Diabetes in primary care : quality of life, metabolic control, drugs and socioeconomic factors

Abstract

Diabetes is one of the most common chronic diseases affecting the Swedish population, with a prevalence of 3-4%. Most diabetic patients receive their care in the primary health care service. The study populations consisted of 358 diabetes subjects in 1992, and 439 in 1995, selected from three community health centres (CHCs) in the Stockholm metropolitan area and chosen to reflect the differences in demographic and socioeconomic factors in different parts of Stockholm County. As references we drew two control subjects of the same age and sex for each diabetic subject from the standard population samples (SPS) in 1991 and 1995, consisting of 2,366 and 2,500 individuals, respectively. In 1995, we also compared patients with glaucoma and mild or severe angina pectoris with the SPS. The diabetic subjects were studied with regard to their health-related quality of life (HRQOL), metabolic control, use of drugs, and to some extent socioeconomic factors.

The HRQOL was assessed by the SWED-QUAL, developed from the Medical Outcomes Study and consisting of 13 scales. There were minor differences in the versions used in 1992 and 1995. Medical data were extracted from the medical records kept at the CHCs, from half of the patients in 1992 and from all the patients in 1995. Socioeconomic information was obtained from Statistics Sweden regarding the patients in 1992.

We also studied 361 diabetes subjects from the Survey of Living Conditions (SLC) 1988-89 from Statistics Sweden, including a total of 12,717 subjects. These diabetic subjects were studied regarding their use of drugs, socioeconomic factors and psychological symptoms, compared with patients with other chronic conditions, with healthy subjects and with the general population. The responding rate on the SWED-QUAL was almost 70%. The HRQOL in diabetic patients was decreased in almost all scales regarding physical and emotional health compared with the standard population sample. both in 1992 and in 1995. The greatest differences were noted in the scales "Satisfaction with physical health", "Sleep problems" and "General health perceptions" in 1992, and in the "General health perceptions" scale in 1995. The differences between diabetic patients and thelr SPS controls were less pronounced in 1995 compared with 1992, especially regarding emotional well-being. There were, however, no differences regarding the social scales of family and marital functioning. There were only minor differences when the SWED-QUAL results for the 1992 and 1995 diabetic samples were compared. The most important predictive factors of a decreased HRQOL were vascular and non-vascular co-morbidity. Diabetic patients without heart disease showed only a minor impact on the health. while those with heart disease showed a considerable impact. Glaucoma patients in general had a HRQOL similar to that of the general population, which shows that the presence of a chronic disease per se does not affect the HRQOL. There was no correlation between the SWED-QUAL results and metabolic control.

As regards metabolic control, acceptable values were found for HbAlc in 46% and for fasting blood glucose in 44% in 1995, in line with the findings in studies from other parts of Sweden. There was no significant difference in this regard between 1992 and 1995. Eye examination was noted in 65%, urine examination in 73%, and neuropathy examination in 49% in 1995. There were significant differences between the three CHCs. The rate of severe complications was low, diabetic blindness was present in 2.2%, uraemia in 0.3%, and amputation due to gangrene in 1.2% in 1995.

The drug use in diabetic patients in the SLC was greater compared with the general population as regard overall use (93% vs. 72%) and also use of cardiovascular drugs (52% vs. 36%), analgesics (44% vs. 37%) and psychoactive drugs (24% vs. 15%). There were, however, no great differences compared to patients with hypertension or musculoskeletal disease. The pattern of diabetes treatment shifted from 1992 to 1995, with diet only from 30% to 20%, tablets from 42% to 49%, tablets and insulin combined from 1% to 8% and insulin from 27% to 23%. The prescription of drugs increased between 1992 and 1995, especially regarding ASA, from 9% to 21%, ACE inhibitors, from 5 to 21 %, and lipid-lowering drugs, from I to 7%. There were considerable variations between the three CHCs.

The sick leave and rate of disability pension in diabetic patients in the SLC were higher than in the general population (sick leave 54 vs. 27 days and disability pension 26% vs. 8%), and at the same level as in patients with chronic musculoskeletal disorders. Psychic symptoms were as common as in patients with other chronic disorders, and more common than in the healthy persons. In conclusion, diabetes is associated with a decreased HRQOL, mostly dependent on cardiovascular complications and non-vascular co-morbidity, with an increased use of drugs and with an increased rate of disability pension. Metabolic control is acceptable in only half of the patients.