International Journal of Clinical Pharmacy

, Volume 35, Issue 1, pp 101–112 | Cite as

Adherence to clinical guidelines in management of diabetes and prevention of cardiovascular disease in Qatar

  • Mohammad Issam DiabEmail author
  • B. Julienne Johnson
  • Steve Hudson
Research Article


Introduction The prevalence of diabetes mellitus (DM) in the UK increased in 2009 to 4 %, of which type-2 diabetes accounts for 85–95 % of all cases. In Qatar the prevalence of DM among the adult Qatari population in 2008 was 16.7 %; around four times higher than the prevalence in the UK. The aim of the study was to design and to apply a medication assessment tool (MAT) to determine the level of adherence to internationally recognised guideline recommendations in type-2 diabetes management and in primary prevention of cardiovascular disease (CVD) among type-2 diabetes patients, to quantify any gaps in guideline implementation. Materials and methods 305 patients were included in this study; all diagnosed with type-2 diabetes with no history of CVD. A 38 criteria MAT was designed from published guideline recommendations on the management of type-2 diabetes and combined with recommendations relevant to primary prevention of cardiovascular disease. The MAT comprised 21 criteria assessing control of blood glucose, 5 criteria assessing management of diabetes complications and 12 criteria assessing preventive medication use in CVD. The MAT was validated by a group of practitioners and researchers and field tested in the diabetes outpatient clinic within Hamad General Hospital, Qatar, with electronic and manual access to patients’ medical records. Levels of applicability and adherence to each criterion were calculated individually and the overall adherence was determined. Results The MAT was applied to the whole study sample (11,590 assessed criteria in 305 patients). Application of the MAT identified 19/38 criteria with high levels of adherence (≥80 %), 9/38 criteria with intermediate levels of adherence (≥50 %; <80 %) and 10/38 criteria with low levels of adherence (<50 %). The overall adherence in 305 patients was 68.1 % (95 % CI: 67, 69) in 6,657 applicable criteria. Total non-adherences, both justified and unjustified, were found in 30.8 % (95 % CI: 30, 32) in 2,049 of the applicable criteria in which only 5.8 % (95 % CI: 5, 7) in 118 criteria had a documented justification. Consequently 94.2 % of all non-adherences (95 % CI: 93, 95) in 1,931 criteria had unjustified non-adherence and indicated a need for inclusion in treatment review through an appropriate pharmaceutical care plan. Discussion and conclusion The study identifies levels of adherence to guideline recommendations, the need for additional documentation and criteria with low adherence that might be a focus for an educational intervention and a starting point for targeted pharmaceutical care.


Cardiovascular disease Clinical audit Clinical guidelines Primary prevention Qatar Type-2 diabetes 



The authors would like to acknowledge Hamad Medical Corporation for the financial support and diabetes consultants from Hamad General Hospital who participated in this study.


Mohammad Diab was supported by a studentship from Hamad Medical Corporation, Qatar.

