Improving Diabetes Outcomes in Rural Dominican Republic

The Dominican Republic (DR) is a Caribbean country of 10 million with estimated diabetes prevalence at ∼11%. While the public health system has a diabetes program, there are few reliable surveillance data to portray diabetes outcomes in the DR. The HbA_1c is not a widely available test for metabolic control in the DR. In 2010, a non-profit group, Chronic Care International (CCI), began a diabetes and hypertension program with 2 clinics in poor, rural DR. CCI developed a model of quality improvement for care and self-management with its Dominican medical team, including doctors, nurses and community health workers. We present process and outcome data collected over 6 years utilizing electronic medical records. In addition to quality improvement analyses, we fit a random-effects linear model to the data to assess trends over time. By May 2017, subjects (N=1,031) were adults: mean age 60.1 years, 45% men, 74% with T2DM. Of those with diabetes (n=758), 76% had an HbA_1c <9%, with 86% having had an HbA_1c test done in the last 4 mos. Of 650 with hypertension, 64% had a BP < 140/90mmHg. In assessing trends over time, we found the modeled HbA_1c trajectory for those with diabetes showed an average decline of 0.13 percentage points per year (95% CI 0.10-0.15) over 6 years. The modeled BMI trajectory for all subjects showed an average decline of 0.kg/m² per year (95% CI 0.04-0.08) over 6 years. For those with a dx of hypertension, the modeled BP trajectories are biphasic, showing decreases over years 1 and 2, followed by increases. Systolic BP averaged a decline of 3.5mmHg (95% CI 3.0-4.0) per year, followed by an average increase of 1.7mmHg (95% CI 1.3-2.1) per year. Diastolic BP averaged a decline of 2.4mmHg (95% CI 2.1-2.7) per year, followed by an increase of 0.27mmHg (95% CI 0.03-0.5) per year. While decline trends in HbA_1c and BMI are encouraging for this model of care in rural areas of this developing country, some challenges in managing BP remain, even with access to several antihypertensive medications. Program sustainability and access to healthy food and exercise are DR priorities.