An Assessment of Quality of Documented Diabetes Care Provided at PIH-Supported Non-Communicable Diseases Clinics in Rwanda

Diabetes presents an increasing burden globally as a leading cause of disability and cardiovascular diseases. To prevent the complications of diabetes, patient retention and quality care, including adherence to guidelines by clinicians, is critical. This project explored the documentation of key patient information and the care provided by the Non-Communicable Diseases (NCD) program at ten Inshuti Mu Buzima health care facilities between June 2012 and June 2015. The current standards of diabetes care have been adapted from the “PIH Guide to Chronic Care Integration for Endemic Non-Communicable Diseases-Rwanda Edition.” Providers document care delivered into a paper record and this is then transferred into the electronic medical record system (EMR), which has been adapted in all NCD clinics. We reviewed EMR data to measure: (1) completeness of baseline demographic and clinical history information important for patient follow-up and care, and (2) rates of documented delivery of recommended care. Descriptive statistics was used to describe the level of documentation of all measures. We found that documentation of patients’ address was excellent with only 1% missing, but about one quarter of patients had missing information for other demographic and clinical history information including marriage status (27%), occupation (28%), HIV status (25%), smoking status (22%), and alcohol use (25%). Phone number was largely missing (75%). Rates of documented receipt of recommended care varied at intake and on follow-up care. There were good levels of documentation of basic routine measures including blood pressure, pulse, and weight at both intake and follow-up visits. Documentation of delivery of less frequent routine measures like creatinine, HbA1c, proteinuria, and monofilament testing were much lower. Foot examination for ulcers was well documented at intake (76%), but very poor for follow-up visits (1%). Documentation of blood sugar was low at intake (only 41%) and completely absent at follow-up (0%). Overall, there were suboptimal levels of documented care. There are many factors that could contribute to the level of documentation seen. These include: (1) gap in care delivery, (2) a gap in documentation in paper charts, and (3) gap in EMR documentation. There is likely a combination of all factors at play. The next steps will be to identify the cause of these observed results, and subsequently implement necessary quality improvement initiatives.