Correlations between Direct and Calculated Low-Density Lipoprotein Cholesterol Measurements in Children and Adolescents.

BACKGROUND: Low-density lipoprotein cholesterol (LDL-C), as a modifiable risk factor for atherosclerotic cardiovascular disease, should be assessed and monitored. This study compared directly measured and Friedewald-estimated LDL-C values in children and adolescents. METHODS: Blood samples were collected from 464 children and adolescents. Calculated LDL-C (CLDL-C) levels were estimated using the Friedewald formula for any triglyceride value below 4.6 mmol/L. Direct LDL-C (DLDL-C) levels were measured on an ARCHITECT c8000 Abbott Clinical Chemistry Analyzer. The differences in LDL-C were then calculated. RESULTS: The correlation coefficients (R) between DLDL-C and CLDL-C were 0.978 (P = .148) and R = 0.970 (P = .052) for children and adolescents, respectively. Children with LDL-C values above 4.92 mmol/L had a correlation value of 0.971 (P = .419). The correlation and agreement between DLDL-C and CLDL-C in adolescents were moderate for LDL-C below 2.85 mmol/L (R = 0.806; 84.1%) and improved above 2.85 mmol/L (R = 0.978; 91.5%). In children, good correlations between DLDL-C and CLDL-C were observed for normal (<0.85 mmol/L), borderline (0.85-1.12 mmol/L), and abnormal (≥1.13 mmol/L) triglyceride levels (R = 0.9782, 0.990, and 0.951, respectively). The rates of agreement were better for normal (80.5%) and borderline (82.9%) but not abnormal (68.2%) triglyceride levels. CONCLUSION: We observed good agreement between DLDL-C and CLDL-C in both children and adolescents. The Friedewald formula provided an adequate estimate of LDL-C for most fasting specimens. LDL-C difference percentage can also be used as a quality indicator to check laboratory analyzer performance in healthy subjects.

Diabetes control in a primary care setting: a retrospective study of 651 patients.

BACKGROUND AND OBJECTIVES: As part of an ongoing evaluation of the process of care, the management of type 2 diabetes in primary healthcare settings was studied in a series of audits with the objective of improving diabetes care in a primary care center of the Saudi National Guard Health Affairs, Riyadh, Saudi Arabia. METHODS: A sample of 30 files was randomly selected every 2 weeks from a sampling frame of medical records of type 2 diabetes patients seen over the previous two weeks. The criterion of good management was arbitrarily defined as a glycated hemoglobin (HbA(1c)) less than 7%, with a test frequency of once every 3 months. The proportion of patients not conforming to the criterion was reported back to the care providers. Specially trained nurses did all randomization, data extraction, and entry. RESULTS: Data were extracted form 651 medical records, including 355 (54.5%) for females and 296 (45.5%) for males. Both the mean and median age of those studied was 53 years. Mean HbA(1c) was 9.0+/-2.0%, mean fasting plasma glucose was 9.9A+/-3.9 mmol/L, and mean 2-hour postprandial plasma glucose was 15.0+/-5.3 mmol/L. In 20.6% (134/651) (95% CI, 17.5%-23.9%) of patients the HbA(1c) level was less than 7%. Only 10.4% (68/651) (95% CI, 8.2%-13.0%) had HbA(1c) measured in the previous 3 months that was less than 7.0% and thus met the criterion for good management. In the previous 3 months, 55.4% (95% CI, 51.5%-59.3%) had been tested for HbA(1c). CONCLUSION: Management of diabetes at the primary care level leaves much to be desired. There is a need for an ongoing process of evaluation to follow up the implementation of care guidelines.

A tale of two audits: statistical process control for improving diabetes care in primary care settings.

BACKGROUND: Diabetes constitutes a major burden of disease globally. Both primary and secondary prevention need to improve in order to face this challenge. Improving management of diabetes in primary care is therefore of fundamental importance. OBJECTIVE: The objective of these series of audits was to find means of improving diabetes management in chronic disease mini-clinics in primary health care. In the process, we were able to study the effect and practical usefulness of different audit designs - those measuring clinical outcomes, process of care, or both. SETTING: King Saud City Family and Community Medicine Centre, Saudi National Guard Health Affairs in Riyadh city, Saudi Arabia. METHODS: Simple random samples of 30 files were selected every two weeks from a sampling frame of file numbers for all diabetes clients seen over the period. Information was transferred to a form, entered on the computer and an automated response was generated regarding the appropriateness of management, a criterion mutually agreed upon by care providers. The results were plotted on statistical process control charts, p charts, displayed for all employees. Data extraction, archiving, entry, analysis, plotting and design and preparation of p charts were managed by nursing staff specially trained for the purpose by physicians with relevant previous experience. RESULTS: Audit series with mixed outcome and process measures failed to detect any changes in the proportion of non-conforming cases over a period of one year. The process measures series, on the other hand, showed improvement in care corresponding to a reduction in the proportion non-conforming by 10% within a period of 3 months. Non-conformities dropped from a mean of 5.0 to 1.4 over the year (P < 0.001). CONCLUSION: It is possible to improve providers' behaviour regarding implementation of given guidelines through periodic process audits and feedbacks. Frequent process audits in the context of statistical process control should be supplemented with concurrent outcome audits, once or twice a year.

