In a clinical care set-up, treatments are normally used in curing or alleviating signs and. In as much as there has been advances in research to come up with the best formulation for treatment of millions of diseases, its effectiveness is limited by the increase in rise of chronic conditions, which treatment can only manage but cannot completely treat (Gérvas, Starfield, Heath 2008). Additionally, at the point of treatment, a patient may have already been subjected to pain and suffering as well as a drain in financial resources. Prevention on the other hand is done to mitigate occurrence of a health condition whereby, future diseases are anticipated in currently healthy individuals. This effectively reduces the risk of occurrence of an illness and thus saving a potential patient from the suffering and pain surrounding a condition as well as other detrimental effects that diseases bring about. The value of prevention in health care has always been intuitively understood by clinicians (Lawrenson, 2013). In this regards therefore, prevention emerges as a more preferable option to treatment especially for chronic conditions.

The rates of diabetes have continued to increase as accelerated by a change in lifestyle, further away from physically active way of life, as well as a change in eating habits; leaning more on sugary foods. Pre-diabetic conditions and type 2 diabetes mellitus (T2DM) have particularly exhibited a rapid increase in their prevalence. Some of the pre-diabetic conditions include impaired glucose tolerance (IGT) and/or impaired fasting glucose (IFG). Individuals who portray insufficient levels of physical inactivity are more likely to develop T2DM. Certain lifestyle strategies in conjunction with exercise training play a pivotal role towards averting the onset of T2DM and improving glycaemia control in individuals that present pre-diabetic conditions (Hodern et al. 2012). The cardiovascular risk profile of the individual exercises regularly also improves. Moreover, the cardio respiratory fitness and body composition of the individual also improves thereby resulting in better health outcomes on the part of the individual. According to the results of random controlled trials, it is evident that persons that have IFG, IGT or both have higher chances of developing diabetes. As a result, they necessitate interventions that reduce the onset of the disease.

This quality improvement proposal recommends a change in my organization’s clinical processes in favor of a preventive-based approach in management of chronic conditions over treatment approach. The importance of the research in health care will be to evaluate and measure the quality and safety of preventive approach, based on an evidence-based discussion. The paper develops the proper strategies for health promotion and the primary prevention of T2DM. Moreover, the paper presents the understanding of the community regarding its attitudes and knowledge towards diabetes. Finally, the paper demonstrates an awareness of the sources of evidence in prevention, early detection and screening in diabetes. Problem statement is: Unhealthy lifestyle increase the chance of chronic disease that affect societies. Available knowledge base will be compiled using different recent research studies, both locally and globally. The rationale will be; by increasing governmental awareness in favor of healthy life style as per Qatar’s vision 2022. The study will measure effectiveness of the proposed quality improvement/change intervention by identifying the measures chosen for studying the processes and outcomes of the intervention.

The importance of evaluation, research and measurement

It is paramount that any organization constantly work to improve the quality of its processes and outcome. Quality improvement in this regards must take stock of the level of performance in an organization and work towards improvement of the prevailing standards. The first step in improving quality is to measure the quality levels currently in place (Morris & Bailey, 2014). In healthcare, quality measurement involves use of data to evaluate the performance of an organization’s processes against recognized quality standards. Upon measuring, evaluation comes about as a way of making judgment about the intervention needed to achieve the ideal standard of quality. Evaluation in healthcare involves making judgement or assessment of important aspects of a program, system, or care process. According to Green and South (2006), evaluation is the determination of value or worth of a healthcare initiative against an acceptability standard. Research, then extrapolates the best evidence-based intervention to reach the standards. In a bid to improve healthcare quality, the categories of intervention that can be evaluated include: the organizational policies, services, treatment and changes in structures and processes (Ovretveit, 2002). As a package therefore, measurement, evaluation and research comprehensively addresses the quest for quality improvement in an organization.

The concern emanating from the increasing prevalence of pre-diabetic conditions and T2DM has necessitated a quality improvement change with the objective of reducing the prevalence and enhancing the health outcomes of the affected individuals. It is through measurement, evaluation and research, that effectiveness of the current management practices of the condition are dissected and placed in the microscope and the most appropriate intervention follows suit. For instance, the research would play a pivotal role in emphasizing the importance of a more proactive approach in management of Diabetes through increasing the proportion of the individuals under the optimal management of diabetes initiative (Redmont et al. 2014). Being a chronic disease, diabetes requires continuous education on patient self- management and medical care to avert possible acute complications arising from the disease. Continuous education also enables the identification of effective life strategies and exercise training that reduces long-term complications. The complexity associated with diabetes care also provides the other reason for conducting evaluations, research and measurements on diabetes. Therefore, the research will also enable the understanding of the effects of the screening tests on the society, health systems and individuals (WHO 2003). Additionally, there are other issues that diabetes care entails such as glycaemia control. Therefore, continuous research on the topic ascertains the development of sufficient intervention measures to improve the health outcomes of diabetic patients (ADA 2010).

