Free Microalbuminuria Testing Essay Example
Diabetes simply refers to a medical condition whereby glucose level in the human blood system gets too high due to the fact that the body is unable to use it properly and also because the pancreas that is responsible for producing insulin does not produce enough of it to assist the glucose the body to get into the body cells (Diabetes UK, 2010). A study performed by Shaw et al. (2009) across 91 nations and that was aimed at estimating the prevalence of the ailment for two specific time periods; 2010 and 2030 showed that 6.4% of the world’s population (285 million) would be suffering from diabetes in the year 2010 while this rate would rise to 7.7% (439 million) by the year 2030. Recent years have seen diabetes become a major health problem in Oman (National Diabetes Guidelines 2012). Although Oman is not included in the newest official International Diabetes Federation Atlas, statistics however indicate that over 7000 new cases of diabetes are reported on a yearly basis in Oman and diabetes in therefore a serious issue in the nation (Bhattacharjee 2013). Diabetes prevalence in Oman is expected to increase by 190% over the next 20 years meaning that 217,000 people will be diabetic by the year 2025. This is according to the World’s Health Organization (Al-Shookri et al., 2011). Al Ryami (2010) writes that there is a pervasiveness of diabetes-related complications among Omanis. For instance, about 27% of Omanis have microalbuminuria.
This complication is usually an early indicator for nephropathy as well as cardiovascular disease (Satchell 2008). Generally, the microalbuminuria test is usually used to indicate or measure the urine ratio of albumin to creatinine. A result considered normal for this test ranges around 30mcg/mg (Burke, 2014). The year 2008 saw the American Diabetes Association recommend this test for patients of type 2 diabetes. The same organization went on to state that an abnormal result for a test was one that ranged from the values 30-300mg/24 hours (Foohey and Selgren 2009).
The Oman Diabetes Mellitus Guidelines (2012) suggests that the microalbuminuria test is supposed to be carried annually for all people who suffer from type 2 diabetes and that this should essentially be done by collecting samples of urines, early in the morning (Ministry of Health, 2012). Diabetic clinics are obliged to follows these guidelines when it comes to primary health care delivery to patients. This particular audit aims to evaluate the extent to which these guidelines are abided by or followed and the areas where weaknesses are observable.
This particular audit was carried out at a local diabetic clinic from December 30, 2014 to December 31, 2014. The major objective was to establish whether type 2 diabetes patients had undergone any screening for microalbuminuria in the past one year that is from the December of 2013 to that of 2014. Clinical audits are aimed at improving the quality of care by assessing the service being provided and therefore contributing towards ensuring that patients are provided with the highest quality of care (Bullivant and Nolan, 2010). An audit can essentially be defended as a comparison of actual care practice against the evidenced based standard that has been documented with the intention of improving overall patient care (Dally, 2008, p.4). In this, the criteria was the occurrence or nonoccurrence of a microalbuminuria test in type 2 diabetes patients. The standard used was that 95% of all patients who visit the diabetic clinic would in the last 12 mounts have undergone a microalbuminuria screening. A checklist for this audit had been developed (see Appendix 1). In regards to reliability and validity, the recommendation of the guidelines was that all patients suffering from type 2 diabetes have to go undergo the microalbuminuria test yearly in order to establish if the test is negative or positive (MOH, 2012). Additionally, patients are required to collect urine samples early in the urine put in a special urine container already having the relevant details of the patient. This is to prevent mixing of samples and ensure that the samples delivered to the lab belong to the right patients. Before the commencement of the audit, permission as sought from the nurse and objective and benefit of the audit was explained. This audit adhered to the code of professional conduct and thus, the names of the patients, as well as the health institution under study, are withheld (Oman Nursing and Midwifery Council, 2011). The total number of patient participant was 25, all who had type diabetes and who visited the clinic for follow up. Additional data was also gathered for the previous year from the Oman National Diabetic Registers and Records.
Analysis for this particular study involved comparing the official audit standard with the collected data. The figure below (figure 1) indicates out of all the 15 patients involved in the study, only 40% (6 patients) had undergone the microalbuminuria during the previous 12 months. The other nine patients had not undergone any kind of testing.
The result from this study therefore failed to meet the audit standard of 95%. This was because of several reasons.
1. The patients did not understand why the test was important and were therefore not tested
2. Lack of relevant reagents for carrying out the test in the tertiary hospital lab.
3. A large number of patients usually visit clinics in the afternoon and, therefore, miss collecting the required early morning urine sample.
4. The staff did not inform patients to visit the clinic in the morning with a urine sample
Generally, the results indicate that health professionals in this health center failed to adhere to the MOH (2012) recommendations for screening patients for microalbuminuria annually.
