Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Can we bridge the gap? Knowledge and practices related to Diabetes Mellitus among general practitioners in a developing country: A cross sectional study

Can we bridge the gap? Knowledge and practices related to Diabetes Mellitus among general... Background: Diabetes mellitus is becoming a serious public health problem in Sri Lanka and many other developing countries in the region. It is well known that effective management of diabetes reduces the incidence and progression of many diabetes related complications, thus it is important that General Practitioners (GPs) have sound knowledge and positive attitudes towards all aspects of its management. This study aims to assess knowledge, awareness and practices relating to management of Diabetes Mellitus among Sri Lankan GPs. Methods: A cross-sectional study was conducted among all 246 GPs registered with the Ceylon College of General Practitioners using a pre-validated self-administered questionnaire. Results: 205 responded to the questionnaire(response rate 83.3%). Their mean duration of practice was 28.7 ± 11.2 years. On average, each GP had 27 ± 25 diabetic-patient consultations per-week. 96% managed diabetic patients and 24% invariably sought specialist opinion. 99.2% used blood glucose to diagnose diabetes but correct diagnostic cut-off values were known by only 48.8%. Appropriate use of HbA1c and urine microalbumin was known by 15.2% and 39.2% respectively. 84% used HbA1c to monitor glyceamic control, while 90.4% relied on fasting blood glucose to monitor glyceamic control. Knowledge on target control levels was poor. Nearly 90% correctly selected the oral hypoglyceamic treatment for obese as well as thin type 2 diabetic patients. Knowledge on the management of diabetes in pregnancy was poor. Only 23.2% knew the correct threshold for starting lipid-lowering therapy. The concept of strict glycaemic control in preference to symptom control was appreciated only by 68%. The skills for comprehensive care in subjects with multiple risk factors were unsatisfactory. Conclusions: The study was done among experienced members of the only professional college dedicated to the specialty. However, we found that there is room for improvement in their knowledge and practices related to diabetes. We recommend continuing medical education and training programs to update GP’s knowledge in order to improve health outcomes in this group of patients. Keywords: Diabetes Mellitus, general practitioners, Sri Lanka, Primary care * Correspondence: yashas2004@yahoo.com Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka Full list of author information is available at the end of the article © 2011 Katulanda et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 2 of 6 http://www.apfmj.com/content/10/1/15 information on awareness and attitudes of GPs in the Background management of diabetes at the primary care level. The Diabetes mellitus is becoming a serious public health present study was designed to fill this void in our problem in Sri Lanka and many other developing coun- knowledge using evidence-based guidelines of the Amer- tries in the region. Latest prevalence studies demon- ican Diabetes Association (ADA) and International Dia- strateaprevalenceof9.8% and 10.9%amongadult betes Federation (IDF) as a bench mark [8,9]. The males and females respectively [1]. These figures are present study aims to determine the level of awareness, expected to further increase resulting in escalating attitudes and practices related to diabetes mellitus in a health care costs with primary care having to shoulder a group of GPs from Sri Lanka. larger burden in caring for these patients. At present majority of these patients are managed in the primary Methods care, mostly by full-time General Practitioners (GPs).In A cross-sectional study was conducted between Octo- Sri Lankan context any doctor having a medical degree ber-December 2008 using a pre-tested self-administrated (MBBS) and registered with the Sri Lanka Medical anonymous questionnaire. All 246 GPs registered with Council (SLMC) can practice as a GP. A general practi- the Ceylon College of General Practitioners (CCGP) tioner therefore plays a pivotal role in the management were invited to participate in the study. Since this is the of diabetes mellitus in the community. The complexity only College dedicated to General Practice in Sri Lanka, and chronic nature of diabetes present many challenges we assumed that they would approximate with best to the family physician. With regard to diabetes the pri- practice in the country. The invitation to participate mary goal of these GPs would be to achieve and main- together with the questionnaire was mailed. The accom- tain optimal glycaemic control, prevent micro and panying letter indicated that they should not refer books macrovascular complications and thereby to improve or journals or discuss with others in order answer the patients’ quality of life. It is well known that effective questions. After 2 weeks non-responders were sent management of diabetes reduces the incidence and pro- reminders. gression of many diabetes related complications [2-7]. The questionnaire included sections on the diagnosis, HenceitisimportantthatGPs have soundknowledge glycaemic control, assessment and management of and positive attitudes towards all aspects of the manage- related risk factors (hypertension and dyslipidaemia), ment of this chronic disease including all the levels of practices of screening for complications and delivery of prevention. vital health messages including life style modifications. The American Diabetes Association (ADA), Interna- tional Diabetes Federation (IDF) and many other organi- In addition information regarding the experience of GPs, the volume of practice and proportion of diabetes zations have developed evidence-based guidelines for the consultations per week were collected. Case scenarios management of diabetes mellitus [8,9].As shown in table were also used to assess knowledge of GPs in manage- 1thereare specificdiagnosticcriteriafor theproper ment of a diabetic patients (e.g. A 35 year old patient diagnosisofdiabetesforthepatientstobeproperly with type 2 diabetes, who is 5 feet 6 inches in height, identified and managed as well as to be cautious of over weighing 85 kg, blood pressure 140/100 mmHg, FBG treatment. To improve the quality of care of patients 300 mg/dL, LDL cholesterol 200 mg/dL and smoking 10 with diabetes we need to evaluate the existing practice cigarettes a day. He had a first degree family history of adopted by the GP’s, who handles bulk of the diabetic heart attacks in fifties. Physical examination was patients at the community level. There is scarce Table 1 American Diabetes Association diagnostic criteria for diabetes mellitus 1. HbA1c ≥ 6.5% The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay□ OR 2. FPG ≥ 126 mg/dL(7 mmol/L). Fasting is defined as no caloric intake for at least eight hours.