Cardiometabolic risk among Saudi children and adolescents: Saudi childrens overweight, obesity, and lifestyles (S.Ch.O.O.Ls) study.

BACKGROUND AND OBJECTIVES: Diabetes and atherosclerotic cardiovascular disease are major contributors to the global burden of disease, with a high reported prevalence of risk factors among different populations. Early and efficient assessment of cardiometabolic risk is important to identify target groups for preventive interventions. The aims of Saudi children's overweight, obesity, and lifestyles study were to estimate the prevalence of the metabolic syndrome and to compare the different paradigms of assessing such risk among children and adolescents. The study was funded by National Guard Health Affairs and approved by the ethics committee. DESIGN AND SETTINGS: A cross-sectional study of students from primary, middle, and secondary schools located in the residential areas for the Saudi National Guard employees in Riyadh. METHODS: A random sample of 2149 students, clustered by school and stratified by grade, was selected from a sampling frame of 16 812 students from 10 schools in the residential areas for Saudi National Guard employees. Informed consent was taken from children and parents. Blood pressure, height, weight, waist circumference, and hip circumference were documented. Fasting blood samples were taken for blood glucose and lipid profile. RESULTS: The prevalence of metabolic syndrome ranged from 2% to 18%, according to the sensitivity of the 6 different definitions. Systolic blood pressure and triglycerides-to-HDL (high-density lipoprotein) ratio showed a dose-response increase with the quartiles of waist circumference and body mass index (BMI). Assessment of cardiometabolic risk by diagnosing the metabolic syndrome would lead to missed opportunity of intervention in 94% to 95% of children identified to be in need of intervention by waist circumference and BMI above 75th percentile. CONCLUSION: Relying on the diagnosis of the metabolic syndrome can harm primary preventive initiatives. BMI and waist circumference for age should be used for assessing cardiometabolic risk in children and adolescents.

Guideline implementation in clinical practice: use of statistical process control charts as visual feedback devices.

OBJECTIVE: To use statistical control charts in a series of audits to improve the acceptance and consistant use of guidelines, and reduce the variations in prescription processing in primary health care. METHODS: A series of audits were done at the main satellite of King Saud Housing Family and Community Medicine Center, National Guard Health Affairs, Riyadh, where three general practitioners and six pharmacists provide outpatient care to about 3000 residents. Audits were carried out every fortnight to calculate the proportion of prescriptions that did not conform to the given guidelines of prescribing and dispensing. Simple random samples of thirty were chosen from a sampling frame of all prescriptions given in the two previous weeks. Thirty six audits were carried out from September 2004 to February 2006. P-charts were constructed around a parametric specification of non-conformities not exceeding 25%. RESULTS: Of the 1081 prescriptions, the most frequent non-conformity was failure to write generic names (35.5%), followed by the failure to record patient's weight (16.4%), pharmacist's name (14.3%), duration of therapy (9.1%), and the use of inappropriate abbreviations (6.0%). Initially, 100% of prescriptions did not conform to the guidelines, but within a period of three months, this came down to 40%. CONCLUSIONS: A process of audits in the context of statistical process control is necessary for any improvement in the implementation of guidelines in primary care. Statistical process control charts are an effective means of visual feedback to the care providers.

Prescription non-conformities in primary care settings: how useful are guidelines.

BACKGROUND: Apart from having a negative impact on work flow in practice, prescription errors may pose a threat to patient safety. Such errors have been reported in the pharmaceutical services in spite of the clear guidelines issued by the parent organization. OBJECTIVE: This study was to explore the degree of conformity to the prescribing guidelines at Primary Care level in the Saudi National Guard Health Affairs in Riyadh. METHODS: Prescriptions were collected during audits done fortnightly through a simple random selection from a sampling frame of all prescriptions given within the period. Information about each prescription was entered in a database by the pharmacists and each prescription was classified according to its conformity to the guidelines. Information was presented on 330 prescriptions for eleven audits carried out from September 2004 to February 2005. RESULTS: 87% of the prescriptions did not conform to the given guidelines. Less than 1% of the inconsistencies were potentially harmful to the patient, 77.8% had possible negative effect on the pharmacist's work, while 21.3% were unimportant. Patient information was deficient in 16.9% of cases, drug information in 49.6% and archiving/record information related non-conformities constituted 33.5%. CONCLUSIONS: Conformity to prescribing guidelines is quite low in spite of the significant input of resources by the parent organization. This burden on work flow, utilization of time and service delivery needs to be studied and addressed by ensuring that there are periodic audits in the work routines of primary health care, and a feedback given to the care providers.