Diabetes complication screening in primary care: an opportunity to identify and support the high-risk patients?

Samuel YS Wong

HK Pract 2019;41:1-2

With aging population and changes in lifestyle, chronic diseases have become the leading causes of morbidity and mortality in both developed and developing countries. In this issue of the Hong Kong Practitioner, all three articles concern chronic disease. Yim¹ provide an update on the management of rheumatoid arthritis while Modi² provides a review of the increasing prevalence of pre-term births and the relationships between preterm births and the development of chronic conditions in adult life. Of particular interests to policy makers and front-line healthcare providers, Shiu et al³ examines patient factors associated with non-attendance of diabetic complication screening for retinopathy among eligible patients in general outpatient clinics in the Kowloon East Cluster. In their study to examine factors associated with non-attendance among those who had been scheduled appointments for diabetic complication screening for retinopathy in two general outpatient clinics (GOPCs) of the Kowloon East Cluster of Hospital Authority, they found that around 1/3 of patients were non-attenders. Moreover, being male, having a high HbA1C and diabetic retinopathy were significantly associated with non-attendance. These findings highlight an area that deserves further attention to improve the provision of diabetic complication screening programme in GOPCs. The findings suggest that those who need to be screened the most (due to their poorer HbA1c status and retinopathy) may be the least likely to attend the screening. They also echoed findings from other overseas studies^4,5 which show that those with missed appointments for diabetes follow up or have low adherence to anti-diabetic medications, have poorer control of diabetes when compared to those who keep their appointments or who are adherent to their medications.

Several factors have been proposed and examined by the authors to account for the reasons for missed appointments of complication screening. The main one being patients who have forgotten their appointment date. Because of this, the authors proposed telephone reminders as a potential intervention to improve attendance. Although evidence shows that reminders may work for those who miss appointments for medical visits, we still do not have adequate information on why patients with poorer HbA1C are more likely to miss their appointments. Other factors that could potentially explain the non-attendance but have been less well explored in Hong Kong are factors associated with social determinants of health.⁶

Evidence, mostly from overseas studies, shows that people who are socially disadvantaged tend to have poorer health outcomes.⁶ The causes for poorer health outcomes among the socially disadvantaged population include having poorer lifestyle such as cigarette smoking, having had early life deprivation such as those who experienced adverse childhood experiences, having been exposed to chronic psychosocial stress, and having poorer social support.⁶ In support of these findings, a study⁷ conducted using the U.K. general practice database shows that diabetes clinic non-attenders were more likely to be smokers, more likely to have higher HbA1c levels and were more likely to have greater morbidity. In the same study, these same factors were also associated with medication non-compliance. Importantly, poorer compliance of clinic appointments and medication were both independently associated with all-cause mortality.

As the GOPC population consists of people who are older, with more chronic conditions and people with lower socio-economic status, unmeasured social factors^8,9 could have contributed to poorer compliance of medical treatment and poor attendance of diabetes complication screening, resulting in poorer diabetes control and poorer clinical outcomes. Leese et al⁹, using regional diabetes population-based retinal screening programme and regional ophthalmology laser database in Scotland, show that patients who missed screening appointments were more likely to have longer diabetes duration, to have poor HbA1C levels and blood pressure control, to be smokers and to live in deprived areas. As poor glycemic control, poor blood pressure control and long duration of diabetes are three of the strongest established risk factors for the development of diabetic retinal diseases, the authors commented that social deprivation plays a key role in poor retinal screening uptake. They proposed a targeted approach of increasing screening opportunities in areas of high deprivation.

As the study conducted by Shiu et al was only a cross-sectional study, it is unknown whether the poorer HbA1c levels of non-attenders were caused by non-attendance of complication screening or whether both non-attendance and poorer HbA1C levels were caused by other factors not measured in this study. As only a few hundred patients were recruited in this study, future larger studies can use a prospective cohort design, supplemented with qualitative work, to further examine the root causes of non-attendance for complication screening among this high risk group who should deserve more attention, not only in diabetes care but also other aspects of medical care, due to the likelihood that they are more likely to have higher morbidity and mortality. Interventions supported in primary care settings, such as telephone reminders or other evidence-based approach may be most needed in this population to increase their attendance in complication screening and compliance in medical treatments.