□ OR 3. 2-h plasma glucose ≥ 200 mg/dL(11.1 mmol/L)during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water□ OR 4. Random plasma glucose ≥ 200 mg/dL(11.1 mmol/L) In a patient with classic symptoms of hyperglycemia or hyperglycaemic crisis □ In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed by repeat testing. Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 3 of 6 http://www.apfmj.com/content/10/1/15 otherwise normal. The respondents were then required Table 2 Preferred management options by the GPs to choose answers for a set of questions that tested their Preferred diagnostic tests used for diagnosis of diabetes mellitus decision-making in relation to the scenario. Fasting blood glucose 99.2% The Diabetes Control and Complications Trial Random blood glucose 54.4% (DCCT), significantly changed the management princi- Oral glucose tolerance test 41.6% ples of Diabetes mellitus from the 1990 s onwards [10]. Urine sugar 36.8% DCCT study examined whether intensive treatment with HbA1c 27.2% the goal of maintaining blood glucose concentrations Use of statins in patients with diabetes mellitus close to the normal range could decrease the frequency With IHD 44% and severity of those complications. The DCCT pro- vided quantifiable justification to healthcare providers When LDL>100 mg/dL 23.2% that the additional expenses associated with intensive In all diabetes 6.4% glycemic control and close monitoring of diabetes are When LDL>150 mg/dL 3.6% cost effective. Similarly the UKPDS results confirmed When HDL >65 mg/dL 1.6% and extended previous evidence supporting the hypoth- Use of low dose aspirin in patients with diabetes mellitus esis that hyperglycemia and its sequelae are a major With IHD 87.2% cause of the microvascular complications of diabetes. With other risk factors 80.8% This also indicated that the presence of hyperglycemia is All >40 years of age 32.8% a toxic state whether it occurs early or late in life and All diabetics 10.4% irrespective of its underlying cause[10,11]. It was Never 0.2% assumed that the GPs knowledge should be updated for their clinical practice based on the importance of these Knowledge on the cut off values for metabolic and blood pressure control two landmark studies. Thus the awareness of the trials HbA1C 63.2% among the GPs was also explored. Fasting Blood Sugar 43.2% Ethical clearance for the study was obtained from the Ethics Review Committee of the Faculty of Medicine, Blood pressure 43.2% University of Colombo. Data was double-entered, cross Triglycerides 31.2% checked for consistency and analysed using SPSS version LDL Cholesterol 28.8% 14 (SPSS Inc., Chicago, IL, USA) statistical software package. HbA1c, 28.8% used urine sugar and 62.4% used Post Results Prandial Blood Sugar (PPBS). Two hundred and five (response rate 83.3%) responded to the questionnaire. The mean duration of practice after Screening for complications registration as a medical practitioner was 28.7 (SD ± Upon diagnosis of a patient most GPs routinely arrange 11.2) years. The average number of weekly consultations for urine dipstick examination (75.2%), urine for micro- was 355 (SD ± 235) while those for diabetes related pro- albumin(88.0%), lipid profile (31.2%), serum creatinine blems was 27 (SD ± 25) per week. Majority of GPs (96%, (68.0%), and Electrocardiograms (80.0%) as initial inves- n = 196) manage diabetic patients by themselves with tigations. A majority of GPs screened their patients for 24% seeking specialist opinion from time to time. Dia- retinopathy (85.6%), neuropathy (89.6%), nephropathy betic patient records were maintained by 182 (88.8%). (88.8%) at some point in their follow up. However a lower proportion of GPs screened their Diagnostic testing patients for diabetic foot (42.4%).At least an annual fun- Urine sugar and HbA1c were used by 36.8% and 27.2% doscopic examination for retinopathy was carried out by respectively as diagnostic tests in their practice (Table majority of the GPs (75.2%), though only 20.8% exam- 2). However, 200 (99.2%) used fasting blood glucose for ined the optic fundi after dilatation of pupils. diagnosis, though only 48.8% knew the correct cut-off value for the diagnosis. In addition random blood sugar Knowledge on diabetes and oral glucose tolerance tests were also being carried More than 95% of GPs accepted that a positive family out for diagnosis. history, obesity, sedentary life style, western food habits and gestational diabetes mellitus as risk factors for type Monitoring glycaemic control 2 diabetes mellitus in Sri Lankans, despite not having Fasting Plasma Glucose (FPG) was used by 90.4% for documented evidence, while 94% felt that psychological monitoring of glycemic control while 84.0% used stress was a risk factor for diabetes mellitus. Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 4 of 6 http://www.apfmj.com/content/10/1/15 In this study 84.0% knew that microvascular complica- Table 3 The responses to the case scenario as preferred management options tions of diabetes can be prevented by tight glycaemic control, while 71.2% were aware of the possibility of pri- Management option selected Percentage of preferred responses mary prevention of diabetes. Only 72.0% identified the Strict diet control 90.4 cardiovascular diseases as the leading cause of death in Quit smoking 86.4 those with diabetes. However only 50.4% knew the com- Regular exercise 81.6 mon association of retinopathy and nephropathy. Start on statins 77.6 Though nephropathy was identified as the cause of Start on anti-hypertensives (ACE 75.2 renal failure in diabetics by 87.2% of the GPs, only inhibitors/b blockers) 36.8% knew that progression of nephropathy can be slo- Start on Meformin 69.6 wed down once established. When it comes to investiga- Weight reduction 66.9 tionsonlyaminorityknew theprecise purposeof Regular check for glycemic control 58.4 testing urine for microalbumin (39.2%) and measuring Start on aspirin 44.8 HbA1c levels (15.2%). GPs seem to be uncertain about Examine eyes 21.6 how best to manage and follow up patients. Only a Drug compliance 13.6 small number of GPs stated that blood pressure (58.4%), Examine foot 9.6 feet (30.4%) and weight (12.0%) as essential examina- tions that they perform in follow up visits. Metformin was used as the drug of choice for patients who were overweight by 89.6% of the GPs and sulpho- (86.4%), starting statins(77.6%),starting anti-hyperten- nyureas were used by 88.0% for thin patients. Glitazones sives (75.2%) and prescribing metformin(69.6%) were were used by 77.6% as the second line oral hypoglycae- among the popular management steps of a diabetic who mic agent. In the management of female diabetic patient was 35 years old with 5 feet 6 inches in height, weighing on glibenclamide desiring to be pregnant, 60.8% GPs 85 kg, blood pressure 140/100 mmHg, FPG 300 mg/dL, admitted that they would change their therapy to insulin LDL cholesterol 200 mg/dL and smoking 10 cigarettes a and 68.0% desired to take specialist opinion. There were day with a strong family history of heart attacks. 