OUTCOME INDICATORS OF MULTI-PROFESSIONAL DIABETES CARE IN A REFERENCE SERVICE

San Antonio. Murcia, Murcia, Espanha. ABSTRACT Objective: to identify outcome indicators of the multi-professional Diabetes Mellitus care of a reference outpatient service. Method: a descriptive study of evaluative nature, according to the health evaluation framework, carried out by documentary analysis of 173 medical charts, from August to October 2018. The variables were analyzed in the Statistical Package for the Social Science (SPSS), version 22.0, by descriptive statistics, as well as the association of variables, with the Chi-square, Mann-Whitney , and Wilcoxon tests being used, considering p-values ≤ 0.05 as statistically significant. Results: predominance of older adult women, with a mean diagnosis time of 11.9 years. The tracking of complications due to Diabetes Mellitus occurred in 90.2% of the users, with a prevalence of 68.2%, of which 34.7% were diagnosed in the service. Absenteeism was 21.4%. The systolic and diastolic arterial pressure and total cholesterol parameters were in line with the proposed goals, while glycated hemoglobin (A1c), fasting glycaemia, HDL-c, LDL-c, triglyceride fractions, and BMI did not reach the target range. There was a significant reduction in final A1c, comparing to initial A1c, as well as an increase in the proportions of users who reached the goals in glycemic control. Conclusion: a significant improvement in glycemic control, despite the fact that the parameters did not fully meet the goals, ratifying the importance of an effective assistance model for successful care


INTRODUCTION
Diabetes Mellitus (DM) is a 21 st century public health problem, becoming a disease with high incidence and prevalence at a global level. In addition to the 425 million adults who are estimated to have diabetes in the world scene, there are 352 million adults with diminished glucose tolerance, which puts them at elevated risk of developing the disease in the future. [1][2] Brazil occupies the fourth position on the world ranking, with regard to the number of adults who live with DM, with 12.5 million individuals. Every year, the number of people with the disease increases, resulting in life changes arising from the treatment and/or other complications deriving from the disease. 2 In addition, the costs associated with DM include the increase in the use of health services, loss of functional productivity, and disability. As a result, DM imposes an onerous economic burden and generates an impact on the lives of individuals and families, as well as on the health systems, being a significant obstacle to economic sustainable development. 3 In 2017, the health expenses related to DM exceeded $727 billion in the world and $24 billion in Brazil, corresponding to 12% of the expenses intended for health care, with projections of $48 billion in 2045. 2 In this scenario, Brazil invests progressively in models of DM care which aim to motivate and qualify individuals to assume the control of their own condition. In these approaches, health professionals, among them physicians, nurses, nutritionists, physiotherapists, and psychologists, promote health complementary actions, aiming at the effective control of the disease. 4 DM therapy is broad, involving changes in lifestyle, adherence to healthy nutrition, regular practice of physical exercise, systematic glycaemia monitoring, ceasing inadequate life habits like smoking and alcoholism, acknowledgment and proper handling of acute complications, such as hypoand hyper-glycaemia, deserving, for that, support from a multi-professional health team to cover the nuances involved in the treatment. 5 Despite the measures and efforts towards the control, treatment, and prevention of complications related to the disease, the most of the users with DM does not reach the control goals for this disease proposed by the societies related to it. 6 This fact supports the need to evaluate care, focusing on the structure, process, and result components, with regard to DM care, generating indicators that enable redirecting health actions. [7][8] For the evaluation of the health services, structure is understood as the relatively stable characteristics of the care providers, instruments, and resources that are within range, such as physical and organizational places, and human and financial resources that contribute to care. The process refers to the activities developed by professionals and patients. The results cover the final care product, considering the health indicators, the satisfaction of patterns, and expectations. 9 Thus, this research sought to identify the result indicators of the multi-professional diabetes care of a reference outpatient service.
The data coming from this study may direct interventions, allowing for the discussion with regard to the role of the service in DM care, aiming at effective health promotion.

