Diabetic Complications among Adult Diabetic Patients of a Tertiary Hospital in Northeast Ethiopia

Background.The diabetic complications are becoming common community problems.The outcomes of diabetic complications are increased hospitalization, increased direct patient costs, andmortality. In Dessie, the prevalence of the diabetic complications is not well studied so far. Thus, the aim of this study is to assess prevalence of diabetic complications and associated factors among adult diabetic patients of Dessie Referral Hospital, Northeast Ethiopia. Methods. Cross-sectional study was conducted in the diabetic clinic of Dessie Referral Hospital from April to May 31, 2013. All diabetic patients who visited the clinic during the study period were included. Data was collected using interview guided self-administered questionnaire. Presence of complications and the type of medications the patient was on were identified through review of patient records. Data were cleaned, coded, and entered into SPSS for Windows version 17.0. Descriptive statistics and chi-square tests were carried out to meet the stated objective.The Results. Overall 129 (59.7%) of the patients were found to have been affected by one or more of the diabetic complications. Complications were identified mainly among type II diabetic patients. The age of patients (P value-0.048), type of diabetes (P value-0.00), and medication (P value-0.00) were strongly associated with the occurrence of diabetic complication but self-reported adherence, attitude, and knowledge level of patients and the family history were not associated with the presence of complication. Conclusion. The prevalence of complications among diabetic patients in Dessie Referral Hospital was high. Targeted counseling and health information provision to the patients by the clinical staff will be helpful in reducing avoidable morbidity and mortality in the patients.


Introduction
Diabetes mellitus (DM) is a group of common metabolic disorders that share the phenotype of hyperglycemia, which are caused by a complex interaction of genetics and environmental factors. It is the leading cause of end-stage renal disease (ESRD), traumatic lower extremity amputations, and adult blindness. It also predisposes to cardiovascular diseases. With an increasing incidence worldwide, DM will be a leading cause of morbidity and mortality in the foreseeable future. The goal of treatment for DM is to prevent mortality and complications by normalizing blood glucose level. But blood glucose level might be increased despite appropriate therapy resulting in complications, such as disturbances in fat metabolism, nerve damage, and eye disease [1][2][3][4][5].
Studies have reported that diabetes and its complications are among the common reasons for inpatient admissions, accounting for about 4.4% [18] of total admissions leading to about 3.4% [20] to 32.5% [19] total deaths. The prevalence of chronic complications varies from 52.0% to 74.2% [7,2 Advances in Public Health   8,21,22]. The most common chronic complications were erectile dysfunction (64%) [23], visual disturbance (33.8%) [7], and cardiovascular disorders (30.1%) [22], though hypertension alone was (68%) [24], neuropathy (29.5%) [7], and nephropathy (15.7%) [7]. Likewise acute complications had similar trend which ranges 30.5% among which diabetic ketoacidosis (DKA) was 71%, followed by hypoglycemia (19.4%) but hyperosmolar hyperglycemic state (HHS) was insignificant [7]. The common risk factors for occurrence of complications were gender [10], long duration with diabetes [21], poor and inadequate glycemic control [9], negative attitude towards diabetes [9,11,25,26], poor treatment adherence [14,27,28], and poor knowledge about the disease and its management [9,11]. Thus, better understanding of perceptions and attitudes among both patients and providers is needed to guide initiatives to improve the management of diabetes [6,16]. Hence, the common causes of diabetic complications are poor control of diabetes either due to nonadherence, poor attitude towards the disease and its complications, unhealthy diet, and insufficient physical activity, and due to poor management by the health care professionals [10,18,29,30]. On top of these complications diabetes can predispose the patient for different infections [7,19,21,31,32]. The final outcome of diabetes is a disability, and/or death [19,21,29,32], and of course has great economic impact which is direct (medical and treatment costs) and indirect (costs of hospitalizations, loss of vision, lower extremity amputations, kidney failure, and cardiovascular events) [33,34]. Thus, prevention is most cost effective than treatment and management of diabetic complications [35,36].
Most of the studies cited above are from the developed countries [30,35,37]; to our knowledge such studies are  patients visiting the hospital during the three-month period of data collection period were given the self-administered questionnaires and get interviewed if they do not read and write. Patients who visited the hospital for the second time were excluded from study and the first visit's data was taken.
The questionnaire contains 18 knowledge, 19 attitude, and 16 practice related questions in addition to 16 general and sociodemographic questions. In addition the last one-month adherence was assessed based on the patients report. Diagnosis of diabetic complications was done by physician and complications and laboratory results were taken from patient cards. The collected data were cleared and checked every day for completeness and consistency before processing.

Data Processing and Analysis.
Collected data were edited, coded, and entered into SPSS for Windows version 17. Descriptive statistics was computed to determine frequency, means, and standard deviations whereas chi-square tests were carried out to determine the association between variables.

Ethical Consideration.
Prior to the study ethical approval was obtained from the ethical review board of Wollo University. The management of the Hospital was requested for cooperation with a formal letter from Wollo University (WU). During and after the data collection process all hospitals and patient-related data were kept confidential. Each study participant signed written consent to participate in the study.