16.0% of the GPs who intended to continue glibencla- Only 20.8% and 11.2% of GPs knew that the UKPDS mide and 23.2% preferred to stop the glibenclamide study and DCCT were done in patients with type-2 dia- without starting on insulin or an alternative agent. Forty betes and type 1 diabetes respectively. four percent of GPs used statins in patients with dia- betes and ischaemic heart disease (IHD) irrespective of Discussion and conclusions the cholesterol levels (table 2). Low dose aspirin was In Sri Lanka, like in many other developing countries, used by 32.8% of GPs in diabetic patients who were remote rural locations lack government specialist medi- above 40 years of age while 87.2% used aspirin when cal clinics and those available in more urban areas are patients had IHD and 80.8% when one or more IHD often overcrowded with patients. Thus GPs play a major risk factors were present in addition to diabetes (Table role in management of patients with diabetes mellitus 2). 87.2% use Angiotensin Converting Enzyme Inhibitors and providing international standards of care will result (ACEI) and Angiotensin Receptor Blockers (ATRB) as in improvement of clinical outcome. the first-line antihypertensives in their diabetic patients, It is encouraging to note that a majority of GPs screen while 54.4% used calcium channel blockers (CCB) as the for eye, neurological, renal and microvacular complica- second-line antihypertensive. tions on newly diagnosed patients. However, only a min- A high percentage of GPs advised their patients about ority do it with precise knowledge (e.g. low level of diet control (96.8%) and exercise (84.0%) but only a few knowledge on the exact purpose of urine for microalbu- advised their patients to quit smoking (22.4%), foot care min and HbA1c) and using the correct methods (as (29.6%) and retinopathy screening (15.2%). demonstrated by very low percentage dilating the fundi The GPs’ knowledge on current ADA cut-off values prior to ophthalmoscopy). Furthermore, an appreciable for metabolic and blood pressure control varied widely; proportion of GPs were not aware of the diagnostic correct values for triglycerides and HbA1c were identi- tests (e.g. need to use the glucose tolerance test) for the fied respectively by 31.2% and 63.2% (Table 2). Only diabetes and the respective cut-off values based on cur- 28.8%% were aware of the cut-off values for LDL choles- rent international guidelines (e.g. cut-off of 126 mg/dL terol for the commencement of statin therapy. for fasting plasma glucose). Knowledge of management of patients was also tested A majority of GPs did not consider other complica- using case scenarios, results of which are shown in tions like diabetic foot disease, dyslipidaemia, hyperten- Table 3. Strict diet control (90.4%), quitting smoking sion and obesity as important issues in patients, as Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 5 of 6 http://www.apfmj.com/content/10/1/15 demonstrated by the small number of GPs consider that to answer the questionnaire. Though the responders routinely measuring blood pressure (58.4%), examining were discouraged from looking up references, some the feet for complications (30.4%) and checking weight might not have obeyed the instructions affecting data (12.0%) as essential examinations that should be regu- validity. Irrespective of this, there is an urgent necessity larly done during follow up visits of diabetic patients. to develop education programmes to improve the Similar studies performed in western countries have knowledge of GPs, and subsequently audit their perfor- mance. Second we failed to explore the use of guidelines indicated better performance by GPs in recording blood by theGPs.All currentlyavailableguidelinesinSri pressure, ranging from 87% to 100% [12-14]. Although Lanka may not be appropriate for use by GPs in their 42% screen for diabetic foot only 30% took time to offer adequate advice for the patients. The disparity is likely busy clinics and we need to make necessary modifica- to be due to lack of time or lack of motivation. Having tions to them to suit the context. Finally, members of a standard printed set of patient information leaflets or the CCGP may not be representative of the complete trained health educationists may help to improve this population of GPs in the country. However, one could situation. This discrepancy between knowledge and argue that since they are members of the only profes- practice among GPs, is further demonstrated by the fact sional College dedicated to the specialty and they had that although 96.8% advise about diet control and 84% considerable experience (mean duration of working as about exercise but only 12% measure the weight and GPs for 28.7 years) their practice and knowledge ought 58.4% do the blood pressure check-up during follow up. to reflect those of the better GPs in the country. Annual screening for lipids among Sri Lankan GPs Since this study very well depics the gap between the was low (31.2%) when compared to 56% in United King- knowledge and practice there is an identified risk of dom [14] and 45% in USA [15]. However, Sri Lankan management of some diabetes patients in Sri Lanka. GPS often lack qualified support staff (e.g. qualified Thus it is recommended to go ahead with outcome stu- managers to manage the appointments, enter data, type dies of patient management in units that are complying/ letters, obtain reports from the laboratories etc.) and not with guidelines. may deliberately avoid requesting for more effective In conclusion, the study found that there is much tests (e.g. HbA1c) due to patients not being able to room for improvement in knowledge and practices afford them. related to diabetes among GPs. We recommend conti- The results of the case scenarios showed that the sub- nuing medical education and regular training programs to