METHOD
This is a descriptive study of an evaluative and quantitative nature, with a cross-sectional design, based on a classical framework for health evaluation. 9 It was carried out in an outpatient service located in a reference University Hospital of Fortaleza, Ceará, Brazil, specifically in the Endocrinology and Diabetes service, specialized assistance unit, which includes the multi-professional DM care service, integrated into the Unified Health System (Sistema Único de Saúde, SUS).

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The sample consisted of the medical records of 173 users under regular monitoring in the unit. Data collection took place from August to October 2018 and considered the records for the years 2017 and 2018, in which the evaluation checklist was used for the construction of the indicators. Clinical and laboratory variables were considered, and they were confronted with the control goals proposed by the guidelines of the Brazilian Diabetes Society. 1 The tracking and the evolutions to complications related to DM were evaluated, as well as these diagnoses in the service, hospitalizations, and absenteeism, among others. Finally, DM care result indicators were elaborated, based on the mentioned parameters.
The study variables were grouped and the database was analyzed in the Statistical Package for the Social Science (SPSS) statistical program, version 22.0, by using descriptive statistics, as well as the association of the variables, in which the Chi-square, Mann-Whitney, and Wilcoxon tests were used, considering a p-value ≤ 0.05 as statistically significant.
Regarding the ethical aspects, the study followed the precepts of Resolution 466/2012 of the National Health Council, meeting the formal requirements related to research studies involving human beings, approved by the research ethics committees of the related institutions.

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The SBD, DBP, TC mean parameters were in accordance with the goals proposed by the SBD, while A1c, fasting glycaemia, HDL-c and LDL-c fractions, triglycerides, and BMI did not reach the proposed target range.
The Wilcoxon test detected a statistically significant difference in the reduction of final A1c (MN 7.9%), comparing to initial A1c (MN 8.9%), (p= 0.001). Moreover, in the bivariate analysis, the Mann-Whitney test revealed a significant difference in the final glycated hemoglobin values between the patients who attended the regular follow-up at the service (MN=8.06) and those who had absenteeism records (MN=11.0), in the evaluated period (p<0.01), according to Table 4. In the analysis of the proportions of attainment of the A1c goals by age group, the chi-square test revealed statistical significance, both in relation to the proportion of users under 60 who had altered initial A1c and evolved to normal A1c (p<0.01), and in the general proportion of users who had altered initial A1c and evolved to normal A1c (p<0.01), according to Table 5.