Continuous research on diabetes will enable the identification of the standards of care that will provide patients, researchers, clinicians, and other interested stakeholders with the critical aspects involved in diabetes care such as the tools of evaluating the quality of patient care and treatment goals. However, prior to understanding the standards of care and treatment, the evaluation and research will enable the understanding of the various classes of diagnosis including the recommended diagnosis tests (ADA 2014). The research also enables the modification of the treatment goals based on certain patient factors such as individual preferences to ascertain the attainment of goals and targets that are desirable for most diabetic patients. The setting of the standards does not intend to preclude extensive patient evaluation and management. On the other hand, the standards provide a pathway for the development of recommendations for screening, therapeutic actions and diagnosis of the patients. The recommendations will play a pivotal role towards impacting favourably on the health outcomes of diabetic patients. Towards meeting the objective, the American Diabetes Association (ADA) developed a grading system that codifies and clarifies the evidence that forms the guideline for the basis of the standard recommendations. The system uses letters A, B, C or E to list each recommendation against the level of evidence that supports the recommendation (ADA 2010).

Classification and Diagnosis

The current diabetes management strategies can be considered inadequate to the extent that the prevalence rates are increasing by the day. Going by the current trends, if proper intervention and preventive strategies are not put in place, the diabetes epidemic is likely to prove fatal. According to Hoque et al. (2009), the current global diabetes epidemic and the projected increase in prevalence over the coming two decades necessitates a change in approach. One of the most promising approach is shift from treatment-based management to preventive management. Health organizations have a duty in this shift, particularly in raising awareness of the means to reduce chances of developing the condition. Health literacy levels with regards to diabetes in Qatar remain still low and need to be boosted.

Exercise training is one of the methods, that if adopted, can lead to a more-healthy lifestyle. In order for exercise training to be effective, it is required that individuals prone to pre-diabetic conditions and T2DM perform exercise for a minimum of 210 minutes every week in the case of moderate training (Hodern et al. 2012). As an alternative, they should accumulate a minimum of 125 minutes in every week of rigorous training. They should never fail to exercise for two consecutive days. Considering the time efficiency of vigorous high-intensity training, it is appropriate to recommend the training to individuals since it yields better health outcomes bearing in mind the contraindications and complications associated with the exercise training. The persons should also undergo at least two resistance-training sessions per week that consist of 2-4 sets of 8-10 repetitions. This paints a picture of a program that cannot be effective by simply administering blood glucose management drugs. There is however, little emphasis for exercise trainings and other preventive measures in the hospital, which, if properly emphasized, may significantly curb the growing prevalence of diabetes.

There are four clinical classes of diabetes. Type -1diabetes is the first class that results from the destruction of the beta (?) cells of an individual thereby resulting in absolute insulin deficiency (American Diabetes Association 2010). Type 2 diabetes emanates from a continuous defect in insulin secretion on top of insulin resistance. There are other types of diabetes that emanate from different causes such as genetic defects in the action of insulin, genetic defects in the functioning of beta cells and exocrine pancreas diseases such as cystic fibrosis and chemical and drug-induced diseases. There are three ways of diagnosing diabetes that necessitate a confirmatory diagnosis on the subsequent day unless the individual presents unequivocal symptoms of hyperglycaemia. It is evident that the 75-g OGTT (Oral Glucose Tolerance Test) is more specific and sensitive as compared to the fasting plasma glucose (FPG) in the diagnosis of diabetes, performing it in practice is difficult besides its poor reproducibility. As a result, the FPG stands out as the most preferred diagnosis test due to its lower cost, accessibility to patients and ease to use.

However, patients that present normal FPG or IFG have to undergo the OGTT test for further evaluation. The Impaired Glucose Tolerance (IGT) test and the Impaired Fasting Glucose (IFG) are the diagnosis tests applicable to testing pre-diabetes. The presentation of both types of pre-diabetes indicates risk factors for future cardiovascular disease and diabetes. The test is applicable to adults of any age that are either obese or overweight or both that present a Body Mass Index (BMI) that is greater or equal to 25kg/m2. The test is also more applicable to individuals that present one or more risk factors. However, in the case of individuals that do not present any risk factors, they should undergo the diagnosis after having attained the age of 45 years. In case the results are normal, the individuals should repeat the tests at intervals of three years. In a bid to better define the diabetes risk in individuals that present IFG, it is proper to conduct an OGTT test. The individuals that present positive pre-diabetes results should undergo treatment for other risk factors associated with cardiovascular diseases.