update their knowledge in order to improve health jects correctly selected the class of oral hypoglycaemic outcomes in this group of patients. Further studies to agents and antihypertensive to suit the diabetic patient. However practices regarding use of aspirin and statins investigate whether outcomes of diabetic patients (e.g. in diabetic patients were unsatisfactory. Most GP’suse glycaemic control) relate to knowledge and practice FBG and HbA1c to assess glyceamic control but some among GPs are indicated. continue to rely on urine reducing substances. The awareness of Sri Lankan GPs on the current ADA target Abbreviations values for metabolic control with regard to blood glu- GP: General practitioner; CCGP: Ceylon College of General Practitioners; FPG: cose was inadequate and most lacked adequate knowl- Fasting Plasma Glucose; PPBS: Post Prandial Blood Sugar; UKPDS: United Kingdom Prospective Diabetes Study; DCCT: Diabetes Control and edge on the management of diabetes in pregnancy (e.g. Complications Trial. need to avoid sulphonylureas and start insulin). Only a very few GPs were aware of important clinical Acknowledgements The authors sincerely acknowledge the College of General Practitioners’ in trials, reflected by the lower level of awareness on land- Sri Lanka for their valuable support and participation. mark clinical trials on diabetes such as UKPDS (20.8%) and DCCT (11.2%) which was comparable to results Author details National Hospital of Sri Lanka, Colombo, Sri Lanka; Department of Clinical from Pakistan [16]. This deficiency in knowledge of the Medicine, Faculty of Medicine, Colombo, Sri Lanka. Diabetes Research Unit, recent advances in management protocols is most likely 3 Faculty of Medicine, University of Colombo, Sri Lanka. Department of due to lack of continuous medical education among Sri Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka. 4 5 Ceylon College of General Practitioners, Colombo, Sri Lanka. Oxford Centre Lankan GPs. This study identifies the fact that avenues for Diabetes, Endocrinology and Metabolism, University of Oxford, UK. Post to update their knowledge are meagre and it needs to Graduate Institute of Medicine, Colombo, Sri Lanka. be rectified by continuous medical education activities. Authors’ contributions The study had several limitations. The response rate PK, GR, YS and MW carried out the study design, participated in data couldhavebeenimproved inthefuturebyincreasing collection and drafted the manuscript. YS and JG participated in the design the coordination and introducing feedback to GPs. The of the study and performed the statistical analysis. PK, DM, RS, MW, GR and PW conceived of the study, and participated in its design and coordination. studywas notabletoensurewhether someof the All authors read and approved the final manuscript. responders read textbooks or consulted their colleagues Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 6 of 6 http://www.apfmj.com/content/10/1/15 Competing interests ’The authors declare that they have no competing interests. Received: 20 April 2011 Accepted: 24 November 2011 Published: 24 November 2011 References 1. Katulanda P, Constantine GR, Mahesh JG, Sheriff R, Seneviratne RDA, Wijeratne S, et al: Prevalence and projections of diabetes and pre- diabetes in adults in Sri Lanka–Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Diabetic Medicine 2008, 23:1062-9. 2. The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993, 329:683-9. 3. Parving HH, Oxenboll B, Svendsen PA, Christiansen JS, Andersen AR: Detection of patients at risk of developing diabetic nephropathy. A longitudinal study of urinary albumin excretion, Endocrinologica(Copenhagen) 1982, 100:550-5. 4. UK Prospective Diabetes Study Group: UKPDS 28: A randomized trial of efficacy of early addition of metformin in sulfonylurea-treated type 2 diabetes. Diabetes Care 1998, 21:87-92. 5. UK Prospective Diabetes Study Group: UKPDS 39: Group Efficacy of atenolol and captopril in reducing risk for macrovascular and microvascular complications in type 2 diabetes. BMJ 1998, 317:713-20. 6. UK Prospective Diabetes Study Group: UKPDS 33: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998, 352:837-53. 7. Ohkubo Y, Kishikawa H, Araki E, Miyata T, Isami S, Motoyoshi S, et al: Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non insulin dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract 1995, 28(2):103-17. 8. American Diabetes Association: Standards of care in diabetes-2009. Diabetes Care 2009, 32:S13-S61. 9. International Diabetes Federation: International Curriculum for Diabetes health professional education. 2004 [http://www.idf.org/webdata/docs/ Curriculum_Final%20041108_EN.pdf], (accessed April 11, 2009). 10. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993, 329(14):977-86. 11. Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care 2002, 25:s28-s32. 12. Worrall G, Freake D, Kelland J, Pickle A, Keenan T: Care of patients with type II diabetes: a study of family physicians’ compliance with clinical practice guidelines. J Fam Pract 1997, 44(4):374-81. 13. Tunbridge FK, Miller JP, Schofield PJ, Spencer JA, Young G, Home PD: Diabetes care in general practice: an approach to audit of process and outcome. Br J Gen Pract 1993, 43:290-5. 14. Campbell SM, Hann M, Hacker J, Durie A, Thapar A, Rolandet M: Quality assessments of the panels for angina, asthma and type 2 diabetes. Qual Saf Healthcare 2002, 11(2):125-30. 15. Zoorob RJ, Mainous AG: Practice patterns of rural family physicians based on the American diabetes association Standards of Care. J Community Health 1999, 21(3):17582. 16. Shera AS, Jawad F, Basit A: Diabetes related knowledge, attitude and practices of family physicians in Pakistan. J Pak Med Assoc 2002, Submit your next manuscript to BioMed Central 52(10):465-70. and take full advantage of: doi:10.1186/1447-056X-10-15 Cite this article as: Katulanda et al.: Can we bridge the gap? Knowledge • Convenient online submission and practices related to Diabetes Mellitus among general practitioners • Thorough peer review in a developing country: A cross sectional study. Asia Pacific Family Medicine 2011 10:15. • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Asia Pacific Family Medicine Springer Journals

Can we bridge the gap? Knowledge and practices related to Diabetes Mellitus among general practitioners in a developing country: A cross sectional study

Loading next page...
 
/lp/springer-journals/can-we-bridge-the-gap-knowledge-and-practices-related-to-diabetes-XdacKjPEmT
Publisher
Springer Journals
Copyright
Copyright © 2011 by Katulanda et al; licensee BioMed Central Ltd.
