title: A first country-wide review of Diabetes Mellitus care in Bhutan: time to do better.
abstract: BACKGROUND
  There is an increasing trend of non-communicable diseases in Bhutan including Diabetes Mellitus (DM). To address this problem, a National Diabetes Control Programme was launched in 1996. There is anecdotal evidence that many patients do not visit the DM clinics regularly, but owing to lack of cohort monitoring, the magnitude of such attrition from care is unknown. Knowledge of the extent of this problem will provide a realistic assessment of the situation on the ground and would be helpful to initiate corrective actions. In this first country-wide audit, we thus aimed to determine among type 2 DM patients registered for care the i) pre-treatment attrition ii) one-year programme outcomes including retention in care, died and Lost-to-follow-up (LTFU, defined as not having visited the clinic at least once within a year of registration) iii) factors associated with attrition from care (death + LTFU) and iv) quality of follow-up care, measured by adherence to recommended patient-monitoring protocols including glycaemic control.
  
  
  METHODS
  A retrospective cohort study involving a review of records routinely maintained under the National Diabetes Control Programme. All type 2 DM patients registered between 1st January and 31st December 2012 in 18 district hospitals of Bhutan were included. Glycaemic control was defined as glycosylated haemoglobin of <7% or [Fasting Blood Sugar of <130 mg/dl and, Post-prandial Blood Sugar of <180 mg/dl].
  
  
  RESULTS
  Of 350 registered DM patients (52% female, median age 55 years), 63(18%) were LTFU before treatment initiation (pre-treatment attrition). Of the remaining 287 individuals who started treatment, 226(79%) were retained in care while 61(21%) either died or were LTFU. Glycaemic control was achieved in 85(38%) patients retained in care. Between 7 and 98% of monitoring parameters had missing data.
  
  
  CONCLUSIONS
  Nearly one-third of DM patients were LTFU and there were short comings in monitoring. Qualitative research is urgently needed to find out the reasons for high attrition. Given the high political commitment by the Royal Government of Bhutan, the findings provide ample grounds for instituting corrective measures and propelling DM care further. It is time to do better!
authors.affiliation: Policy and Planning Division, Ministry of Health, Thimphu, Bhutan. kinleyzam@health.gov.bt.
authors.forename: Kinley
authors.initials: K
authors.lastname: Zam
authors.affiliation: International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India. akumar@union.org.
authors.forename: Ajay M V
authors.initials: AM
authors.lastname: Kumar
authors.affiliation: WHO Country Office for India, New Delhi, India. achantas@rntcp.org.
authors.forename: Shanta
authors.initials: S
authors.lastname: Achanta
authors.affiliation: WHO Country Office for India, New Delhi, India. bhatp@rntcp.org.
authors.forename: Prashant
authors.initials: P
authors.lastname: Bhat
authors.affiliation: WHO Country Office for India, New Delhi, India. naikb@rntcp.org.
authors.forename: Balaji
authors.initials: B
authors.lastname: Naik
authors.affiliation: Policy and Planning Division, Ministry of Health, Thimphu, Bhutan. kadozangpo1973@gmail.com.
authors.forename: Kado
authors.initials: K
authors.lastname: Zangpo
authors.affiliation: Department of Public Health, Ministry of Health, Thimphu, Bhutan. Tandindorji@health.gov.bt.
authors.forename: Tandin
authors.initials: T
authors.lastname: Dorji
authors.affiliation: National Diabetes Control Programme, Department of Medical Services, Ministry of Health, Thimphu, Bhutan. ywangdi@health.gov.bt.
authors.forename: Yeshey
authors.initials: Y
authors.lastname: Wangdi
authors.affiliation: Medecins Sans Frontieres, Brussels Operational Center(Operational Research), Luxembourg City, Luxembourg. rony.zachariah@brussels.msf.org.
authors.forename: Rony
authors.initials: R
authors.lastname: Zachariah
mesh_terms: D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities; D001631:Bhutan; D001786:Blood Glucose; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D005260:Female; D006442:Glycated Hemoglobin; D006801:Humans; D008297:Male; D008499:Medical Records / Q000706:statistics & numerical data; D008875:Middle Aged; D012189:Retrospective Studies
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin