title: The two levels of care for diabetes in a developing country: Mechanisms for improved intermediate health outcomes.
abstract: India has over 70 million citizens with diabetes, the second-most of any country worldwide. Disparities in learning skills, resources, education, and physician practices make it difficult to practically implement the diabetes management guidelines recommended by international scientific organizations. In its guidelines, the International Diabetes Federation advocates for three different levels of care based on availability of resources. This study investigates the differences in intermediate health outcomes between two diabetes care programs: one a comprehensive diabetes centre, the other a limited care setting. The comprehensive centre offers telemedicine and periodic diabetes education, empowering patients and providing 24-hour advice on lifestyle modifications, diet, and exercise. All patients of this centre practice self-monitoring of blood glucose. The subjects in the limited care setting receive minimal investigations and periodic physical follow-ups, and few patients have access to home glucose monitoring. The results showed that HbA1c (7.62 vs. 8.58, p=0.003), cholesterol (134.4 vs. 173.4, p<0.001), and diastolic blood pressure (72.9 vs. 77.0, p=0.016) were significantly lower in patients receiving comprehensive care, while the reductions in systolic blood pressure (134.6 vs. 138.7, p=0.202) did not achieve statistical significance. These reductions, which remained significant after correcting for confounding factors, could be attributed to more aggressive treatment regimens in the comprehensive care centre, as well as the real-time, frequent communication with medical professionals in the telemedicine program.
authors.affiliation: Departments of Medicine and Pediatrics, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Rebecca J
authors.initials: RJ
authors.lastname: Vitale
authors.affiliation: Department of Diabetes, Jothydev's Diabetes Research Centre, Trivandrum, Kerala, India.
authors.forename: Pradeep B
authors.initials: PB
authors.lastname: Pillai
authors.affiliation: Department of Diabetes, Jothydev's Diabetes Research Centre, Trivandrum, Kerala, India.
authors.forename: Gopika
authors.initials: G
authors.lastname: Krishnan
authors.affiliation: Department of Diabetes, Jothydev's Diabetes Research Centre, Trivandrum, Kerala, India.
authors.forename: Sunitha
authors.initials: S
authors.lastname: Jothydev
authors.affiliation: Department of Diabetes, Jothydev's Diabetes Research Centre, Trivandrum, Kerala, India. Electronic address: jothydev@gmail.com.
authors.forename: Jothydev
authors.initials: J
authors.lastname: Kesavadev
mesh_terms: D000328:Adult; D000368:Aged; D003191:Comprehensive Health Care / Q000706:statistics & numerical data; D003695:Delivery of Health Care / Q000379:methods* / Q000458:organization & administration; D003906:Developing Countries / Q000706:statistics & numerical data; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology / Q000628:therapy*; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D008019:Life Style; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement; D017216:Telemedicine; D016896:Treatment Outcome
keywords: Comprehensive care; Levels of care; Minimal care; Outcomes; Targets of therapy