and eye examinations were not offered by the UNRWA clinics. Interviews with patients showed that: 67% (95% confidence intervals [CI]: 0.59-0.70) had to buy their medication at their own expense at least once due to medication shortage in the UNRWA clinics, 48% (95% CI: 0.40-0.55) displayed poor knowledge regarding the cause and exacerbating factors of diabetes, 65% (95% CI: 0.56-0.72) had not heard of insulin, and 43% (95% CI: 0.35-0.51) did not know for how long they needed to take their medications.
    Full-text · Article · May 2014
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    • "Doctors and nurses use the e-health system (Khader et al. 2012), to record all clinical information. Quarterly cohort analysis is carried out routinely through the use of e-health, with standard patient outcomes recorded every quarter (attended clinic, did not attend clinic, died, transferred out to another health centre and lost to follow-up). "
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    ABSTRACT: In a primary healthcare clinic in Jordan to determine: (i) treatment outcomes stratified by baseline characteristics of all patients with diabetes mellitus (DM) ever registered as of June 2012 and (ii) in those who failed to attend the clinic in the quarter (April-June 2012), the number who repeatedly did not attend in subsequent quarters up to 1 year later, again stratified by baseline characteristics. A retrospective cohort study with treatment outcome data collected and analysed using e-health and the cohort analysis approach in UNRWA Nuzha Primary Health Care Clinic for Palestine refugees, Amman, Jordan. As of June 2012, there were 2974 patients with DM ever registered, of whom 2246 (76%) attended the clinic, 279 (9%) did not attend, 81 (3%) died, 67 (2%) were transferred out and 301 (10%) were lost to follow-up. A higher proportion of males and patients with undetermined or poor disease control failed to attend the clinic compared with those who attended the clinic. Of the 279 patients who did not attend the clinic in quarter 2, 2012, 144 (52%) were never seen for four consecutive quarters and were therefore defined as lost to follow-up. There were a few differences between patients who were lost to follow-up and those who re-attended at another visit that included some variation in age and fewer disease-related complications amongst those who were lost to follow-up. This study endorses the value of e-health and cohort analysis for monitoring and managing patients with DM. Just over half of patients who fail to attend a scheduled quarterly appointment are declared lost to follow-up 1 year later, and systems need to be set up to identify and contact such patients so that those who are late for their appointments can be brought back to care and those who might have died or silently transferred out can be correctly recorded.
    Full-text · Article · Jan 2014 · Tropical Medicine & International Health
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    ABSTRACT: En dépit de leur énorme charge de morbidité et de mortalité, les maladies chroniques non transmissibles dans les pays à faibles et moyens revenus ont souvent été négligées, avec une approche de soins primaires peu structurée pour leur prise en charge et un manque de suivi systématique et de surveillance des soins. Un modèle d’évaluation systématique de la prise en charge des MNT à travers le suivi de cohorte s’appuie sur l’expérience du déploiement des interventions de deux maladies infectieuses chroniques, la tuberculose et le VIH. A pesar de su alta carga de morbilidad y mortalidad en países con ingresos medios y bajos, las enfermedades crónicas no infecciosas a menudo están olvidadas, con una manejo poco estructurado dentro de la atención primaria y una falta de seguimiento sistemática y monitorización de los servicios. Un modelo de evaluación sistemática de enfermedades no transmisibles mediante la monitorización de cohortes aporta experiencia en la ampliación de intervenciones para dos enfermedades infecciosas crónicas: tuberculosis y VIH.
    Preview · Article · Oct 2012 · Tropical Medicine & International Health
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