Problem description

The increasing prevalence of pre-diabetes and T2DM among the individuals in the community is the major problem that the study seeks to address. As a result, the research targets to determine the causes for the increasing prevalence. One of the potential causative factors that this study seeks to evaluate is the current lifestyle trends exhibited by the members of the target population. At the end of the study, the change agent aims at implementing the recommended solutions, with the main one being adoption of healthy lifestyles; consisting of proper diets and exercising. The team used to develop the guideline is comprised of the expert committee, the executive committee and the steering committee that had substantial geographical representation and expertise in diabetes issues. The study consisted of 1,079 participants that encompassed 45% ethnic and racial minorities (DPP Research Group 2002).

There were two major study objectives that targeted to attain a 7% reduction in the weight of the participants and a minimum of 150 minutes of exercise training. The research team considered the goals to be effective, safe and feasible with reference to past researches conducted in other countries. They key attributes of the research methodology encompassed the use of individual “lifestyle coaches”, maintaining frequent contact with the participants, and the development of a well-structured co-curriculum 16 session strategies for behavioural self-management. The lifestyle coaches would also supervise the exercise training sessions of the individuals. The maintenance intervention programme used in the research comprised of “restarts”, motivational campaign and both individual and combined group approaches. The “toolbox” of adherence strategies also enabled the individualisation of the interventions. The research team also tailored the strategies and materials to cater for the prevailing ethnic diversity. Finally, the research team offered feedback responses, training and clinical support to the participants (DPP Research Group 2002).

According to the Centre for Disease Control (CDC), type 2 diabetes that has a connection with physical inactivity and obesity as the primary causes accounts for 90%-95% of diabetes cases in the USA. The disease is prevalent among individuals aged at least 40 years. As a result, it has an association with old age, family history of diabetes and gestational diabetes, physical inactivity, ethnicity, race and impaired glucose metabolism. However, there is an increase in the prevalence of diagnosed cases of T2DM among young American Indians, Hispano/Latino Americans, Asian/Pacific Islanders and African Americans. The research conducted on pre-diabetes revealed that the condition arises when the glucose levels in an individual surpass the normal levels but are not high enough to warrant diabetes classification. A research on the American population conducted by CDC in 2007 revealed that there were approximately 57 million adult Americans that had pre-diabetes. It is evident from research that pre-diabetic individuals are more likely to develop T2DM, stroke and heart attacks in the future.

Available knowledge

The research conducted on the American population by CDC and the Canada-based panel that aimed at developing guidelines for the prevention, treatment and behavioural changes of T2DM and pre-diabetes revealed similar screening results that indicate whether an individual is diabetic or not. It is evident that at least 2.8% of the adult population may have undiagnosed T2DM. In fact, the figure increases to 10% in some populations that exhibit high risk factors. Hyperglycaemia tests are effective in identifying individuals that have T2DM. Majority of the persons will either present diabetes or be at a high risk of developing diabetes- related complications. In a population-based screening endeavour, the primary goals of the screening include identifying and intervening to minimize mortality and morbidity that may arise from the disease. The screening strategies for T2DM entail multiple stages.

The ADDITION-Europe Study is a good example of T2DM screening conducted in Europe. The first blood glucose test of the study covered between 20% and 94% of valid participants in primary care practices. The results of the screening exercise revealed that between 0.33% and 1.09% of the individuals presented diabetes. In a similar study conducted in Cambridge, 3% of the population had diabetes. Based on the lower than anticipated results realized from the screening exercises, it turned out that screening target populations that presented high- risk factors was more appropriate than screening the general population. Some of the high- risk factors include individuals that present diabetes-associated conditions for T2DM. Therefore, 40 years suffices to be the minimum age of screening for T2DM in an individual. The recommended screening tests for T2DM are the glycated haemoglobin (A1C) and the fasting plasma glucose (FPG) tests. However, in the event that the FPG ranges between 6.1 and 6.9 mmol/L, or where the A1C results vary between 6.0% and 6.4%, a 75g OGTT is appropriate. OGTT is also recommended in cases where by there is suspicion for T2DM and the FPG and A1C results vary from 5.6 to 6.0 mmol/L and 5.5% to 5.9% respectively. Moreover, an OGTT screening is appropriate in cases where there is a high impaired glucose tolerance (IGT).