DISCUSSION
Health evaluation is a complex process that contemplates multiple dimensions and organizational realities, involving structural and process issues related to the health services, professionals, and users. The evaluative product will be able to provide answers and solutions to the existing or emerging problems, indicating the effectiveness of the program, as well as providing subsidies for recruiting information that will allow for the improvement of health actions, coverage, and access, among other aspects that can be measured in this field. 10 In this study, there was predominance of older adult women, retired, with low schooling and a family income varying between one and two minimum wages. This user profile was similar to that of a research carried out in an outpatient assistance unit for users with DM in Ceará, Brazil. 11 In addition, more participation of women in health services is frequent, and this pattern can be related to the preponderant tendency to self-care, as well as to a greater perception of the health status, which motivates them to a greater search for care. 12 The identification of the users' profile can help in the conduction of the DM care process, allowing for the development of strategies, such as carrying out tracking and early diagnosing campaigns, to recruit users who, despite the need, do not seek the health services.
As for the clinical aspects, the users of this study presented a mean time of DM diagnosis of 11.9 (±7.71) years, with SAH and dyslipidemia as the main associated comorbidities. In line with these findings, a survey conducted in Maringá, Paraná, Brazil, which aimed to analyze the behavior and comorbidities associated with the DM microvascular complications, has evidenced SAH and hypercholesterolemia as the most prevalently associated comorbidities, reaching 66.4% and 37.7% of the population, respectively. 13 These findings reinforce the importance of paying attention to the control of these comorbidities in DM users, seeking to minimize their influence on clinical complications.
With regard to the DM-related complications, this research pointed out that most of the users in follow-up presented some microvascular complication related to DM, with sensory-motor neuropathy being the most prevalent.
A study conducted in an outpatient care center for users with DM, in Fortaleza, Ceará, Brazil, found a frequency of microvascular complications of 50.7%, with retinopathy being the most frequent (61.7%). Regarding the time with the disease, there was a statistical association between time of DM diagnosis over 10 years and the presence of the retinopathy complication. 11 A cross-sectional research study, carried out by phone inquiry with 318 diabetic users in Paraná, Brazil, which aimed to estimate the prevalence of diabetes microvascular complications, showed a 53.8% predominance of self-reported complications related to the DM, with the retinopathy being the most frequent one, followed by the sensory-motor neuropathy. Age group and time of diagnosis were variables significantly associated with the presence of complications. 14 As for the result indicators of this survey, there were records of multi-professional monitoring for the vast majority of the assisted users (98.3%). The mean interval between consultations was 4.7 months, with 21.4% of the patients presenting absenteeism records during the evaluated period, which can interfere with the spacing in the intervals between the consultations. Furthermore, there was a significant difference in the glycemic control of the users who underwent regular follow-up at the service and of those who had absenteeism records, which suggests negative implications of absenteeism over DM control.
In this research, processes involving assistance flows from multiple professional categories related to the care of users with DM were evaluated. The multi-professional follow-up, with distinct although interconnected approaches, favors the broadening and the search for integrality of care of the assisted user, seeking to reach dimensions that can positively interfere with quality of life, despite the disease. As an important point, inter-professional work is highlighted, in which the assignments of each category are distinct, but interactive and complementary, with integrated and collaborative work, focusing on the health needs of the clients, as well as on the provision of individualized care. 15 Regarding the tracking of complications, most of the users (90.2%) had undergone it in the service. Most of the patients presented a complication related to DM, and 34.7% of the users obtained their diagnosis from the tracking performed at the service. During the period evaluated, there was a limited record of hospitalizations related to DM. Both the tracking of complications and their diagnosis in the service were significantly higher in users over 60 years of age.
Thus, the importance of tracking complications is highlighted in the search for a better quality of life for the DM patient. This process, however, does not yet occur in a uniform manner, following the example of a study carried out in primary health care units in Spain, which revealed that the indicators related to the tracking of complications were incipient and did not meet the recommendations proposed by the related guidelines. 16 Also regarding the tracking of complications, a study conducted in Switzerland, which evaluated process and result indicators in 12 months of DM assistance (kidney function, feet evaluation and eye deep test, A1c, lipid profile, and blood pressure), found efficacy in the care routine process, except for the tracking of complications by kidney function, and feet and eye deep exams. The study highlights the importance of systematic reports with process and result indicators, with a view to improving DM care. 17 The patients' absenteeism significantly contributes to the decline of many aspects inherent to health care, including the worsening of clinical outcomes, impairments related to diagnosis and treatment, inadequate follow-up of users, decline in adherence, interruption in continuity of care and in the patient-provider relationship. It also interferes negatively in the organizational sphere, with a decline in the productivity of the professionals, inefficient use of resources, increase in the team's workload and in costs.
