River District

Data last updated: 5-Aug-2023

DM treatment outcomes

Outcomes for 3,500 patients under care (registered before 1-May-2023) between 1-May-2023 to 31-Jul-2023

Blood sugar controlled at latest visit in past 3 months

20%

700 patients with FBS <126 mg/dl or HbA1c <7%

Blood sugar not controlled at latest visit in past 3 months

41% 1,435 patients with FBS 126-199 mg/dL or HbA1c 7-8.9%

17% 595 patients with FBS ≥200 mg/dL or HbA1c ≥9%

No visit in past 3 months

22%

770 patients with no visit

Patients under care

Patients under care: Registered patients with diabetes with at least 1 visit in the past 12 months. Dead patients (60) and 12 month lost to follow-up patients (600) are excluded.

Cumulative registered patients: All patients with diabetes registered. Dead patients (60) are excluded.

Monthly registered patients: Patients with diabetes registered each month.

Patients with diabetes with at least 1 visit in the past 12 months

3,500

50 patients registered in Jul-2023

of 4,100 cumulative registered patients

12 month lost to follow-up

Numerator: Patients with no visit in the past 12 months

Denominator: Registered patients with diabetes. Dead patients (60) are excluded.

Patients with diabetes with no visit in the past 12 months

15%

600 patients with no visit from Jul-2022 to Jul-2023

of 4,100 cumulative registered patients

Diabetes treatment cascade

Estimated adults (>30) in River District with diabetes who are registered, under care, and controlled.

Estimated adult (>30) population with diabetes is derived from a STEPS Community Survey conducted in 2022.

100%

60,800

Estimated people with diabetes

4,100

Cumulative registered patients

3,500

Patients under care

700

Patients with blood sugar controlled

Opportunistic screening

% of estimated adult OPD patients screened for diabetes

16%

4,800 individuals screened for diabetes in Jul-2023

of ~30,000 estimated OPD patients >18 years

Patients prescribed statins

Numerator: Patients from the denominator who were prescribed statins at their most recent visit

Denominator: Registered patients ≥40 years old with diabetes with at least 1 visit in the past 12 months. Dead patients (60) and 12 month lost to follow-up patients (600) are excluded.

Patients under care for diabetes ≥40 years old who were prescribed statins at latest visit in the past 12 months

66%

2,300 patients prescribed statins at latest visit in past 12 months

of 3,500 patients under care

Compare sub-regions

Treatment outcomes for patients with diabetes at their latest visit from 1-May-2023 to 31-Jul-2023

scroll table →

Sub-regions	Total	Jul-2023	Total	Percent	Total	Percent	Total	Percent	Total	Percent	Total	Percent
	Patients under care	Monthly new patients registered	Patients prescribed statins		FBS <126 mg/dl or HbA1c <7%		FBS 126-199 mg/dL or HbA1c 7-8.9%		FBS ≥200 mg/dL or HbA1c ≥9%		No visit in past 3 months
River District	3,500	50	2,300	66%	700	20%	1,425	41%	595	17%	770	22%
Cherry Blossom County	300	3	186	62%	93	31%	84	28%	66	22%	57	19%
Fern Grove County	1,100	10	572	52%	286	26%	440	40%	176	60%	198	18%
Grasslands County	80	2	41	50%	20	25%	27	34%	14	18%	18	23%
Hillside County	90	2	45	48%	22	24%	32	35%	15	17%	22	24%
Ice Caps County	50	0	22	44%	11	22%	20	40%	9	18%	10	20%
Mangrove County	1,200	6	430	36%	216	18%	540	45%	216	18%	228	19%
Mountain County	30	1	10	33%	6	17%	14	46%	5	15%	6	22%
Oceanside County	15	12	4	32%	2	16%	7	45%	2	14%	4	25%
Peaks County	46	2	14	30%	7	15%	22	47%	6	12%	12	26%
Rain Forest County	47	0	12	24%	6	12%	20	42%	6	12%	16	34%
Rivers Edge County	90	0	18	20%	9	10%	41	46%	11	12%	29	32%
Sunshine Coast County	18	0	4	18%	2	9%	8	44%	2	10%	7	37%
Tree Top County	300	6	36	12%	18	6%	114	38%	54	18%	114	38%
Vineland County	140	6	14	10%	7	5%	59	42%	17	12%	57	41%
Wind Canyon County	21	0	2	8%	1	4%	11	50%	1	4%	9	42%

Quarterly cohort reports

The treatment outcomes for newly registered patients at the end of the following quarter

scroll chart →

23%

46%

18%

13%

Q4-2021 cohort 300 patients

Result from past visit in Q1-2022

25%

48%

18%

Q1-2022 cohort 350 patients

Result from latest visit in Q2-2022

28%

49%

16%

Q2-2022 cohort 300 patients

Result from latest visit in Q3-2023

29%

48%

18%

Q3-2022 cohort 800 patients

Result from latest visit in Q4-2023

30%

47%

18%

Q4-2022 cohort 1,000 patients

Result from latest visit in Q1-2023

33%

47%

20%

Q1-2023 cohort 750 patients

Result from latest visit in Q2-2023

Q2-2023 cohort 300 patients

Coming Oct-2023

FBS<126 mg/dl or HbA1c <7%

FBS 126-199 mg/dL or HbA1c 7-8.9%

FBS ≥200 mg/dL or HbA1c ≥9%

No visit in quarter

Diabetes drug stock

Numerator: Facilities with ≥30 patient days protocol drugs in stock.