Operational Definition and Terms
(i) Good self-reported adherence: patients who answered correctly more than or equal to mean score.
(ii) Poor self-reported adherence: patients who answered below the mean score.
(iii) Good attitude: patients who answered correctly more than mean score.
(iv) Poor/negative attitude: patients who answered below the mean score.
(v) Good knowledge: patients who answered correctly more than mean score.
(vi) Poor knowledge: patients who answered below the mean score.
(viii) Chronic complications: including vascular (microvascular and macrovascular) and nonvascular complications of diabetes.

Sociodemographic Characteristics of Diabetic Patients.
Two hundred and sixteen (216) diabetic patients who came to the followup clinic during the 2-month period of data collection were included in the study. The majority of the patients (57.4%) were males, Amhara by ethnic group (94.4%) and Muslims by religion (72.7%). The median age of the patients was 45 (±17.677) and they were known diabetic patients for the mean duration of 5.00 (±5.70) years ( Table 1). The majority of the patients, 145 (67.1%), were of type II with the remaining 71 (32.9%) being type I patients. The medications used for the treatment of diabetes were oral hypoglycemic agents, 111 (51.39%), either in combination or alone. But it was noted that insulin was used for both type I and II diabetics to manage the complications ( Table 2).

Prevalence of Diabetic Complications among Diabetic
Patients. The overall complications were 129 (59.7%) of which 105 (48.6%) were from type II patients. When we see the type specific complications, 105 (70.5%) and 24 (35.8%) were among types II and I diabetes, respectively. Attitude 37 (55.2%) and knowledge levels 37 (55.2%) are better among the type I diabetic patients when compared to type II patients (Table 3).

Factors Associated with Diabetic Complications.
The age of patients, type of diabetes, the regimen, and specific medications the patient is taking were strongly associated with the presence of complication but it has to be noted that selfreported adherence, attitude and knowledge level of patients, as well as the average blood glucose level, and the family history, were not associated with the presence of complication (Table 5). Close to nine in ten, 183 (86.11%), the three-month average blood glucose level is still elevated.

Discussion
This study examines diabetic complications in the diabetic clinic in referral hospital. It is highlighted that diabetic complications are common in the Ward in which the majority were among type II patients and around 41% of patients have Advances in Public Health 5 In this study, 59.7% of diabetic patients had at least one diabetic complication. This was lower than the finding reported from Jimma, Ethiopia, where 83.00% of the patients had complications [7]. The majority of the complications (48.6%) in this study were among type II patients, which is similar to another study in Jimma (52.5%) and Taiwan (52.6%) [7,38]. The fact that a diagnosis of complications was made by general practitioners, the sociocultural differences in health seeking behavior and disclosing complications like sexual problems might result in the differences.
In this study, 70.5% of type II patients have at least one complication. This was similar to other studies in Libya (68.7%), Iran (74.2%), and Russia (70.7%) [8,21,39]. But it was higher than another study in China (52.0%) [22]. The difference might lie at the level of practice and the attitude and knowledge gap between the patients.
Acute complications occurred in 28.24% of the patients of which 61.71% had diabetic ketoacidosis as a complication at least once. Similar findings were reported by an earlier study in Jimma, Ethiopia [7]. Moreover, diabetic ketoacidosis occurred in both types of diabetic patients [7,40,41]. This indicated that diabetic ketoacidosis is the problem of both types I and II diabetes. Hyperosmolar hyperglycemic state occurred in 7.9% of patients in this study. This is high when compared with other studies in different studies which was insignificant or none [7,8,22]. The reason might be due to the type of medications to control the blood glucose level and poor integrated effort in the management of patients on top of poor knowledge and attitude of patients.
In this study, chronic complication occurred in more than a third of the patients (58.8%). This is almost comparable with other reports in Jimma (52.5%) and China (52%) [7,22] but it was lower than reports in Iran (75%) and Libya (68.7%) [8,22]. Hypertension (43.3%), visual disturbance (25.68%), and neuropathy (14.4%) were the commonest chronic complications in this study. Except hypertension this was similar with the study in Ethiopia (visual disturbance (33.8%), neuropathy (29.5%), and hypertension (24.9%)) but its pattern is totally different than in China [7,22]. The difference in management practitioners and the screening practices in different hospitals might have contributed to differences in occurrences of complications doubling with medication selection, poor knowledge, and attitude of patients.
In this study, age of patients, type of diabetes, antidiabetic drugs, and type of diabetes were significantly associated with the occurrences of diabetic complications in the clinic. This was similar with other studies in Ethiopia, Jordan, Libya, and Taiwan, [7,9,21,38].
As limitation of study, it must be noted that this study did not determine severity of complications, and outcomes of the complications. Protein concentration, HbA1c, and direct ophthalmoscopy to detect retinal changes were not performed. Moreover, clinical findings and questionnaire based approaches were used to determine complications and the factors that could affect their occurrences.
In Conclusion. Diabetic complications in Dessie Referral Hospital were prevalent. Type II patients were more prone to complications in the hospital. The contributing factors for occurrences of complications were multiple. There should be training on the management of the diabetic patients and of course screening of complications should soon be starting. Thus, integrated effort should be in place to prevent the development of complications and manage the disease progression.