Comprehensive diebetic care at Base Hospital Panadura

Sri Lanka Journal of Health Policy and Management
Case Study
A Model for Comprehensive Diabetic Care: A Case Study at a Secondary Care
Government Hospital in Sri Lanka
Kiriwandeniya, D.P.S 1
, Wijepala, K.H.C. 2
, Wijesingha, K.D.P. 3
, Peris, T.D.P. 4
,
Gamlathge, P.U. 5
,
1. Anti Filariasis Campaign
2. Base Hospital – Horana
3. District General Hospital – Kalutara
4. Office of Medical Officer of Health – Moratuwa
5. Base Hospital – Awissawella
Abstract
Introduction: Diabetes mellitus is a disease having an important public health and clinical
concern as it is a chronic and potentially disabling disease which creates an economic burden
on the individual, family, and society. In Sri Lanka diabetic patients are treated with other
patients in the general medical clinics or in very busy diabetic clinics where a limited time is
spent on a patient resulting incomplete case management. This study aimed to evaluate a
model for comprehensive diabetic care established as a preventive and curative care centre at a
secondary care government hospital to deliver individualized comprehensive diabetic care.
Objectives: To review the process and outcome of the diabetic education and prevention
centre of the Base Hospital, Panadura and to ascertain the factors contributing to the
sustainability of this project.
Methodology: Retrospective review of secondary data, informal discussions, information from
diabetic patients who had earlier visited general medical clinics was used.
Results: The project of the Panadura Base Hospital had been in progress since 2010 and 2723
diabetic patients had been treated in that year and 1972 patients in the year 2011. 338 patients
were screened for complications in 2010 and 361 patients were screened in year 2011.
Conclusion: A comprehensive diabetic care package could be developed in a secondary care
hospital with existing resources. Most important factor for the success is inter-sectoral
coordination and communication within the hospital and the motivation of the staff towards the
achievement of a common vision. The findings could be used to develop and execute cost
effective strategies, policies and programmes for better management of diabetes for better
management of diabetes and in secondary and primary care health institutions.

Introduction
Diabetes mellitus is a chronic and
potentially disabling disease which presents
a vital public health and clinical concern.
People with diabetes mellitus are at an
increased risk of developing long term
complications related to cardiovascular,
renal, ophthalmic, neurological,
cerebrovascular, and peripheral vascular
systems.
Studies reveal that as a result of the disease
and its complications, people with diabetes
have more frequent and intensive encounters
with the healthcare system 1
. Studies also
show the relative cost for diabetes is
between 2% to 3% of every country’s
healthcare expenditure 2
. Additionally, the
prevalence of diabetes for all age-groups
worldwide was estimated to be 2.8% in
2000 and expected to increase to 4.4% in
2030. The total number of people with
diabetes is projected to rise from 171 million
in 2000 to 366 million in 2030 3
. Closer to
home, Sri Lanka now having transitioned
from a low income country to a middle
income country, has a life expectancy of 71
years, and is in the advanced stages of a
demographic transition. The proportion of
people 60 years of age and older will be
more than double by 2040. In addition, an
epidemiologic transition is shifting the
disease pattern from maternal and child
health and infectious diseases towards
NCDs, which now account for nearly 90 per
cent of the disease burden. Mortality rates
from NCDs are currently 20–50 per cent
higher in Sri Lanka than in developed
countries 4
.
Latest statistics of the Ministry of Health
reveals that 25% of the population in Sri
Lanka is suffering from diabetes and the
figure is estimated to be doubled by 2050.
According to the Ministry about 500 to 600
people undergo lower limb amputations
annually due to the disease. The Ministry
also reveals that 40% of the urban
population and 19% of the rural population
are suffering from diabetes. The trend of
increasing in the prevalence of diabetes is
mainly due to changes in life style
associated with urbanization increased
consumption of refined fats, fast food and
reduced exercise, and increased mental
stress. Another disturbing feature in Sri
Lanka is the increase of diabetes among the
younger generation. Ten per cent of school
children are suffering from diabetes while
another 15% are at the risk of being affected
by the disease 5
.
Healthcare professionals alone cannot
manage diabetes; the challenge is to provide
the environment in which diabetes can be
jointly managed, promoting self-care and
empowerment 6
. The primary healthcare
system in Sri Lanka has been a success story

