Assessing predictors for sustainable management of type 2 diabetes using evidence-based guidelines in public primary care in a predominantly Afro-Caribbean population.

PURPOSE: The purpose of our study was to assess the success in the public primary health care clinics in Barbados, a developing nation with a predominantly Afro-Caribbean population, of achieving the targets for the management of type 2 diabetes (T2D) set by local guidelines introduced in 2006. The targets are: A1C < 6.5% (48 mmol/mol), blood pressure (BP) ≤130/80 mm Hg and LDL cholesterol < 1.8 mmol/L. METHODS: A retrospective descriptive chart review of 499 (317 females, 182 males) T2D patients using random quota sampling. RESULTS: Only 41.2% (Men 48.3%, women 36.8%, P = .048) of the patients reached the A1C target, 39.3% (men 48.6%, women 34.0%, P = .002) reached BP target and 8.6% (men 10.8%, women 7.3%, P = .24) reached the LDL target and only 1.2% (n = 3) attained all three targets. CONCLUSION: Similar to other studies in developed and developing countries of varying ethnic composition, there was suboptimal attainment of the defined targets for all parameters and inadequate monitoring. The main predictors affecting the attainment of treatment goals were the frequency of monitoring, duration of the disease, sex and ethnicity related factors. Interestingly, the findings support a possible viewpoint that ethnicity, defined by an interplay of genetics, culture and environmental attributes, is not the single most important predictor for poor target attainment in T2D. The low attainment of the targets emphasizes the question of less rigorous and more individualized treatment to achieve better outcomes in a developing territory as recommended by the 2014 guidelines.

Discrete event simulation as a tool in optimization of a professional complex adaptive system.

Similar urgent needs for improvement of health care systems exist in the developed and developing world. The culture and the organization of an emergency department in developing countries can best be described as a professional complex adaptive system, where each agent (employee) are ignorant of the behavior of the system as a whole; no one understands the entire system. Each agent's action is based on the state of the system at the moment (i.e. lack of medicine, unavailable laboratory investigation, lack of beds and lack of staff in certain functions). An important question is how one can improve the emergency service within the given constraints. The use of simulation signals is one new approach in studying issues amenable to improvement. Discrete event simulation was used to simulate part of the patient flow in an emergency department. A simple model was built using a prototyping approach. The simulation showed that a minor rotation among the nurses could reduce the mean number of visitors that had to be refereed to alternative flows within the hospital from 87 to 37 on a daily basis with a mean utilization of the staff between 95.8% (the nurses) and 87.4% (the doctors). We conclude that even faced with resource constraints and lack of accessible data discrete event simulation is a tool that can be used successfully to study the consequences of changes in very complex and self organizing professional complex adaptive systems.

Retrospective incremental cost analysis of a hospital-based COPD Disease Management Programme in Sweden.

This paper reports on a retrospective analysis of hospital-based healthcare costs associated with the management of chronic obstructive pulmonary disease (COPD). During the second half of 2001, Simrishamn Hospital, Sweden, implemented a structured Disease Management Programme (DMP) for COPD and a total of 784 patients with COPD, enrolled in the DMP, were included in the analysis. The goal was to reduce the number of clinical events, such as severe exacerbations by early intervention, aggressive drug treatment, specialists easy available for advice, improved support for smoking cessation, increased number of scheduled follow-ups and closer tracking of high-risk COPD patients. The hospital administrative system provided data on resource consumption, such as outpatient care, inpatient care and drugs and unit cost, used in the economic analysis. The total cost of COPD drugs doubled (from euro 14,133 to euro 30,855 per year) as did the total number of outpatient visits (from 580 to 996 visits per year). The number of hospitalizations for acute COPD exacerbations and COPD with acute lower respiratory infection decreased from 67 to 25 per year. Total COPD-related healthcare costs decreased. The results presented here support the hypothesis that a COPD DMP can offer substantial overall direct cost savings.