Audit by Dr Rania Alnounou, 2016 (Incretin drugs for diabetes management)
Aim of the study (objectives) 

To critically evaluate healthcare practice based on a literature background, and to suggest real practice improvement. 


Background:
The prevalence of type 2 diabetes, is increasing at an alarming rate, with only half of patients achieving the recommended HbA1c target. This study tends to focus on incretin based treatment for type 2 diabetes, and their utility in clinical practice specifically in private clinical practice in Abu Dhabi, the results of clinical audit, done in our organization will pave the way for new strategies in diabetes management, depending on supporting evidence.
The progressive nature of type 2 diabetes, results in a progressive decline in beta-cell function, and after 3 years of starting first line medication with MF (Metformin) and SU (Sulfonylureas), 50% of patients with type 2 diabetes require additional drug to maintain the glycosylated hemoglobin (HbA1c). 
Incretin drug group, stimulates insulin secretion and inhibit glucagon production, they also improve beta-cell health, slow gastric emptying, promote early satiety and reduce food intake (Nyenwe EA 2011)
The choice of anti-glycemic agents in type 2 diabetes should be guided by medical needs of patient and treatment should meet the goals in achieving optimum glycemic control, tolerability, safety, and cost-effectiveness. Some drug combinations appear to be promising and can reach the target in lowering HbA1c, in addition to beneficial extra glycemic effect, like heart safety.

This study is a clinical audit supported by literature review that shows new drugs for diabetes management and despite being expensive, still do not reach the target of diabetes control. A lot of gaps in our clinical practice, especially primary care level need to be modified to achieve holistic management. Our aim is to reach the target goal of care, manage complications, and teach self-management skills, especially when prescribing new medicine to treat a long-term condition for the first time, extra help and advises are needed through designated strategies for monitoring for at least one month, at the beginning and every three months thereafter.
Participants: I consided around 150 patients with type 2 DM who are taking Incretin drugs with or without other diabetic medication.
The drugs which be followed are:
GLP-1RA:
-	Liraglutide (victoza)
-	Dulaglutide (trulicity)
-	Exenatide (byetta, bydureon)
DPP-4 Inhibitors
-	Sitagliptin (Januvia, janumet)
-	Linagliptin (tradjenta,jentadueto)
-           Vildagliptin (Galvus,Galvusmet)

Variables: I followed five parameters, HBA1c, BG, BP, BW, and eGFR.

Settings: the audit conducted in the UAE, Abu Dhabi, Al Noor hospital, Al Bateen and musaffah branches, for 3-6 months between September and December 2016.
Results:
Criterion	Number sampled	achievement	standard
-	Main criterion: HbA1c< 7% (NICE)	97 patients	49%	70%
-	 Main criterion: HbA1c<8%(AL NOOR)	97 patients	74%	95%
-	A1c reduction by 0.5%-1% after 3-6 months of treatment
	82 patients	29%	70%
-	BG reduction  > 20mg/dl (1.1 mmol/l) after 3-6 months of treatment
	83patients	28%	80%
-	GFR increase > 10 ml/min after 3-6 months of treatment
	78patients	26%	70%
-	SBP reduction> 10mmhg after 3-6 months of treatment
	88 patients	23%	70%
-	Weight reduction > 2 kg after 3-6 months of treatment
	84 patients	23%	90%
-	Parameters achieved the overall target after 3-6 months of treatment
	97 patients	25.8%	90%


 






The results of the audit were generally positive and emphasized the feasibility of improving the current practice, our individualized approach will help us to achieve a better targets in adherence to management plan and following the national and international guidelines.
results were discussed at a clinical team meeting to raise every one awareness of the issue and since then we have been more vigilant at aiming for tighter targets,  Steps required for change state were studied and main points were documented. The Gaps which noticed in clinical practice like over investigations was discussed also, further work is needed to design, raise, train, and sustain better management for diabetes, Patients with type 2 diabetes should be involved in decision about their individual HbA1c target, and should be encouraged to achieve the target and maintain it.
Suggestions are summarized below:
-	Development of a system which would enable easier identification of uncontrolled DM.
-	Development of a system which would facilitate communication between all related team particularly regarding cardiology, ophthalmology, podiatric, and dietitian, coordinated team of health professionals is required.
-	Development of structured education program with education classes for patients with diabetes.
-	Identification criteria for routine case examination of health visits using check-list (which examines a number of aspects of patients, including structured education, eye test, lab test, foot test, cardiology consultation, echocardiogram, biomarkers (ie, NT-proBNP)  etc).
-	Establish diabetic clinic with multidisciplinary team. Meanwhile there was a suggestion about making diabetic day every week to follow all patients with diabetes.
-	Development of telecare intervention via web-based system or mobile devices, to be in continuous contact with HCPs.
-	Establish a new medication program, in our local pharmacy to give extra help and advice about any new medication prescribed for the first time to treat long term condition like diabetes.

Monitoring of incretin drugs for type2 diabetes in private health care in Abu Dhabi - Clinical audit