Dominican Republic Diabetes Project: Insulin Delivery to a Rural Community and a Retrospective Review

Abstract

Purpose: A non-governmental organization (NGO) conducts short-term medical missions in the Dominican Republic. Diabetes (DM) diagnosis and treatment, including a recent pilot of insulin, is an important practice of the NGO clinic. Here we report on 1) initial outcomes of the insulin treatment program (clinical component) and 2) longer-term blood glucose control among patients diagnosed with DM (research component). Methods: In the clinical component, patients identified with uncontrolled DM had baseline HbA1c measurements drawn before starting insulin and were trained by community health workers (CHWs) to use insulin. The patients reported daily fasting blood glucose measurements to the CHWs for insulin dose titration. Follow-up was scheduled for three and six months after starting insulin. In the research component, charts were reviewed at the NGO clinic for patients diagnosed with diabetes between 2004 and 2018. Researchers recorded baseline characteristics and outcome measurements of diabetic patients. We examined HbA1c over time, defining a “target” HbA1c measurement of 1% decrease compared to baseline or a measurement less than 8%. We estimated the proportion of measurements at which the target was met. Results: In the clinical component, four patients began insulin treatment in late June 2018. There were no episodes of hypoglycemia. Patients reported 93% of expected daily fasting blood glucose measurements. The median net change in HbA1c compared to baseline after three months of insulin was -0.7 (IQR: -1.9, 0.8) %. The median net change in HbA1c from baseline after six months was -1.1 (IQR: -2.9, 1.1) %. One patient discontinued insulin after five months. In the research component, we found 170 patients with DM. 53.5% were female. The median age at DM diagnosis was 56 (IQR: 49, 67) years. DM patients had their disease followed at the NGO clinic for a median duration of 4.8 (IQR: 1.5, 7.4) years. 71% of diabetic patients had hypertension. 51% of the patients had two or more comorbidities at the time of diagnosis. A median of 2 (IQR: 1, 5) follow-up HbA1c measurements were available per patient, 1 (IQR: 0, 3) measurement of which was at target. 56% of patients had at least one HbA1c measurement at target. Conclusions: The NGO was able to successfully and safely introduce insulin therapy in a rural setting. Increased frequency of HbA1c monitoring in diabetic patients and expanded insulin use are recommended. Follow up among the diabetes patients is limited and may be more frequent among diabetes patients with better glycemic control.