It is observed in the past, that there is variation in quality of T2D care based on age, gender and socioeconomic status. A study in Finland examined the difference in achievement of control and treatment targets in T2D patients by different areas and the study found that area-level inequalities exist in the care of T2D by a detailed 7-class area classification. The study also analyzed the influence of demographic factors in achievements of control or treatment targets of T2D and found that gender, age, area-level education and the area class in which patient belongs to are associated with achievements in control and treatment targets (Toivakka et al. 2015).
2.6.1 Variation in the quality of T2D care by age
Quality of care is found to be associated with age. A study in Hong Kong examining the quality of care of patients with T2D in primary care setting found that older people are more likely to achieve the HbA1c target but less likely to have been followed up regularly (Wong et al. 2012). Another study investigating the quality of the process of diabetes care provided to the patients under universal health insurance coverage found that annual testing for HbA1c was less frequent among young diabetic individuals compared with elders (Tanaka et al. 2016). Also, a study among urban African Americans, after follow-up of 5 to 12 months from baseline, found that young adults had higher prevalence of poor glycemic control (El-Kebbi et al. 2003).
2.6.2 Variation in the quality of T2D care by gender
Many studies have observed the association between gender and the quality of T2D care along with age. Significant variation was found in the quality of care based on gender. A study investigating the literature about gender specific care differences, found that women were at higher risk than men in developing diabetes related complications. The study showed that women are at 4-6-fold higher risk for developing CVD and less likely to receive treatment for it compared with men. It was also observed that diabetic women have a higher risk for hypertension and dyslipidemia compared with men. Therefore, the author concluded that gender specific care should be highly considered during the planning of policies for diabetes care (Legato et al. 2006). Another study investigated the potential disparities in the quality of T2D care in Hong Kong by patient characteristics and clinics. The study found that women were 17% less likely to achieve the HbA1c target compared with men (Wong et al. 2012). A study investigating the racial and gender influence on diabetes care using health care effectiveness data and information set (HEDIS), medicare
enrollment files and U.S. Census found that females have received more HbA1c screenings and eye examination compared with males and cholesterol screening was almost similar in males (91.4%) and females (91.9%) (Chou et al. 2007). A study conducted in Italy to investigate the quality of T2D care according to gender found that the proportion of patients achieving the HbA1c goal was higher among men in almost 80% of the diabetic centers and women were 14% more likely to have HbA1c > 9.0% in spite of insulin treatment, 42% more likely to have LDL cholesterol (LDL-C) ≥ 130 mg/dl in spite of lipid-lowering treatment and 50% more likely to have BMI ≥ 30 kg/m2 compared with men. Monitoring for foot and eye complications was also lower in women than men (Rossi et al. 2013). Franzini et al. (2013) also found that control of HbA1c and LDL is less satisfactory in women than men. A study in Finland found that found that gender, age, area-level education and the area class of the patient are associated with achievements in control and treatment targets (Sikio et al. 2014).
2.6.3 Variation in the quality of T2D care by area
Differences exist in the care of T2D according to the area. People living in rural area and having poor access to health care services were found to have deferred T2D care (Andrus 2004). A study in Finland aimed to investigate the area level differences in the achievement of the control and treatment targets of T2D patients using urban and rural classification and other area level classifications. The study found that area-level inequalities exist in the care of T2D by a detailed grid-based area classification instead of only by urban and rural area (Sikio et al. 2014).
2.6.4 Variation in the quality of T2D care by Socio-economic status
Individual socio-economic status (SES) and residential area deprivation have influence on T2D care and achievement of the treatment targets in T2D patient (Grintsova et al. 2014). A study in Germany examining the association between social status and quality of T2D care found that patients with lower social status have a higher HbA1c level and lower social status is associated with worse quality of diabetes care (Baz et al. 2012). Another registry based study in California assessing the disparities in the outcomes of T2D found that there is an association between neighborhood SES and HbA1c control, lower income neighborhoods having higher HbA1c level but no association was found with LDL control (Geraghty et al. 2010). Area-level socio-economic status is also found to have influence on diabetes care, a study analyzing data from regional electronic patient database during the years of 2011-12 to observe the influence of area-level
socio-economic factors on the prevalence and outcomes of T2D in North Karelia, Finland, found that the low SES in the postal code area was related to poor HbA1c measurement rate and control (Sikio et al. 2014). A systematic literature review was conducted to investigate the inequalities in health care among patients with T2D by individual socio-economic status (SES) and regional deprivation found that patients living in deprived areas achieve the glycemic control targets less often and also worse lipid profile control was more prevalent (Grintsova et al. 2014). Another study in England, found that worse diabetes control and lower quality of care is associated with deprived regions (Bottle 2008).
3 AIMS OF THE STUDY
To assess whether the follow-up and achievement of treatment targets of T2D patients have been improved from the period 2011-12 to 2013-14 in North Karelia.
Assessment of the quality of T2D care in 2011–12 and 2013-14 in North Karelia, Finland using HbA1c and LDL as treatment outcome indicator.
Assessment of adequate HbA1c and LDL follow-up
Assessment of socioeconomic variables that can anticipate the change in follow-up rate or control of HbA1c and LDL.