Subject
Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
eISSN
1447-056X
DOI
10.1186/1447-056X-10-15
pmid
22115027
Publisher site
See Article on Publisher Site

Abstract

Background: Diabetes mellitus is becoming a serious public health problem in Sri Lanka and many other developing countries in the region. It is well known that effective management of diabetes reduces the incidence and progression of many diabetes related complications, thus it is important that General Practitioners (GPs) have sound knowledge and positive attitudes towards all aspects of its management. This study aims to assess knowledge, awareness and practices relating to management of Diabetes Mellitus among Sri Lankan GPs. Methods: A cross-sectional study was conducted among all 246 GPs registered with the Ceylon College of General Practitioners using a pre-validated self-administered questionnaire. Results: 205 responded to the questionnaire(response rate 83.3%). Their mean duration of practice was 28.7 ± 11.2 years. On average, each GP had 27 ± 25 diabetic-patient consultations per-week. 96% managed diabetic patients and 24% invariably sought specialist opinion. 99.2% used blood glucose to diagnose diabetes but correct diagnostic cut-off values were known by only 48.8%. Appropriate use of HbA1c and urine microalbumin was known by 15.2% and 39.2% respectively. 84% used HbA1c to monitor glyceamic control, while 90.4% relied on fasting blood glucose to monitor glyceamic control. Knowledge on target control levels was poor. Nearly 90% correctly selected the oral hypoglyceamic treatment for obese as well as thin type 2 diabetic patients. Knowledge on the management of diabetes in pregnancy was poor. Only 23.2% knew the correct threshold for starting lipid-lowering therapy. The concept of strict glycaemic control in preference to symptom control was appreciated only by 68%. The skills for comprehensive care in subjects with multiple risk factors were unsatisfactory. Conclusions: The study was done among experienced members of the only professional college dedicated to the specialty. However, we found that there is room for improvement in their knowledge and practices related to diabetes. We recommend continuing medical education and training programs to update GP’s knowledge in order to improve health outcomes in this group of patients. Keywords: Diabetes Mellitus, general practitioners, Sri Lanka, Primary care * Correspondence: yashas2004@yahoo.com Department of Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka Full list of author information is available at the end of the article © 2011 Katulanda et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 2 of 6 http://www.apfmj.com/content/10/1/15 information on awareness and attitudes of GPs in the Background management of diabetes at the primary care level. The Diabetes mellitus is becoming a serious public health present study was designed to fill this void in our problem in Sri Lanka and many other developing coun- knowledge using evidence-based guidelines of the Amer- tries in the region. Latest prevalence studies demon- ican Diabetes Association (ADA) and International Dia- strateaprevalenceof9.8% and 10.9%amongadult betes Federation (IDF) as a bench mark [8,9]. The males and females respectively [1]. These figures are present study aims to determine the level of awareness, expected to further increase resulting in escalating attitudes and practices related to diabetes mellitus in a health care costs with primary care having to shoulder a group of GPs from Sri Lanka. larger burden in caring for these patients. At present majority of these patients are managed in the primary Methods care, mostly by full-time General Practitioners (GPs).In A cross-sectional study was conducted between Octo- Sri Lankan context any doctor having a medical degree ber-December 2008 using a pre-tested self-administrated (MBBS) and registered with the Sri Lanka Medical anonymous questionnaire. All 246 GPs registered with Council (SLMC) can practice as a GP. A general practi- the Ceylon College of General Practitioners (CCGP) tioner therefore plays a pivotal role in the management were invited to participate in the study. Since this is the of diabetes mellitus in the community. The complexity only College dedicated to General Practice in Sri Lanka, and chronic nature of diabetes present many challenges we assumed that they would approximate with best to the family physician. With regard to diabetes the pri- practice in the country. The invitation to participate mary goal of these GPs would be to achieve and main- together with the questionnaire was mailed. The accom- tain optimal glycaemic control, prevent micro and panying letter indicated that they should not refer books macrovascular complications and thereby to improve or journals or discuss with others in order answer the patients’ quality of life. It is well known that effective questions. After 2 weeks non-responders were sent management of diabetes reduces the incidence and pro- reminders. gression of many diabetes related complications [2-7]. The questionnaire included sections on the diagnosis, HenceitisimportantthatGPs have soundknowledge glycaemic control, assessment and management of and positive attitudes towards all aspects of the manage- related risk factors (hypertension and dyslipidaemia), ment of this chronic disease including all the levels of practices of screening for complications and delivery of prevention. vital health messages including life style modifications. The American Diabetes Association (ADA), Interna- tional Diabetes Federation (IDF) and many other organi- In addition information regarding the experience of GPs, the volume of practice and proportion of diabetes zations have developed evidence-based guidelines for the consultations per week were collected. Case scenarios management of diabetes mellitus [8,9].As shown in table were also used to assess knowledge of GPs in manage- 1thereare specificdiagnosticcriteriafor theproper ment of a diabetic patients (e.g. A 35 year old patient diagnosisofdiabetesforthepatientstobeproperly with type 2 diabetes, who is 5 feet 6 inches in height, identified and managed as well as to be cautious of over weighing 85 kg, blood pressure 140/100 mmHg, FBG treatment. To improve the quality of care of patients 300 mg/dL, LDL cholesterol 200 mg/dL and smoking 10 with diabetes we need to evaluate the existing practice cigarettes a day. He had a first degree family history of adopted by the GP’s, who handles bulk of the diabetic heart attacks in fifties. Physical examination was patients at the community level. There is scarce Table 1 American Diabetes Association diagnostic criteria for diabetes mellitus 1. HbA1c ≥ 6.5% The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay□ OR 2. FPG ≥ 126 mg/dL(7 mmol/L). Fasting is defined as no caloric intake for at least eight hours.