Evaluating quality of life and satisfaction with pharmaceutical care services among patients with type II diabetes mellitus receiving care in a resource-limited setting

INTRODUCTION

Diabetes mellitus (DM) is a diverse group of metabolic disorders that are often associated with a high disease burden in developing countries such as Nigeria.^[1] A report from an epidemiological survey between 1990 and 2017 has shown an increase in the prevalence of DM in Nigeria. All regions of the country have been affected with the highest prevalence seen in the south-south geopolitical zone.^[2]

A report suggests that Nigeria has the greatest number of people living with DM in Africa with an increasing burden of the disease over 25 years.^[3] A recent study placed the prevalence of DM in two regions of the country (south-south and south-east) at approximately 8%, with Akwa Ibom state reported to have a DM prevalence of 9.5%.^[4] These recent findings suggest a rising prevalence of DM in Nigeria, surpassing previously reported values.

The level of care received by patients with DM is perceived as low due to prolonged waiting times for appointments, long waiting hours in the out-patient clinics, and long queues waiting for medication.^[5,6] At present, DM care is poorly coordinated especially at primary and secondary public health-care centers. This lack of coordination has led to a greater reliance on unorthodox medicine and complimentary or alternative medicine with disastrous consequences.^[5-7]

DM is a major cause of morbidity and mortality both in developing and developed countries. Due to rapid urbanization with changes in lifestyle and nutrition in the 21^st century, there has been a rise in the disease and its complications.^[1] Morbidity and mortality from DM are very high in Nigeria due to poor management and non-compliance with global treatment guidelines.^[6] A descriptive study carried out by Aguocha et al. reported that out of 1124 diabetic patients admitted between 2000 and 2004 in a tertiary health-care facility in south-east Nigeria, 14% died.^[8]

The provision of pharmaceutical care services enhances drug therapy and improves the health-related quality of life (HRQOL) of patients. HRQOL can be reported directly by the patient as a patient-reported outcome.^[9-11] Pharmacists are professional health-care experts on drug therapy and can contribute to the optimization of treatment through various clinical interventions including medication review follow-up, patient counseling, therapeutic drug monitoring, and by also providing patients with information on drug interactions, adverse drug effects, and the appropriate use of medications.^[12,13]

Pharmacy practice has evolved over the years to provide patient-oriented pharmaceutical care services. This has created a need for periodic assessment of the quality of the services provided. The patient satisfaction with these services can be used as a variable to assess the quality of care offered by pharmacists.^[14]

The measure of patient satisfaction as a patient’s subjective assessment of pharmaceutical care service is an important parameter that can be employed to improve the services offered by pharmacists.^[15-17]

Evaluating patient satisfaction helps to identify changes in patient needs, and findings from such evaluations can be used in developing measures to improve service and maximize the professional capacity of pharmacists.^[15-17]

HRQOL is increasingly accepted as a relevant assessment variable in health-care delivery. It can be defined as the value assigned to the duration of life as modified by the social opportunities, perceptions, functional states, and impairments that are influenced by disease, injuries, treatments, or policy.^[18] It is also viewed as an individual’s or the perceived physical and mental health over time.

Determining the HRQOL of patients with DM is important as it provides pharmacists with a means of evaluating the efficacy of therapeutic interventions and provides evidence for service improvement. A recent study found that adults with complicated DM living in South East Nigeria had significantly reduced overall and domain-specific quality of life. Moreover, the researchers also found that the patients’ HRQOL was worsened by presence of comorbid conditions.^[19]

Patients’ satisfaction with the pharmaceutical care services provided is an important indicator for measuring the quality of healthcare offered by pharmacists. This study is, therefore, aimed at providing more data on the HRQOL and satisfaction with pharmaceutical care services among patients with DM in Nigeria with a bid to identify gaps in the management of these patients and develop measures to improve therapeutic outcomes in patients with type II DM.

MATERIALS AND METHODS

RESULTS

Patients’ fasting blood sugar, glycated hemoglobin, and blood pressure levels

The recent levels of the patients fasting blood sugar and blood pressure are shown in [Figure 1]. In 100% (120) of the cases studied, there was no evidence of glycated hemoglobin investigation. Only 20% (24) of the cohort studied attained blood sugar control (<126 mg/dl/7.0 mmol/L) based on their recent fasting blood sugar test results, while only 27.5% (33) of the study participants had their blood pressure within clinically acceptable values (<140/90 mmHg).

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Figure 1:

FBS, HbA1C, and BP readings. FBS: Fasting blood glucose, HbA1C: Glycated hemoglobin, and BP: Blood pressure.

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DISCUSSION

Although studies have shown that more females visit health facilities for medically related issues than males,^[23] the majority of our study participants were male. These findings are similar to an observation in a previous study by Prajapati et al. in South India, where males constituted about 64% of the study population.^[22]

Most of the patients we studied were aged 60 years and above. A previous study on the global prevalence of diabetes by Wild et al. found that in developing countries, majority of the people with diabetes were in the age range of 45–65 years.^[24] A similar observation was reported in a previous study by King et al. who reported that in developing countries, majority of patients with DM are in the age range of 45–64 years.^[25]

Sixty-five percentages of the patients we studied had comorbidities. Hypertension was found to be the most frequently documented comorbidity in this population of patients. Lloyd et al., in their study, reported that hypertension was the most prevalent complication of DM, occurring in 46% of the patients that they studied.^[26] This finding is also similar to that reported by several other studies on patients with diabetes. For instance, Wexler et al. reported 89%, while Gautam et al. and Spasić et al. also reported 41% and 76%, respectively.^[27-30]

We found no evidence of glycosylated hemoglobin investigations in all the cases studied. This lack of data is a huge concern. Routine glycosylated hemoglobin investigation is imperative in the management of DM, because it is an important measure of long-term glycemic control and is directly correlated with the long-term complications of diabetes. Although the ideal frequency of glycosylated hemoglobin testing is yet to be determined; it is generally recommended that 2–4 tests be performed annually. The lack of monitoring of glycosylated hemoglobin in this population may be due to the high costs of this test and the pervasive challenge of lack of equipment, commonly reported in resource limited settings.