where it has reached a high standard of care
despite limited resources. Similarly, in the
case of diabetes cost-effective mechanisms
should be identified and implemented in
screening, education and the delivery of
diabetes care and its prevention 7
.
Diabetic care in Sri Lanka is delivered at
government hospitals, private hospitals and
by the general practitioners. A study
conducted in a diabetic clinic at a teaching
hospital in the government sector shows the
quality of care is less than what is expected
due to lack of resources and overcrowding 8
.
Base Hospital Panadura being an A – Grade
government Base Hospital with 267 beds,
served around one million patients in the
year 2009. This hospital was serving an
average of 1011 OPD patients, 543 clinic
patients, and 59 ETU patients per day. There
was an average of 122 admissions per day
and the bed occupancy rate was high. In
medical wards, the bed occupancy rate was
more than 100 % 9
. Hospital medical clinics
were always crowded and the patients with
different diagnosis visited the same clinic.
There were around 600 patients per day.
This led to incomplete care for diabetic
patients as well as the other patients. With
the limited time, the Medical Officers spent
less time for a patient. Therefore,
comprehensive examination, investigations
and proper treatment could not be done in
common medical clinics.
Objectives
 To review the process and outcome of
the diabetic education and prevention
centre at the Base Hospital Panadura,
 To ascertain the factors contributing to
the sustainability of this project.
Methodology
Retrospective review of the records and
secondary data, holding preliminary
discussions with the staff to assess the
background situation, obtaining information
from diabetic patients who had previously
visited general medical clinics was done
Data Analysis and Discussion
 Magnitude of the problem;
Medical clinics were held in the hospital
twice a week (4 hours per day). There were
about 600 patients per day with different
diagnosis. They were examined and treated
by about five doctors. As the time was
limited for one patient, they were not
examined, listened to and treated
adequately. This resulted in the absence of a
complete assessment of relevant
complications of diabetes. Investigations
were not done periodically and were done
on an ad hoc manner. These factors
contributed for inadequate provision of

required and comprehensive treatment for
the patients.
Establishment of a separate unit to handle
the diabetic patients for comprehensive,
accessible and efficient provision of
coordinated diabetes prevention and
management services for all was identified
as one of the essential and urgent
requirement in the hospital. It was planned
to ensure all clinic patients with diabetes
receive comprehensive, on-going care.
Several measures were planned such as
using guidelines for management of diabetic
patients, development of local protocols,
registration of diabetic patients in a separate
data base, and preparing recall systems and
introduction of patient-held management
plans. The expected outcome of the project
was prevention and slow progression of
diabetic complications. Heart disease, renal
failure, impaired vision and lower limb
amputations were expected to be prevented
or minimized by having a separate unit.
Additionally, the quality of life of the
diabetic patients was expected to be
improved.
 Objectives of the Project
1. To establish a centre for comprehensive
diabetic care in order to prevent
complications.
2. To develop a sustainable system to
manage the centre.
3. To find out necessary human and
physical resources for the centre.
 Strategies and activities implemented
The Diabetic Education and Prevention
Centre was specially designed to give
individualized overall diabetic care which is
not met by the conventional diabetic clinics.
As the hospital was introducing the
productivity and quality concepts during the
same period, directing the staff towards the
common vision was not a difficult task. The
relevant staff members did not take the
project as an additional burden for them.
The idea about the centre itself was born
from a dedicated Medical Officer who was
willing to work in addition to his routine
work in the Outpatient Department. The
Centre was led by a dedicated team
comprising of Consultants, Physicians,
Medical Officers and two specially trained
Nursing Officers. The service of the centre
was open twice a week to all residents in the
area. Personalized diabetic consultations
were carried out, in which patient’s state of
diabetes and other relevant medical
conditions and socio-economical
background were well assessed. All the
diabetic patients were examined
periodically. Relevant laboratory
investigations such as Fasting Blood Sugar
(FBS) / Post Prandial Blood Sugar (PPBS),
Haemoglobin A1C (HbA1C), and Urine for
micro- albumin, Serum Creatinine, Serum

electrolytes, Lipid profile and Electro
Cardiograph (ECG) were also carried out.
However, out of these investigations the
hospital catered only for FBS, PPBS, and
ECG as there were no facilities to undertake
other investigations in the hospital. The rest
were done via private laboratories on a
concessional change and some patients were
funded by a motivated team of hospital
members and some donors from the
community. When there were
complications, the patients were
immediately referred to the relevant units
for specialized care.
Figure 1: Conduction of Diabetes Clinic at Base Hospital – Panadura
A health education package was given to
each patient. Patients were provided with
all the necessary information on diabetes
and its complications, diet, exercise, foot
care, drug and insulin therapy. Patients were
given a record book prepared by the centre
which consisted of all the personal and case
management data of the individual and the
health education information. This book was
prepared according to the guidelines of
International Diabetes Federation, Asian
Diabetes Federation and World Diabetes
Federation. The patients were appropriately
educated about insulin therapy, awareness of
self-injecting of insulin, oral hypoglycaemic
agents, self-identification of symptoms of
hypoglycaemia and what to do about it. All
the patients were given an emergency
diabetes ID card which contains details of
the patient, whom to be contacted in an
emergency and the treatment patient is on.
Dedicated podiatry service for diabetes
related foot problems was a very important
service provided by the centre. All the
patients registered in the centre were
provided with special tailor made shoes.
Steps were taken to increase knowledge of
available resources by health care providers
and people with diabetes.
Diabetes Education and Prevention Centre
received referrals from all the wards of the
hospital, all the clinics and the Out-patient