In the national diabetes register, some entries only documented information of the patient but did not indicate the particular type diabetes that a given patient was suffering from. Since the target of the study was inly type 2 diabetes patients, it was difficult to recognize which patients suffered from this kind of diabetes. The problem was however solved by entering patient’s registration into the computer database and establishing the type of diabetes that one was suffering from.
The National Diabetes guidelines stipulate that diabetic patients can be diagnosed with nephropathy using the V test. If the result turns out positive, a repeat test is essentially required, and this should take place twice between 3 and months. Positive results in two out of three test demand for the patient to be immediately taken to a diabetologist for immediate commencement of medical therapy (MOH, 2012). There is, however, another recommendation by the National Institute of Health and Clinical Excellence (NICE) and this is that early samples should be used to check the albumin –creatinine ratio and that tests should be repeated twice or once a month if it is positive (Willacy 2011).
According to Selgren and Foohy (2009), samples of urine collected randomly can be used for tests, either 24 hour collection or time collection. The collection of urine early in the morning and that assess the albumin creatinine ratio is, however, the best since the others can lead to the generation of inaccurate results due to sample contamination among other reasons (Vivekanandan, 2012). Nurse have the mandate to inform patients to collect the early morning samples per the National Diabetic Management Guidelines (2012).
In Oman, risk factors associated with diabetic nephropathy and microalbuminuria include illiteracy, male gender, family history of the condition, retinopathy, hypertension, poor glucose regulation and finally prolonged diabetes duration (Alrahawahi e al, 2012). According to Silva (2012), more than 15% of all diabetes patients in India are illiterate. Illiterate diabetes patients are at a greater risk for complications development as they lack adequate knowledge on diabetic control; the importance adhering to therapy and medication, tests available for complications, options of care and so on. (Alrahawi et al., 2012). Additionally, absence of interests as well as prevalence of patient refusal to be tested is a sign of lack of knowledge and proper education about the importance of these test and the role they play in the prevention of diabetes-related complications (Silva 2011). Health education is, therefore, crucial when it comes to management and once of the main topics of this health education should be on the importance of annular test and checkups (MOH, 2012).
An observational trial was carried out by Al-Futaisi et al. (2006), between the years 2003 and 2003 to show the determinants and prevalence of microalbuminuria among diabetes patients in Oman. Out of 261 participants each suffering from type 2 diabetes, 27% showed positive results for microalbuminuria. This study also revealed that HbA1c, creatinine and hypertension are great microalbuminuria predictors. For instance, an increase of HbA1c by a single unit was responsible the development of microalbuminuria in 23% of the patients. Creatinine increased the risk for microalbuminuria by a multiple of 5.72 while hypertension increased the risk of microalbuminuria by 2.37. However, this study is quite old and the sample used is small and thus, the result from the study may be considered weak and could perhaps be strengthened by a larger sample (Fain, 2009).
Additionally, microalbuminuria is often seen as a predictor of ischemic heart disease, left ventricle failure and general cardiovascular disease. This can be seen from a cross-sectional study conducted by (Jafar et al., 2009) that involved a total of 3143 individuals aged over 40 years in Karachi, Pakistan. The study aimed to assess microalbuminuria effect on CVD prevalence as well as electrocardiography changes. Major ECG changes usually indicate CVD, but the study also assessed other CVD predictors such as hypertension, smoking, diabetes, and obesity. In 92 % of patients whose urine was collected and used as a sample, it emerged that the microalbuminuria incidence ranged between 12.3% and 20.3% in those patients with significant electrocardiography changes. The study generally shows that microalbuminuria increases the risk for electrocardiography changes across patients will all the predictors considered including hypertension, obesity, and smoking. Consequently, the conclusion from the study is that there exist a strong relationship between ECG changes and microalbuminuria and the V test is paramount for both early detection as well as early prevention CVD and early mortality (Jafar et al., 2009).
Moriya et al. (2003) suggests that retinopathy can result from microalbuminuria. A cross-sectional study conducted by Rani et al., (2011) proves this fact. The study showed that out of a sample of diabetic patients who had microalbuminuria; 31% had retinopathy. The authors concluded that microalbuminuria increased the risk for retinopathy and people suffering from the disease should, therefore, undergo regular tests so that they can be adequately treated.
Reddy et al. (2013) also conducted another study, this time in China where it was shown that out of a sample of 137 diabetic patients, 36.5% had retinopathy. Another important finding from this study was that overweight and smoking are linked with retinopathy development in diabetic patients who also have microalbuminuria (Reddy et al. 2003).