In regard to pre-diabetic individuals, it is evident that a high number of such individuals present IGT or have an A1C that varies from 6.0% to 6.4%. Rather than being at a high risk of developing macro-vascular complications, such pre-diabetic individuals are also at a greater risk of developing T2DM especially when they present the metabolic syndrome. As a result, it is proper to recommend such individuals to the strategies for cardiovascular risk factor reduction. Persons that emanate from ethnic populations that exhibit a high history of T2DM require screening for both T2DM and pre-diabetes. As mentioned before, the screening tests applicable to such individuals are OGTT, A1C and FPG. The accuracy of the A1C screening tool reduces due to the increased prevalence of the haemoglo-binopathies among the populations. As a result, the A1C tool is not reliable in screening T2DM and pre-diabetes among such populations. Moreover, holding the glycaemia levels constant, it is certain that individuals emanating from high-risk groups may present A1C results that are slightly higher than other population groups such as the Caucasians. Therefore, A1C threshold levels for pre-diabetes and T2DM are different among ethnic groups.

Based on the recommendations for screening pre-diabetes and T2DM, it is proper to screen all individuals on an annual basis for the conditions. FPG and A1C screening are appropriate for all individuals after every three years provided that the individual has attained 40 years. Higher scores on the risk calculator may also necessitate the screening of an individual even if the individual has not attained the threshold age. The 75g OGTT is appropriate in cases where the individual scores highly on the risk calculator. Some of the risk factors include the existence of a first-degree relative that has T2DM. Moreover, individuals that emanate from a high-risk ethnic group or have a history of gestational diabetes also stand at a high chance of developing T2DM. The history of delivering a macrosomic infant and the history of pre- diabetes also increases the chances of developing T2DM.

The existence of damage complications of the end organ as a result of diabetes complications also increases the chances that the individual will develop T2DM. Vascular risk factors such as hypertension, High Density cholesterol, triglycerides, overweight and abdominal obesity also increase the chances of developing T2DM. Other risk factors include the presence associated diseases such as polycystic ovary syndrome, obstructive sleep apnea, acanthosis nigricans, psychiatric disorders and HIV infection. Finally, the other risk factors entail the use of certain drugs such as Glucocorticoids, Atypical antipsychotics.

Rationale and context

Qatar vision for 2022 is to have a healthy society by providing healthy life style which also fits the larger global mission of a healthy population. One of the main ways of achieving this is through early screening and awareness to detect the early stages of diabetes by using guidelines depending on the update evidence base medicine.

The selection of the program emanated from the need of developing lifestyle recommendations and guidelines and implementing them to reduce the prevalence of pre- diabetes and T2DM in the community thereby enhancing the health outcomes of the individuals. Some of the lifestyle changes include the adoption of a low-calorie diet that has low saturated fat, moderate intensity physical activity, and high-fiber diet (Ransom et al. 2013). The moderate-intensity physical activity should take at least 150 minutes every week to yield a moderate weight loss of about 5% of the initial weight of the body. The Diabetes Prevention Program (DPP) revealed a reduction of the risks by 58% over a period of four years. The studies entailed sustained and comprehensive programs that were pertinent towards achieving the set targets. The lifestyle intervention measures provided by the DPP program to the target individuals for a median period of 5.7 years yielded sustained benefits for 10 years. In order to achieve the outcomes, the availability of lifestyle coaches to offer training to the target population regarding the effective lifestyle strategies is imperative. The coaches should also contact the target individuals on a regular basis to ascertain the proper implementation of the recommended lifestyle strategies. Apparently, self-management is a critical component of the success of the program. The members of the program should be able to manage themselves and adhere to the recommended lifestyle guidelines so as to realize the set targets. Self-management is important in the achievement of the desired weight loss and physical activity. However, it is important that the lifestyle coaches should devote some time towards supervising the training and exercise sessions. The maintenance intervention should also be flexible by utilizing both individual and group approaches. Through the intervention programs, the coaches should motivate the target population to adopt proper lifestyle behaviors. Apparently, ethnic diversity has an influence on the training and implementation of the strategies. Consequently, it is proper to tailor the strategies and materials used in the program.

Objectives for the proposed quality improvement/change intervention

The main objectives (SMART) of the programme include:

Decreasing the number of pre-diabetic patient in upcoming three years to 30%
- Decrease the percentage of high-risk individuals initially diagnosed with T2DM that present cardiovascular risk factors and poorly controlled glucose by 58%
- Create a guide line at the beginning of 2020 and generalize it in all health care sectors
- Train two doctors and two nurses per month to cover and follow the guide lines
- Attain a minimum of 7% weight reduction and 150 minutes physical exercise (DPP Research Group 2002).