Department. Weekly screening programmes
and health education programmes for
patients and their family members were
conducted by the Medical Officer and the
Nursing Officer of the Diabetic Education
and Prevention centre.
 Results of the project
Figure 2: Awareness Booklet on Diabetes Prevention Program
Early detection and optimal management of
complications, coordinated prevention and
management of acute episodes were
undertaken by the centre successfully. The
current programme had been in progress
since 2010, and had treated 2723 diabetic
patients in that year and 1972 patients in
2011. In 2010, 338 patients were screened
for complications and in 2011, 361 patients
were screened. Specially designed tailor
made shoes were given to all the patients
registered in the centre as part of the foot
care programme. Complications of diabetes
such as, cardiac complications, renal
complications, eye related complications,
skin and foot related complications were
identified and treated or referred to the
relevant Consultants. Educating the family
members of diabetes patients in order to
obtain family support to control diabetes and
prevent siblings from getting diabetes was
also undertaken by the centre. Dietary
counselling and exercise programme for
diabetes patients were conducted twice a
week. Health education programmes were
conducted by the Centre for the community
on preventing diabetes. Screening
programmes for the community were
organized for early detection of diabetes.
Carrying out continuous medical education
to Medical Officers, Nurses and other
hospital staff members was also an
important strategy of the centre.

Table 1: Details of Management of Diabetic Patients in the CentreYear
Noofdiabetic
patients
registered
Noofnewly
diagnosed
patients
Noofpatients
screenedfor
complications
Patients found with complications
TotalNoof
complicated
patients
Diabetic
neuropathy
Retinopathy
Nephropathy
Vascular
problems
2010 2723 - 338 117 10 73 38 238
2011 1972 250 361 110 14 112 20 256
Year Foot related problems Distribution of footwear
Leg ulcers Cellulites Fungal
Infections
Donations Purchased on discounted
price
2010 17 65 223 34 142
2011 15 29 208 93 217
The centre found that there were 494
patients with Diabetic complications and
this was 10.52% of the total. There were 557
patients with foot related problems detected
at this clinic. These patients with
complications were detected through this
model of care and they might have missed if
there was a conventional set-up.
Conclusion
This project was carried out with the
existing facilities within the hospital.
Required additional resources such as
assistance for investigations which were not
available in the hospital, and the cost for
specially made shoes were borne by the
well-wishers. Productivity culture, positive
attitude and team work of the staff were the
foundation to establish such a Centre.
For a developing country like Sri Lanka, the
economic costs of diabetes is expected to be
high and with increasing prevalence this will
pose a serious threat to the health systems
and national economy. Health promotion
and patient education would ensure that all
people with diabetes are aware of the nature
of the long-term complications of diabetes,
how they can be prevented and the
importance of regular assessment for early
detection. As the people with declining
health status are able to timely access for
appropriate care, they could avoid
unnecessary hospitalization. It will reduce
the economic burden of inward admission
for the health system and social burden for
the patient. As diabetes is a leading cause of
chronic leg ulcers and amputations,
extending the foot care programme would
facilitate a remarkable socio economic
impact. This project also generates evidence
based strategies targeting the poor patients

who cannot afford to pay for the
comprehensive management of diabetes.
Cost effective models such as this project
should be established with the well-
articulated guidelines in hospitals with wide
range of facilities and services in the context
of investigations treatment, health education
and prevention. The centre could be the
curative and preventive centre for diabetic
patients and the people of the relevant area.
The study could be used to develop
programs and policies for better
management of diabetes and cost effective
strategies in secondary and primary health
care institutions.
References
1. Rubin, RJ., Altman, WM., Mendelson,
DN. (1992) “Health care expenditures
for people with diabetes mellitus.
Journal of Clinical Endocrinology and
Metabolism, 18:809A–809F.
2. Jonsson, B. (1998) “The economic
impact of diabetes”. Diabetes Care,
21(suppl 3):C7–10.
3. Wild, S., Roglic, G., Green, A., Sicree,
R., (2004) “Global Prevalence of
Diabetes – Estimates for the year 2000
and projections for 2030”. Diabetes
Care, 27:5, 1047-1053.
4. Engelgau, M., Okamoto, K., Nawaratne,
KV., Gopalan, S., (2010) “Prevention
and control of selected chronic NCDs in
Sri Lanka. Policy options and Action”.
HNP Discussion Paper.
5. Daily Mirror, (2013) “One Fourth of Sri
Lanka are Diabetics”. Accessed
http://www.dailymirror.lk/news/38674-
one-fourth-of-lanka-are-diabetics.html
6. Diabetes Model of Care, Endocrine
Health network working party,
Department of health, State of Western
Australia, 2008.
7. Illangasekera, U., (2011) “Towards cost
effective delivery of diabetes care in Sri
Lanka”. Journal of Diabetes
Endocrinology and Metabolism, 2011; 1:
55-57.
8. Mulgirigama, A., Illangasekera, U.,
(2000) “A study of the quality of care at
a diabetic clinic in Sri Lanka”. The
Journal of the Royal Society for the
Promotion of Health, 120(3): 164-74.
9. Base Hospital Panadura, (2009) “Annual
Health Bulletin”. Panadura Base
Hospital, Panadura
Correspondence:
Dr. Sagari Kiriwandeniya,
Deputy Director – Anti Leprosy Campaign
Email: dianasagari@gmail.com

Comprehensive diebetic care at Base Hospital Panadura

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