A retrospective analysis carried out in the United States, whose objective was to identify potential predictors of patient absenteeism in an endocrinology service, revealed a 30% higher rate in the records of user absenteeism to the consultations, and this indicator was significantly related to worse metabolic control. 18 This relationship corroborates data obtained from the present research, and may negatively influence the assistance processes concerning DM care to the assisted user.
As for the clinical indicators of the results of this study, the mean parameters of SBP, DBP, TC were in line with the goals proposed by the SBD, while A1c, fasting glycaemia, HDL-c, LDL-c fractions, triglycerides, and BMI did not reach the proposed target range.
Therefore, it signals the importance of the glycated hemoglobin (A1c) parameter as a clinical indicator widely used and validated for the evaluation of glycemic control, with the DM users having to take this exam twice to four times a year, depending on the goals achieved with the treatment in force or the alteration and prescription of new therapeutic schemes. 1 Although the mean A1c did not reach the control goals proposed by the SBD, there was a statistically significant improvement in final A1c (MN 7.9%), compared to the A1c (MN 8.9%). In addition to that, in the evaluation of initial A1c, 29.5% of the users presented A1c within the control goals, while in the evaluation of final A1c, 53.2% did so, which also represents a statistically significant difference.
In line with these results, the importance of A1c reduction is highlighted, by means of the United Kingdom Prospective Diabetes Study, 19 whose multicentric study conducted with 5,100 patients with type-2 diabetes evidenced that, regardless of the initial and final glycated hemoglobin values, for every 1% reduction, the risk of microvascular complications is diminished by 37%; the risk of acute heart attack, by 14%; DM-related deaths by 21%; and DM-related amputations by 43%.
In consonance with the findings of this research, a survey conducted in the United Kingdom in order to evaluate the impact of diabetes specialized care in terms of glycemic control, lipid profile, and blood pressure, revealed that specialized care, when compared to the basic clinical practices, did not have a significant difference in the outcomes and improvements of the lipid or pressure profile, despite the better performance in attaining glycemic control, suggesting the benefits of the specialized approach in DM management. 20 Also regarding glycemic control, a documentary study carried out with 547 medical records in a hypertension and diabetes care center in Viçosa, Minas Gerais, Brazil, revealed that DM control, evaluated from fasting and post-prandial glycaemia, in the referred field, was inadequate in more than half of the assisted users when compared to the control goals. 12 A research study conducted in four health centers in Kuwait, aiming at measuring the performance in the care provided to type-2 DM patients by means of a set of DM quality indicators between 2010 and 2012 (evaluation of glycemic control, lipid profile, blood pressure, renal function and smoking), verified an improvement in 2012, both in the frequency of tests taken, and in the clinical results of the evaluated parameters, except for smoking, compared to 2010. The results suggested progress in DM care between 2010 and 2012, pointing out the indicators of DM quality as an auxiliary resource in the performance of the care provided, as well as in the formulation of policies related to the disease. 21 A European study, which aimed to evaluate the quality of care provided by health teams to diabetic patients, revealed that, concerning the A1c and blood pressure levels, most of the users reached the proposed control goals, with 60% and 76%, respectively. The indicators were deficient with regard to the tracking of diabetes-related complications, with the evaluation of the feet and of the renal function performed in 26% and 20% of the users, respectively, in the year 2016. The study highlighted the importance of effective interventions to improve the care provided to users with DM. 22 In this sense, the relevance is ratified of diabetes specialized multi-professional care, as a facilitator factor for effective assistance that seeks improvement in the health actions offered to this population, aiming at better control of the disease, prevention or delay of related complications, as well as greater quality of life.

CONCLUSION
In this research, the result indicators revealed mean parameters of SBP, DBP, TC, in accordance with the goals proposed by the Brazilian of Diabetes Society, while A1c, fasting glycaemia, HDL-c fractions, LDL-c, triglycerides, and BMI did not reach the proposed target range. Although the mean A1c value did not reach the objectives, there was a significant reduction in final A1c compared to initial A1c, as well as an increase in the proportion of users who reached the glycemic goals at the end of the period evaluated.
In addition, multi-professional follow-up was offered to most of the users. Absenteeism was a factor related to the decline in DM control. These findings suggest the benefit of continued multiprofessional care for better diabetes control, fostering the reflection on the significance of effective care models that seek effective care strategies.
As a methodological limitation, the use of the technique of documentary analysis of medical records is signaled, which, due to the dependence of the records on the documents, it can generate restrictions by deficiency of information, by incomplete filling out, as well as by unreadability of writing. There was no collection of information directly with the subjects involved, which made it difficult to complete the systematization and evaluation of care. In this sense, continuity of the research is suggested, with the use of more robust methodological designs that can meet the expectations of the research initiated.