We set out in this study to compare the quality of out-patient follow-up care offered to persons with type 2 diabetes mellitus at a referral and regional level hospital in Kenya; on the premise widely held by patients that higher quality of care is offered at tertiary facilities. However, we report that the level of glycemic control, as documented by HbA1c levels, is poor and comparable at both facilities. Less than 20 % of clients were well controlled. Drug compliance levels were also low and compliance was the only multivariate predictor of poor control. Low compliance levels are reported despite more than three quarter of clients reporting honoring their clinic appointments. Insulin availability and cost were the same but oral hypoglycemic drugs were more frequently unavailable at the peripheral center.
As markers of quality of care offered, clients at the regional facility were more likely to have a clinic driven routine urinalysis and weight done, and were accorded shorter clinic appointment intervals. Direct costs incurred by patient were half to three quarter lower at the regional facility. Compared to tertiary facility clients, regional facility clients reported greater affordability and satisfactions with care offered, and were less inclined to transfer care to other centers.
We are not aware of studies in Kenya comparing diabetic care between centers. However, studies on level of glycemic control at Kenyatta National Hospital have been documented; a cross-sectional descriptive study done in 2012 at the outpatient diabetes clinic of KNH reported that only 20 % of patients had ever done at least one HbA1c check [18].
In another study done in 1998 in KNH they found that Most patients (71 or 68 %) had very poor long-term glycemic control with an HbA1c level >10.0 %, concluding that the majority of ambulatory diabetic patients attending the out-patient diabetic clinic had poor glycemic control [19].
In a 2002 retrospective study on review of clinical records that was performed in Kwa Zulu natal district in South Africa and Random blood glucose, hemoglobin A1c (HbA1c) and urine albumin/creatinine ratio assayed it Acceptable glycemic control (HbA1c < 2 % above normal population range) was found in only 15.7 % of subjects (95 % confidence interval (CI): 11.4–20.8 %). Mean HbA1c was 11.3 %, therefore concluding that care and control of diabetes in this rural community was sub optimal [20].
A prospective cohort study done in 2008 at Mekelle Hospital in northern Ethiopia concluded that in this severely resource- limited areas, glycemic control amongst diabetic clients was very poor, and attributed this to scattered populations, shortage of drugs and insulin and lack of diabetes team care as major contributing major factors [21].
In another cross sectional, descriptive study done at the University of Benin Teaching Hospital, Benin City, a tertiary health facility in Nigeria, between June and December 2004, it showed that many of the persons with diabetes mellitus in Benin city still had poor glycemic control similar to previous reports [22].
A study in Finland concluded that the follow-up of most diabetic patients—including type 1 diabetes—can be organized in primary health care with the same quality as in secondary care units. The centralized primary care of type 1 diabetes is less, costly and requires fewer specialist consultations [23].
Another study in China concluded that the overall status of glycemic control was unsatisfactory. Although, patients at tertiary hospitals appeared to have better control than those at primary or secondary hospitals [24, 25].
Implications of findings
Our findings point to the need for policy makers to focus their attention on strategies that address quality of care at both regional and tertiary facilities. Targeted interventions at improving care and facilities at peripheral centers will help patient’s access better health care and thus achieve good glycemic control with the attended benefits of complication and cost savings. Decentralization of diabetes care to county, sub-county and health centers is therefore important to enable success in care and management of diabetes at lower care levels and only have complicated cases referred to tertiary facilities.
Strengths and limitations
To the best of our knowledge, our study is the first to compare quality of regional and tertiary center diabetic care in Kenya. A further strength is use of the guideline validated and recommended measure of HbA1c for glycemic control. Though we relied on qualitative non-standardized patient dependent information for some of the measure of quality of care, for purpose of comparison, we have no reason to believe that any bias would be differential.