Gobal et al., (2011) suggests that hypertension increases microalbuminuria risk by 2 to 3 folds. Consequently, micro albumin test can be utilized to monitor the blood pressure in these patients an albumin increase elevates blood pressure (Volpe, 2008).
Foohey and Selgren (2009) suggest that the microalbuminuria test results may be affected by several factors that include high temperature, intensive physical exercise, infection, hyperglycemia, hypertension, and dehydration. In regard to exercise, it reduces the plasma insulin level leading to insulin resistance as well urinary albumin excretion in great amounts.
The Diabetes Management Guidelines of Oman (2012) recommend the treatment of people suffering from diabetes and microalbuminuria with Angiotensin Receptor Blockers (ARB) and ACE inhibitors. The same drugs were recommended by the American Association of Diabetes in 2008. ARB’s stops urinary albumin from being excreted resulting in microalbuminuria prevention and also spur the emergence of diabetic kidney disease in some patients (Cupp, 2012). A study was conducted by Agha et al. in 2009 to augment these findings and it was found that administration of ARB in group of 190 participants reduced albuminuria in the patients by over 30% in about 87.1% of the patients in the study.
Nurse have the role of empowering patients to acquire higher levels of self-care and providing them with sufficient data and information that can be sued to enhance the quality of life (Peimani et al., 2010). To do this, the Omani Nursing and Mid-Wifery Council (2011) claims that nurses must possess adequate knowledge and information on diabetes in order to avail the best care to patients. Nurses are also tasked with the role of educating patients about self-acre and self-management (American Diabetic Association, 2013). Aspects of self-management include healthy eating, regular blood sugar monitoring, self-blood pressure control, not smoking, fully adhering to therapy and medication and routine checkups for both microalbuminuria and the eyes (Simon, 2012).
The study showed that the standard of audit (95%) was not met since only 40% of the patients had been subjected to microalbuminuria testing. This shows that there is a need to initiate an action palm to ensure that microalbuminuria tests take place at the clinic. For example, the knowledge and practice of health workers can be improved by educating them on evidence-based practice regarding the benefits of microalbuminuria testing. This can be in the form of oral presentations. This is as per the Oman Nursing and Midwifery Council (2011) that calls for regular updating of evidence-based practice in healthcare professionals. Patients also need to be educated on the importance of the regular tests. Patient education essentially leads to the enhancement of patient’s knowledge on diabetes knowledge and management (Forde et al., 2009). The results of this study should also be shared with nurses to show them the huge deficiency in the clinic and thus make them knowledgeable and aware about the importance of carrying out the microalbuminuria test once a year as the Diabetic Management Guidelines recommend (2012). The dissemination of these audit findings is crucial as it will ensure that the results are relayed to the relevant professional who will be involved in the implementation of the action plan (Pearce, 2010).
This audit has identified several gaps in the implementation of the national guidelines on diabetes. The guidelines that stipulate that microalbuminuria test should be conducted annually for all type 2 diabetes patients has not been followed through. This is the duty of physicians and nurses in diabetic clinics who should ensure that all patients visiting the clinic undergo this test annually. If reagents are not always available, the nurses should ensure that they invite as many patients for the test when these reagents become available. The nurses and doctors at diabetic critical should also educate patients on the important role of microalbuminuria tests as a means of early detection of complications. Counseling and health education are extremely important in improving the clinical health outcomes of patients (Forde et al., 2009). Additionally, it is recommended that physicians and nurse formulate investigation and treatment plans for every patient in order to ensure patient adherence and routine plan follow up. Patients should also be provided with pre-visit information that enables them to prepare mentally and physically for the tests that they will go through once they visit the clinic next (Hummels and Evans, 2012). It is also recommended that all diabetes-related investigations be conducted in health clinics or centers without having to be sent to major hospitals. Re-audits should also be carried out after a six month period to evaluate if any improvements have occurred and patients are being tested on an annual basis. A re-audit is also necessary as it ensures that the action plan proposed and agreed upon is being implemented (National Health Services, 2010).
This assignment has involved a critical analysis and review of the status of microalbuminuria testing in health centers and it appears that there is a great deficiency when it comes to implementing the proposed national diabetes guidelines that stipulate that microalbuminuria tests be carried out on diabetes patients annually in order to facilitate evidence-based care. This has been found a comprehensives audit of a primary health care institution found in Muscat and that caters to diabetic patients around Oman. The audit focused on the administration of the microalbuminuria test and assessed whether the health care was conducting it in its patients annually. This was found not to be the case. The importance of conducting the microalbuminuria testing be overemphasized. As it has been shown, this test enables early detection of other complication such as diabetic nephropathy and should, therefore, be always undertaken for patients suffering from type 2 diabetes.