□ OR 3. 2-h plasma glucose ≥ 200 mg/dL(11.1 mmol/L)during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water□ OR 4. Random plasma glucose ≥ 200 mg/dL(11.1 mmol/L) In a patient with classic symptoms of hyperglycemia or hyperglycaemic crisis □ In the absence of unequivocal hyperglycemia, criteria 1-3 should be confirmed by repeat testing. Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 3 of 6 http://www.apfmj.com/content/10/1/15 otherwise normal. The respondents were then required Table 2 Preferred management options by the GPs to choose answers for a set of questions that tested their Preferred diagnostic tests used for diagnosis of diabetes mellitus decision-making in relation to the scenario. Fasting blood glucose 99.2% The Diabetes Control and Complications Trial Random blood glucose 54.4% (DCCT), significantly changed the management princi- Oral glucose tolerance test 41.6% ples of Diabetes mellitus from the 1990 s onwards [10]. Urine sugar 36.8% DCCT study examined whether intensive treatment with HbA1c 27.2% the goal of maintaining blood glucose concentrations Use of statins in patients with diabetes mellitus close to the normal range could decrease the frequency With IHD 44% and severity of those complications. The DCCT pro- vided quantifiable justification to healthcare providers When LDL>100 mg/dL 23.2% that the additional expenses associated with intensive In all diabetes 6.4% glycemic control and close monitoring of diabetes are When LDL>150 mg/dL 3.6% cost effective. Similarly the UKPDS results confirmed When HDL >65 mg/dL 1.6% and extended previous evidence supporting the hypoth- Use of low dose aspirin in patients with diabetes mellitus esis that hyperglycemia and its sequelae are a major With IHD 87.2% cause of the microvascular complications of diabetes. With other risk factors 80.8% This also indicated that the presence of hyperglycemia is All >40 years of age 32.8% a toxic state whether it occurs early or late in life and All diabetics 10.4% irrespective of its underlying cause[10,11]. It was Never 0.2% assumed that the GPs knowledge should be updated for their clinical practice based on the importance of these Knowledge on the cut off values for metabolic and blood pressure control two landmark studies. Thus the awareness of the trials HbA1C 63.2% among the GPs was also explored. Fasting Blood Sugar 43.2% Ethical clearance for the study was obtained from the Ethics Review Committee of the Faculty of Medicine, Blood pressure 43.2% University of Colombo. Data was double-entered, cross Triglycerides 31.2% checked for consistency and analysed using SPSS version LDL Cholesterol 28.8% 14 (SPSS Inc., Chicago, IL, USA) statistical software package. HbA1c, 28.8% used urine sugar and 62.4% used Post Results Prandial Blood Sugar (PPBS). Two hundred and five (response rate 83.3%) responded to the questionnaire. The mean duration of practice after Screening for complications registration as a medical practitioner was 28.7 (SD ± Upon diagnosis of a patient most GPs routinely arrange 11.2) years. The average number of weekly consultations for urine dipstick examination (75.2%), urine for micro- was 355 (SD ± 235) while those for diabetes related pro- albumin(88.0%), lipid profile (31.2%), serum creatinine blems was 27 (SD ± 25) per week. Majority of GPs (96%, (68.0%), and Electrocardiograms (80.0%) as initial inves- n = 196) manage diabetic patients by themselves with tigations. A majority of GPs screened their patients for 24% seeking specialist opinion from time to time. Dia- retinopathy (85.6%), neuropathy (89.6%), nephropathy betic patient records were maintained by 182 (88.8%). (88.8%) at some point in their follow up. However a lower proportion of GPs screened their Diagnostic testing patients for diabetic foot (42.4%).At least an annual fun- Urine sugar and HbA1c were used by 36.8% and 27.2% doscopic examination for retinopathy was carried out by respectively as diagnostic tests in their practice (Table majority of the GPs (75.2%), though only 20.8% exam- 2). However, 200 (99.2%) used fasting blood glucose for ined the optic fundi after dilatation of pupils. diagnosis, though only 48.8% knew the correct cut-off value for the diagnosis. In addition random blood sugar Knowledge on diabetes and oral glucose tolerance tests were also being carried More than 95% of GPs accepted that a positive family out for diagnosis. history, obesity, sedentary life style, western food habits and gestational diabetes mellitus as risk factors for type Monitoring glycaemic control 2 diabetes mellitus in Sri Lankans, despite not having Fasting Plasma Glucose (FPG) was used by 90.4% for documented evidence, while 94% felt that psychological monitoring of glycemic control while 84.0% used stress was a risk factor for diabetes mellitus. Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 4 of 6 http://www.apfmj.com/content/10/1/15 In this study 84.0% knew that microvascular complica- Table 3 The responses to the case scenario as preferred management options tions of diabetes can be prevented by tight glycaemic control, while 71.2% were aware of the possibility of pri- Management option selected Percentage of preferred responses mary prevention of diabetes. Only 72.0% identified the Strict diet control 90.4 cardiovascular diseases as the leading cause of death in Quit smoking 86.4 those with diabetes. However only 50.4% knew the com- Regular exercise 81.6 mon association of retinopathy and nephropathy. Start on statins 77.6 Though nephropathy was identified as the cause of Start on anti-hypertensives (ACE 75.2 renal failure in diabetics by 87.2% of the GPs, only inhibitors/b blockers) 36.8% knew that progression of nephropathy can be slo- Start on Meformin 69.6 wed down once established. When it comes to investiga- Weight reduction 66.9 tionsonlyaminorityknew theprecise purposeof Regular check for glycemic control 58.4 testing urine for microalbumin (39.2%) and measuring Start on aspirin 44.8 HbA1c levels (15.2%). GPs seem to be uncertain about Examine eyes 21.6 how best to manage and follow up patients. Only a Drug compliance 13.6 small number of GPs stated that blood pressure (58.4%), Examine foot 9.6 feet (30.4%) and weight (12.0%) as essential examina- tions that they perform in follow up visits. Metformin was used as the drug of choice for patients who were overweight by 89.6% of the GPs and sulpho- (86.4%), starting statins(77.6%),starting anti-hyperten- nyureas were used by 88.0% for thin patients. Glitazones sives (75.2%) and prescribing metformin(69.6%) were were used by 77.6% as the second line oral hypoglycae- among the popular management steps of a diabetic who mic agent. In the management of female diabetic patient was 35 years old with 5 feet 6 inches in height, weighing on glibenclamide desiring to be pregnant, 60.8% GPs 85 kg, blood pressure 140/100 mmHg, FPG 300 mg/dL, admitted that they would change their therapy to insulin LDL cholesterol 200 mg/dL and smoking 10 cigarettes a and 68.0% desired to take specialist opinion. There were day with a strong family history of heart attacks. 