The recent article by Nagpal and Bhartia (1) from New Dehli, India, highlighted the wide gap between practice recommendations and delivery of care in a developing country like India. While standards of care (2) are continually emphasized, few individuals with diabetes actually receive even minimum standards of care. While many factors, including the level of public education, poverty, and poor state healthcare infrastructure, contribute to this in low-income groups, Nagpal and Bhartia (1) highlight deficiencies in quality of care administered to the middle- and high-income groups in their survey. This group may be visiting their providers yet not receiving adequate diabetes care.
We carried out a survey of 104 physicians in Karachi, Pakistan; 96 were general practitioners, and 8 were internists with a stated interest in diabetes care. Mean age of the respondents was 35.8 years. A brief case history of a patient with uncontrolled hyperglycemia (A1C 9.6%), blood pressure 150/90 mmHg, LDL cholesterol 132 mg/dl, loss of vibration sense, and background diabetic retinopathy was described. The patient was on near-maximal doses of glibenclamide and metformin. History included shortness of breath on exertion and poor R-wave progression on an electrocardiogram. Physicians were asked what further investigations they would order and were instructed to write a sample prescription for this patient. Only 47 (45%) physicians requested a urine examination. The most common cardiac investigation sought was a resting echocardiogram, which is quite expensive in our setting, while 22 (21%) physicians asked for a cardiac stress test, concerned about the possibility of silent ischemia. Insulin therapy was selected by only 55 (52.8%) respondents, and, of these, only 18 (32.7%) could write an acceptable initiating regime for therapy. The majority of the others chose switching glibenclamide to another sulfonylurea, generally a more expensive variety. Statins were written in the prescription by 35 (33.6%), ACE inhibitors/angiotensin receptor blockers by 60 (57.6%), and aspirin by only 39 (37.5%) physicians.
This survey among physicians in Karachi treating the middle- and upper-income population describes inadequacies of current physician knowledge and practice of optimal and acceptable diabetes care. Physician education needs to be addressed and improved as a priority in many parts of the developing world where trained endocrinologists are few in number and referral rates are low; otherwise, diabetes quality of care will not be received by the population even if they have the means to attend appointments with physicians and comply with prescribed treatment.
