We had some limitations in our study. Not all T2D patients in the North Karelia region were included as a large amount of the T2D patients are also undiagnosed in Finland (Finnish Diabetes Added Association 2016) even though the detection rate has improved recently. Missing data were another important limitation of our study. There is possibility of missing information for those who did not use the health care services during our study period or may have used only private health
care services. Some postal code area level data was missing as Statistic Finland do not provide data for those post code areas with very few inhabitants, but the range of missing data was between 1 to 4.8% only.
7 CONCLUSION
In a nutshell, we found that HbA1c measurement rate has improved in North Karelia by the subsequent years irrespective of gender. However, achievement in the recommended level of HbA1c deteriorated in both genders over time, which could be partly explained by aging of the population. Less achievement in recommended level of HbA1c may cause more complications, reduce the quality of life in T2D patient and may increase the cost of T2D care in future. Tailored individual treatment strategies may improve the situation. Gender disparity still exist in the management of LDL, male showed more improvement in the management of LDL than females.
It appears that females are at high risk of suffering from cardiovascular consequences related to diabetes in future. New strategies for the prevention of cardiovascular events in diabetic females should be in focus. Older patients were more likely to be measured for HbA1c but less likely to show improvement in HbA1c management. They were more likely to be measured for LDL and more likely to show improvement in LDL management. This statement indicates that there is a gap between process of care and outcomes. It can be a good area to focus in future research.
According to our study, younger patients are less likely to be measured for their HbA1c. If younger patients are not followed up properly, the deterioration of HbA1c level might be overlooked and they might develop complications, which in turn reduce the quality of life among them, increase mortality and the costs of T2D care. In Finland, population is aging and many prior studies have showed that aging causes less achievement in the target levels of HbA1c (Bruce et al. 2000).
However, the main goal of the treatment of T2D in elderly is to improve the quality of life, to promote self-reliance and to get free of symptoms (Current Care Guideline 2016). Thus, it would be interesting to observe whether along with HbA1c and LDL the quality of life among patients with diabetes has improved or not in North Karelia, Finland.
Another important finding of our study was that there is variation in the measurement and management of HbA1c and LDL between area level proportion of education, area level proportion of unemployment, and area level median income of the citizens. However, these socioeconomic (SES) factors were not able to predict the improvement in the follow-up or management of HbA1c and LDL. Availability of health care facilities, awareness about the disease within the community and most importantly the individual health behaviour may cause the variation in the measurement
and management of HbA1c and LDL between area level SES factors (Brown et al. 2004).
Therefore, new targeted health promotion strategies focusing on the improvement of individual motivation for life style modification and adherence to medication may improve the T2D care.
Future studies investigating the underlying causes of socioeconomic differences in process and outcomes of diabetes care considering the factors such as differences in the availability of health care services and individual health behaviour may provide better information for policy planning.
However, our study results have also imperative policy implications for the area level allocation of resources and formulation of better management strategies for T2D patients.
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