16.0% of the GPs who intended to continue glibencla- Only 20.8% and 11.2% of GPs knew that the UKPDS mide and 23.2% preferred to stop the glibenclamide study and DCCT were done in patients with type-2 dia- without starting on insulin or an alternative agent. Forty betes and type 1 diabetes respectively. four percent of GPs used statins in patients with dia- betes and ischaemic heart disease (IHD) irrespective of Discussion and conclusions the cholesterol levels (table 2). Low dose aspirin was In Sri Lanka, like in many other developing countries, used by 32.8% of GPs in diabetic patients who were remote rural locations lack government specialist medi- above 40 years of age while 87.2% used aspirin when cal clinics and those available in more urban areas are patients had IHD and 80.8% when one or more IHD often overcrowded with patients. Thus GPs play a major risk factors were present in addition to diabetes (Table role in management of patients with diabetes mellitus 2). 87.2% use Angiotensin Converting Enzyme Inhibitors and providing international standards of care will result (ACEI) and Angiotensin Receptor Blockers (ATRB) as in improvement of clinical outcome. the first-line antihypertensives in their diabetic patients, It is encouraging to note that a majority of GPs screen while 54.4% used calcium channel blockers (CCB) as the for eye, neurological, renal and microvacular complica- second-line antihypertensive. tions on newly diagnosed patients. However, only a min- A high percentage of GPs advised their patients about ority do it with precise knowledge (e.g. low level of diet control (96.8%) and exercise (84.0%) but only a few knowledge on the exact purpose of urine for microalbu- advised their patients to quit smoking (22.4%), foot care min and HbA1c) and using the correct methods (as (29.6%) and retinopathy screening (15.2%). demonstrated by very low percentage dilating the fundi The GPs’ knowledge on current ADA cut-off values prior to ophthalmoscopy). Furthermore, an appreciable for metabolic and blood pressure control varied widely; proportion of GPs were not aware of the diagnostic correct values for triglycerides and HbA1c were identi- tests (e.g. need to use the glucose tolerance test) for the fied respectively by 31.2% and 63.2% (Table 2). Only diabetes and the respective cut-off values based on cur- 28.8%% were aware of the cut-off values for LDL choles- rent international guidelines (e.g. cut-off of 126 mg/dL terol for the commencement of statin therapy. for fasting plasma glucose). Knowledge of management of patients was also tested A majority of GPs did not consider other complica- using case scenarios, results of which are shown in tions like diabetic foot disease, dyslipidaemia, hyperten- Table 3. Strict diet control (90.4%), quitting smoking sion and obesity as important issues in patients, as Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 5 of 6 http://www.apfmj.com/content/10/1/15 demonstrated by the small number of GPs consider that to answer the questionnaire. Though the responders routinely measuring blood pressure (58.4%), examining were discouraged from looking up references, some the feet for complications (30.4%) and checking weight might not have obeyed the instructions affecting data (12.0%) as essential examinations that should be regu- validity. Irrespective of this, there is an urgent necessity larly done during follow up visits of diabetic patients. to develop education programmes to improve the Similar studies performed in western countries have knowledge of GPs, and subsequently audit their perfor- mance. Second we failed to explore the use of guidelines indicated better performance by GPs in recording blood by theGPs.All currentlyavailableguidelinesinSri pressure, ranging from 87% to 100% [12-14]. Although Lanka may not be appropriate for use by GPs in their 42% screen for diabetic foot only 30% took time to offer adequate advice for the patients. The disparity is likely busy clinics and we need to make necessary modifica- to be due to lack of time or lack of motivation. Having tions to them to suit the context. Finally, members of a standard printed set of patient information leaflets or the CCGP may not be representative of the complete trained health educationists may help to improve this population of GPs in the country. However, one could situation. This discrepancy between knowledge and argue that since they are members of the only profes- practice among GPs, is further demonstrated by the fact sional College dedicated to the specialty and they had that although 96.8% advise about diet control and 84% considerable experience (mean duration of working as about exercise but only 12% measure the weight and GPs for 28.7 years) their practice and knowledge ought 58.4% do the blood pressure check-up during follow up. to reflect those of the better GPs in the country. Annual screening for lipids among Sri Lankan GPs Since this study very well depics the gap between the was low (31.2%) when compared to 56% in United King- knowledge and practice there is an identified risk of dom [14] and 45% in USA [15]. However, Sri Lankan management of some diabetes patients in Sri Lanka. GPS often lack qualified support staff (e.g. qualified Thus it is recommended to go ahead with outcome stu- managers to manage the appointments, enter data, type dies of patient management in units that are complying/ letters, obtain reports from the laboratories etc.) and not with guidelines. may deliberately avoid requesting for more effective In conclusion, the study found that there is much tests (e.g. HbA1c) due to patients not being able to room for