Study, measures and evaluation for the proposed quality improvement/change intervention

The evaluation strategy commences with the current state of diabetes prevention at the population level. As a result, the program should evaluate the existing legislation and policies within the community to determine whether they provide a favourable environment that prevents the continued prevalence of diabetes. The existence of a diabetes prevention plan at the national level that trickles down to the community level is a positive indicator of a favourable environment. Following the implementation of the program, the target individuals should attain a weight loss of between 5% and 10% of their excess body weight. Some of the evaluation indicators encompass the attainment of the recommended body weight, the body mass index (BMI) and the waist circumference over the designated period. The other indicators encompass 2h OGTT glucose and fasting, hbA1C, fasting insulin, total intake of energy, fat intake, saturated fat intake, fibre intake, physical activity and fasting total LDL and HDL cholesterol. The other indicators include fasting triglycerides, diastolic and systolic blood pressure, smoking habits, drug treatments, cost, quality of life and treatment satisfaction (Pajunen et al. 2010). The evaluation indicators should meet the recommended levels to ascertain the success of the program.

Ethical considerations

The project design should be appropriate to meet the target objectives. The protection or concealing of patient information during the program is imperative. The lifestyle coaches and other health professionals should be truthful and be able to offer an honest appraisal of the condition, prognosis and options of the patients under the program. Confidentiality is the other critical aspect of the health professionals that assist in managing diabetic patients to help them handle their situation properly. The professionals should only share what they know with the individuals that they regard as being fit to have the information for the benefit of the patient.

Digitalization of medical records has impacted negatively on the confidentiality of patient information. There have been issues associated with the sharing of patient information by concerned organizations since there are cases where the information lands in wrong hands. Health professionals in the program also have to be discreet in order to absorb the additional information that they understand regarding their patients without impacting negatively on their relationships with their patients.

The health professionals have the privilege of knowing patient preferences, personal circumstances and disposition. However, they should only use the knowledge to make decisions about improving the health outcomes of the patients rather than sharing the information with wrong individuals. In essence, the health professionals should ensure that the project does not yield any social, psychological, economic or physical harm to their patients. The differences in rank and expertise among patients also require trust on the part of the health professionals. For the patients that have limited information about the effective ways of handling their conditions, it is the responsibility of the health professionals to make decisions for them; a requirement that necessitates trust (Williams, 2011).

Limitations

The main limitation involves the difficulty in extrapolating studies involving small samples like the above research to represent a generalised population. Even though many individuals suffering from T2DM agreed to participate in the program, not all of the expected individuals responded to the demands of the study thereby yielding inconclusive results. Moreover, realising a longer-term follow-up of the performance of the target individuals regarding the implementation of the recommended lifestyle strategies was difficult. The difficulty emanated from the fact that the study targeted to create awareness and sensitize different populations to a greater extent as compared to making follow-ups. Some of the subjects also expressed reluctance to avail themselves to the testing centres to undergo subsequent screening aimed at determining their level of progress. Consequently, only a small percentage of the initial population consented to undergoing subsequent screening. The availability of limited studies covering the effectiveness of intervention programs also hampered the evaluation of the program due to the absence of benchmark results for comparison purposes.

Conclusion

The study intended to develop a diabetes intervention program to evaluate the awareness, create more awareness, treat patients and develop recommendations for preventing T2DM and pre-diabetes among older individuals aged at least 40 years. The selection of the age group reclined on the fact that pre-diabetes and T2DM are more common among older individuals as compared to the other age cohorts of individuals. Based on the findings of the study, FPG and A1C are the recommended screening tools for pre-diabetes and T2DM. However, the 75g OGTT tool is applicable in situations whereby the individual presents risk factors for diabetes and scores highly on the risk calculator. Lifestyle changes suffice to be the major strategy of managing T2DM. It entails adopting proper diets comprising of low levels of caloric and saturated fat as well as exercising regularly.

Even as the change process is expected to bring about positive outcomes on the health of individuals, it was apparent that some form of challenges awaited its implementation. One of the things that would cause reluctance in change of attitudes and lifestyle was the lack of awareness on the alarming rising cases of Diabetes. The individuals are largely unaware of the symptoms of the conditions. During the research, it was established that the members of the target population would exhibit moderate understanding of the recommended lifestyle strategies that are appropriate for handling T2DM and pre-diabetes. It is therefore necessary to encourage the implementation of the recommended lifestyle changes in the community with immediate effect as a result of the increasing cases of morbidity and mortality arising from T2DM and its associated complications.

References

American Diabetes Association, 2010. Standards of medical care in diabetes—2010. Diabetes care, 33(Supplement 1), pp.S11-S61.

American Diabetes Association, 2014. Diagnosis and classification of diabetes mellitus. Di

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