Conflicts of interest



  1. 1.
    International Diabetes Federation. IDF Diabetes Atlas fourth edition. 2009 [cited 31-8-2011]; Available from:
  2. 2.
    Gonzalez E, Johansson S, Wallander M, Rodriguez L. Trends in the prevalence and incidence of diabetes in the UK:1996–2005. J Epidemiol Community Health. 2009;63:332–6.PubMedCrossRefGoogle Scholar
  3. 3.
    Diabetes, UK. Diabetes in the UK 2010: Key statistics on diabetes. 2010 [cited 30-08-2011]; Available from:
  4. 4.
    Bener A, Zirie M. IM IJ, Al-Hamaq A, Musallam M. Prevalence of diagnosed and undiagnosed diabetes mellitus and its risk factors in a population-based study of Qatar. Diabetes Res Clin Pract. 2009;84:99–106.PubMedCrossRefGoogle Scholar
  5. 5.
    Diabetes in Scotland. Scottish Diabetes Survey 2008. 2009 [cited 30-08-2011]; Available from:
  6. 6.
    Williams R, Gaal LV, Lucioni C. Assessing the impact of complications on the costs of Type II diabetes. Diabetologia. 2002;45:S13–7.PubMedCrossRefGoogle Scholar
  7. 7.
    Zimmet P, Alberti K. The changing face of macrovascular disease in non-insulin-dependent diabetes mellitus: an epidemic in progress. Lancet. 1997;350:S1–4.CrossRefGoogle Scholar
  8. 8.
    Schramm T, Gislason G, Kober L, Rasmussen S, Rasmussen J, Abildstrom S, et al. Diabetes patients requiring glucose lowering therapy and nondiabetics with a prior myocardial infarction carry the same cardiovascular risk: a population study of 3.3 million people. Circulation. 2008;117:1945–54.PubMedCrossRefGoogle Scholar
  9. 9.
    Jeerakathil T, Johnson J, Simpson S, Majumdar SR. Short-term risk for stroke is doubled in persons with newly treated Type 2 diabetes compared with persons without diabetes: a population based cohort study. Stroke. 2007;38:1739–43.PubMedCrossRefGoogle Scholar
  10. 10.
    Marshall S, Flyvbjerg A. Prevention and early detection of vascular complications of diabetes. BMJ. 2006;333:475–80.PubMedCrossRefGoogle Scholar
  11. 11.
    UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). The Lancet. 1998;352:837–53.Google Scholar
  12. 12.
    Stratton I, Adler A, Andrew H, Neil W, Matthews D, Manley S, et al. (on behalf of the U.K. Prospective Diabetes Study Group). Association of glycemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ. 2000;321:405–12.PubMedCrossRefGoogle Scholar
  13. 13.
    UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ. 1998;317:703–13.CrossRefGoogle Scholar
  14. 14.
    Scrivener R, Morrell C. Principles for best practice in clinical audit. Oxon: Radcliffe Medical Press Ltd; 2002. ISBN 1 85775 976 1.Google Scholar
  15. 15.
    Kamyar M, Johnson BJ, McAnaw J, Gruber R, Hudson S. Adherence to clinical guidelines in the prevention of coronary heart disease in type II diabetes mellitus. Pharm World Sci. 2008;30:120–7.PubMedCrossRefGoogle Scholar
  16. 16.
    Chinwong S, Power A, Kesson C, Hudson S. Prescribing for cardioprevention in type 2 diabetes: Adherence to National Guidelines. American Heart Association. 5th Scientific Forum on Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke. Washington. 2004. (published in Circulation 2004;109(20):P200).Google Scholar
  17. 17.
    Ernst A, Kinnear M, Hudson S. Quality of prescribing: a study of guideline adherence of medication in patients with diabetes mellitus. Prac Diab Int. 2005;22:285–90.CrossRefGoogle Scholar
  18. 18.
    McAnaw J, Hudson S, McGlynn S. Development of an evidence-based medication assessment tool to demonstrate the quality of drug therapy use in patients with heart failure. Int J Pharm Pract. 2003;11:R17.Google Scholar
  19. 19.
    National Institute for Clinical Excellence. Type 2 diabetes (NICE 66). National clinical guideline for management in primary and secondary care (update). London 2008.Google Scholar
  20. 20.
    National Institute for Clinical Excellence. Type 2 diabetes. The management of type 2 diabetes (NICE 87) London 2010.Google Scholar
  21. 21.
    National Institute for Clinical Excellence. Type 2 diabetes: newer agents (NICE 87). London 2009.Google Scholar
  22. 22.
    National Institute for Clinical Excellence. Type 2 diabetes: prevention and management of foot problems (NICE 10). London 2004.Google Scholar
  23. 23.
    Scottish intercollegiate guidelines network. Management of diabetes. SIGN 116. Edinburgh 2010.Google Scholar
  24. 24.
    Scottish intercollegiate guidelines network. Risk estimation and the prevention of cardiovascular disease. SIGN 97. Edinburgh 2007.Google Scholar
  25. 25.
    Al-Taweel D, Awad A, Johnson J. Evaluation of the implementation of international guidelines in patients with type 2 diabetes mellitus: a clinical audit in primary and secondary care settings in Kuwait. Abstract to 40th European Society of Clinical Pharmacy Symposium, Dublin 2011. Int J. Clin Pharm. 2012;34:185.Google Scholar
  26. 26.
    Naing L, Winn T, Rusli BN. Practical Issues in Calculating the Sample Size for Prevalence Studies. Archives of Orofacial Sciences. 2006;1:9–14.Google Scholar
  27. 27.
    Hope K, Jason L, Valerie F. Improving physician adherence to clinical practice guidelines: barriers and strategies for change. New England Healthcare Institute 2008. [cited 31-8-2011]; Available from:
  28. 28.
    Woolf S, Grol R, Hutchinson A, Eccles M, Grimshaw J. Potential benefits, limitations, and harms of clinical guidelines. BMJ. 1999;318:527–30.PubMedCrossRefGoogle Scholar
  29. 29.
    Se-Won O, Ha Jeong L, Ho Jun C, Jee-In H. Adherence to clinical practice guidelines and outcomes in diabetic patients. Int J Qual Health Care. 2011;23:413–9.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2012

Authors and Affiliations

  • Mohammad Issam Diab
    • 1
    Email author
  • B. Julienne Johnson
    • 1
  • Steve Hudson
    • 1
  1. 1.Strathclyde Institute of Pharmacy and Biomedical SciencesUniversity of StrathclydeGlasgowUK

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