improvement in knowledge and practices afford them. related to diabetes among GPs. We recommend conti- The results of the case scenarios showed that the sub- nuing medical education and regular training programs to update their knowledge in order to improve health jects correctly selected the class of oral hypoglycaemic outcomes in this group of patients. Further studies to agents and antihypertensive to suit the diabetic patient. However practices regarding use of aspirin and statins investigate whether outcomes of diabetic patients (e.g. in diabetic patients were unsatisfactory. Most GP’suse glycaemic control) relate to knowledge and practice FBG and HbA1c to assess glyceamic control but some among GPs are indicated. continue to rely on urine reducing substances. The awareness of Sri Lankan GPs on the current ADA target Abbreviations values for metabolic control with regard to blood glu- GP: General practitioner; CCGP: Ceylon College of General Practitioners; FPG: cose was inadequate and most lacked adequate knowl- Fasting Plasma Glucose; PPBS: Post Prandial Blood Sugar; UKPDS: United Kingdom Prospective Diabetes Study; DCCT: Diabetes Control and edge on the management of diabetes in pregnancy (e.g. Complications Trial. need to avoid sulphonylureas and start insulin). Only a very few GPs were aware of important clinical Acknowledgements The authors sincerely acknowledge the College of General Practitioners’ in trials, reflected by the lower level of awareness on land- Sri Lanka for their valuable support and participation. mark clinical trials on diabetes such as UKPDS (20.8%) and DCCT (11.2%) which was comparable to results Author details National Hospital of Sri Lanka, Colombo, Sri Lanka; Department of Clinical from Pakistan [16]. This deficiency in knowledge of the Medicine, Faculty of Medicine, Colombo, Sri Lanka. Diabetes Research Unit, recent advances in management protocols is most likely 3 Faculty of Medicine, University of Colombo, Sri Lanka. Department of due to lack of continuous medical education among Sri Clinical Medicine, Faculty of Medicine, University of Colombo, Sri Lanka. 4 5 Ceylon College of General Practitioners, Colombo, Sri Lanka. Oxford Centre Lankan GPs. This study identifies the fact that avenues for Diabetes, Endocrinology and Metabolism, University of Oxford, UK. Post to update their knowledge are meagre and it needs to Graduate Institute of Medicine, Colombo, Sri Lanka. be rectified by continuous medical education activities. Authors’ contributions The study had several limitations. The response rate PK, GR, YS and MW carried out the study design, participated in data couldhavebeenimproved inthefuturebyincreasing collection and drafted the manuscript. YS and JG participated in the design the coordination and introducing feedback to GPs. The of the study and performed the statistical analysis. PK, DM, RS, MW, GR and PW conceived of the study, and participated in its design and coordination. studywas notabletoensurewhether someof the All authors read and approved the final manuscript. responders read textbooks or consulted their colleagues Katulanda et al. Asia Pacific Family Medicine 2011, 10:15 Page 6 of 6 http://www.apfmj.com/content/10/1/15 Competing interests ’The authors declare that they have no competing interests. Received: 20 April 2011 Accepted: 24 November 2011 Published: 24 November 2011 References 1. Katulanda P, Constantine GR, Mahesh JG, Sheriff R, Seneviratne RDA, Wijeratne S, et al: Prevalence and projections of diabetes and pre- diabetes in adults in Sri Lanka–Sri Lanka Diabetes, Cardiovascular Study (SLDCS). Diabetic Medicine 2008, 23:1062-9. 2. The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993, 329:683-9. 3. Parving HH, Oxenboll B, Svendsen PA, Christiansen JS, Andersen AR: Detection of patients at risk of developing diabetic nephropathy. A longitudinal study of urinary albumin excretion, Endocrinologica(Copenhagen) 1982, 100:550-5. 4. UK Prospective Diabetes Study Group: UKPDS 28: A randomized trial of efficacy of early addition of metformin in sulfonylurea-treated type 2 diabetes. Diabetes Care 1998, 21:87-92. 5. UK Prospective Diabetes Study Group: UKPDS 39: Group Efficacy of atenolol and captopril in reducing risk for macrovascular and microvascular complications in type 2 diabetes. BMJ 1998, 317:713-20. 6. UK Prospective Diabetes Study Group: UKPDS 33: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998, 352:837-53. 7. Ohkubo Y, Kishikawa H, Araki E, Miyata T, Isami S, Motoyoshi S, et al: Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non insulin dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract 1995, 28(2):103-17. 8. American Diabetes Association: Standards of care in diabetes-2009. Diabetes Care 2009, 32:S13-S61. 9. International Diabetes Federation: International Curriculum for Diabetes health professional education. 2004 [http://www.idf.org/webdata/docs/ Curriculum_Final%20041108_EN.pdf], (accessed April 11, 2009). 10. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993, 329(14):977-86. 11. Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care 2002, 25:s28-s32. 12. Worrall G, Freake D, Kelland J, Pickle A, Keenan T: Care of patients with type II diabetes: a study of family physicians’ compliance with clinical practice guidelines. J Fam Pract 1997, 44(4):374-81. 13. Tunbridge FK, Miller JP, Schofield PJ, Spencer JA, Young G, Home PD: Diabetes care in general practice: an approach to audit of process and outcome. Br J Gen Pract 1993, 43:290-5. 14. Campbell SM, Hann M, Hacker J, Durie A, Thapar A, Rolandet M: Quality assessments of the panels for angina, asthma and type 2 diabetes. Qual Saf Healthcare 2002, 11(2):125-30. 15. Zoorob RJ, Mainous AG: Practice patterns of rural family physicians based on the American diabetes association Standards of Care. J Community Health 1999, 21(3):17582. 16. Shera AS, Jawad F, Basit A: Diabetes related knowledge, attitude and practices of family physicians in Pakistan. J Pak Med Assoc 2002, Submit your next manuscript to BioMed Central 52(10):465-70. and take full advantage of: doi:10.1186/1447-056X-10-15 Cite this article as: Katulanda et al.: Can we bridge the gap? Knowledge • Convenient online submission and practices related to Diabetes Mellitus among general practitioners • Thorough peer review in a developing country: A cross sectional study. Asia Pacific Family Medicine 2011 10:15. • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

Journal

Asia Pacific Family MedicineSpringer Journals

Published: Nov 24, 2011

References