Over 30% of the cohort studied had complications associated with DM, with neuropathy being the most frequently reported complication. The long-term effects of diabetes are usually insidious and often times go unnoticed until late; however, they are serious, usually debilitating and may become life-threatening if left untreated. Chronic complications of diabetes are diverse and include macrovascular and microvascular diseases.

In our assessment of the patients’ quality of life based on diabetes related complaint, we identified fatigue as the most frequent complaint, reported in over 96% of the cases studied. More than 50% of the patients had problems in their work and social life. Quality of life has increasingly become recognized as a vital outcome of healthcare. It represents the ultimate goal of all health-care interventions. It is crucially important as it is a predictor of a patient’s capacity to manage his or her disease and maintain health and well-being in the long-term.

The development of long-term complications of diabetes, such as retinopathy, nephropathy, diabetic foot ulcers, cardiovascular diseases, and erectile dysfunction, significantly affects the physical well-being of diabetic patients, and ultimately their quality of life. This decrease in quality of life is because the patient’s ability to undertake usual activities is hindered as a result of these complications, thus negatively affecting their HRQOL.

Patient satisfaction with pharmaceutical care services was categorized into two scales; satisfaction with the friendly explanation of pharmacists and satisfaction with pharmacists’ management of therapy scales. In both scales, the rating of the patients’ satisfaction was above average. These findings may indicate an adequate integration of pharmaceutical care services in the provision of care to patients with DM in the hospital used for the study. This finding is similar to a report by Onavbavba et al., who evaluated patients’ satisfaction with pharmaceutical care services in four selected health-care facilities in Delta state, Southern Nigeria.^[31] In their study, the authors found that in all the four health facilities, patient satisfaction with pharmaceutical care services was rated above average. Several other studies from various health facilities have reported that patients were satisfied with the pharmaceutical care services provided.^[32-36]

The provision of pharmaceutical care services has been found to increase the satisfaction of diabetic patients with health-care services.^[37] The relationship between patient satisfaction and other relevant components of health care has been established. The patient satisfaction has been associated with the health seeking behavior of patients including medication adherence.^[38] Patients who are satisfied with health-care services are more likely to continue with such services, maintain relationship with their health-care provider, comply with therapeutic recommendation, and participate in responsible self-care.^[39]

We found an association between patients’ satisfaction with pharmacists’ friendly explanation and patients’ complaint of weight changes, decreased energy levels, and numbness. We also found an association between patients’ satisfaction with pharmacists’ management of therapy and patients’ complaint of fatigue, numbness, and blurred vision. Our findings suggest that diabetic patients, who are satisfied with pharmacists’ friendly explanation, are less likely to complain about weight changes, decreased energy levels, and numbness. Furthermore, our findings suggest that diabetic patients, who are satisfied with pharmacists’ management of their therapy, are less likely to complain about fatigue, numbness, and blurred vision.

However, we found no association between patients’ satisfaction with pharmaceutical care services and their blood pressure or blood sugar levels. Aharony and Strasser, in their research, report opined that although research is yet to find a direct correlation between patient satisfaction and improved outcome, satisfied patients tend to comply more with treatment recommendations. They also stated that the level of satisfaction and adherence to treatment will ultimately affect other health outcomes of the patient including quality of life and duration of hospitalization.^[39]

Diabetes has become increasingly prevalent and demands better care and control. The quality of life assessment is considered an important measure of outcome in long-term illness and management. The mere presence of diabetes can reduce the quantity and quality of any relationship, hinder traveling, and increase economic burden.^[40] Most health-care providers focus on medically related outcomes only when assessing the efficacy of their intervention. However, for a better outcome, it is important to extend the assessment of clinical interventions to the impact on the physical, emotional, social, and economic wellbeing of the patient, which is the patient’s quality of life. Patients’ quality of life is very important, because it is a powerful tool to predict an individual’s capacity to manage the disease and maintain long-term health and well-being.^[41]

Routine assessment of quality of life as a part of clinical practice has the potential to improve communication between the patient and the health-care provider, identify frequently overlooked problems, assess the problems, and evaluate the effect of therapeutic efforts at the individual patient’s level.^[42] The patient satisfaction surveys are also essential in obtaining a comprehensive understanding of the patient’s needs and their opinion of the services received. It is a vital tool in evaluating the quality of health-care delivery service in hospitals. Low patient satisfaction can lead to poor compliance with treatment recommendations, resulting in poor clinical and humanistic outcomes. We, therefore, recommend routine assessment of quality of life, as well as satisfaction with health-care services provided among diabetic patients. This will help identify gaps in the treatment offered and help improve clinical and humanistic outcomes of management. Our study has certain limitations. Self-reported instruments were used to assess outcome measures; however, the instruments used were reliable instruments deployed in the previous studies.

CONCLUSION

The HRQOL of the patients was poor as majority of the patients had diabetes related complaints. Patients’ satisfaction with the pharmaceutical care services offered was good. There was an association between the patients’ satisfaction with pharmaceutical care services and the diabetes related complains of weight changes, decreased energy levels, numbness, fatigue, and blurred vision.

Periodic evaluation of the quality of life and satisfaction with health-care services among patients with DM is recommended. Furthermore, there is need to institutionalize periodic monitoring of glycosylated hemoglobin for patients with diabetes receiving care in Nigerian hospitals.