Denominator: All facilities in the diabetes program.

Facilities with ≥30 patient days of diabetes protocol drugs in stock

Metformin — 94% in Jul-2023

Glimeperide — 64% in Jul-2023

Availability of blood glucose testing

Numerator: Facilities with point-of-care glucometers or lab testing available.

Denominator: All facilities in the diabetes program.

Facilities with glucometers or lab testing available.

99%

159 facilities with blood glucose testing

of 160 facilities reporting in Jul-2023

1 facility without a blood glucose testing:

CHC Weather Top

Availability of HbA1c testing

Numerator: Facilities with HbA1c lab test available

Denominator: All facilities in the diabetes program.

Facilities with HbA1c lab test available

7 facilities with HbA1c testing

of 160 facilities reporting in Jul-2023

153 facility without a blood glucose testing:

CHC Apple Orchard, CHC Carrot Peak, CHC Cumin Creek, CHC Dandelion Wine, CHC Elderflower Ridge, and 148 others (see table)

Stock reporting by facility

Jul-2023 reports

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Facility	Sub-region	Metformin in patient days	Glimeperide in patient days	Availability of blood glucose testing	Availability of HbA1c testing
River District		54	60
CHC Apple Orchard	Wind Canyon County	54	68	Yes	No
CHC Bramble River	Tree Top County	34	6	Yes	Yes
CHC Bumpy Hill	Fern Grove County	33	120	Yes	Yes
CHC Carrot Peak	Cherry Blossom County	134	180	Yes	No
CHC Cumin Creek	Oceanside County	46	48	Yes	No
CHC Dandelion Wine	Vineland County	44	103	Yes	No
CHC Elderflower Ridge	Riverside County	90	21	Yes	No
CHC Riverside	Grasslands County	40	14	Yes	No
CHC Rhubarb Hills	Mangrove County	65	50	Yes	No
CHC Turnip	Rain Forest County	45	109	Yes	No
CHC Ugly Fruit Bay	Wind Canyon County	54	68	Yes	No
CHC Vine Bay	Tree Top County	34	6	Yes	No
CHC Watermelon Cove	Fern Grove County	33	92	Yes	No
CHC Weather Top	Cherry Blossom County	134	0	No	No
CHC Yellow Melon	Oceanside County	102	90	Yes	No
CHC Young Potato	Vineland County	365	12	Yes	No
CHC Zucchiniville	Riverside County	21	45	Yes	No
District Hospital Strawberry	Oceanside County	102	90	Yes	No
PHC Apricot Island	Grasslands County	14	40	Yes	No
PHC Azalea Hills	Mangrove County	65	50	Yes	No
PHC Bumblebee	Rain Forest County	45	109	Yes	No
PHC Capital Town	Wind Canyon County	54	68	Yes	No
PHC Copperville	Tree Top County	34	6	Yes	No
PHC Cupola	Fern Grove County	33	92	Yes	No
PHC Dartboard Hill	Cherry Blossom County	134	0	Yes	No
PHC Deck Town	Oceanside County	46	48	Yes	No
PHC Dune Hill	Vineland County	44	12	Yes	No
PHC Eagle Hill	Riverside County	90	21	Yes	No
PHC Eggplant Mountain	Grasslands County	12	40	Yes	No
PHC El Toro	Mangrove County	65	50	Yes	No
PHC Fang Cove	Rain Forest County	45	109	Yes	No
PHC Grapefruit Hill	Wind Canyon County	54	68	Yes	No
PHC Gumdrop Cove	Tree Top County	34	6	Yes	No
PHC Happy Street	Fern Grove County	33	92	Yes	No
PHC Hilltop Station	Cherry Blossom County	134	0	Yes	No
PHC Iceberg	Oceanside County	102	90	Yes	No
PHC Idaho Hills	Vineland County	365	12	Yes	No
PHC Jackfruit	Riverside County	21	45	Yes	No
PHC Juniperberry	Grasslands County	14	44	Yes	No
PHC Lard Lane	Mangrove County	65	50	Yes	No
PHC Lobby Mountain	Rain Forest County	45	109	Yes	No
Subdistrict Hospital Grape	Mangrove County	32	40	Yes	No
Subdistrict Hospital Juniper	Oceanside County	202	290	Yes	No
Subdistrict Hospital Grasslands	Grasslands County	100	106	Yes	No
UPHC Cinnamon Hill	Mangrove County	19	66	Yes	No
UPHC Dandelion Mountain	Oceanside County	52	12	Yes	Yes
UPHC Dill Weed	Grasslands County	80	90	Yes	Yes
UPHC Dry Marjoram	Mangrove County	100	12	Yes	Yes
UPHC Dry Mustard	Oceanside County	90	0	Yes	Yes
UPHC Dry Nutmeg	Grasslands County	90	90	Yes	Yes

>180 days drug supply

<30 days drug supply or no blood glucose testing or no ofHbA1c testing

Hypertension and diabetes comorbidity

All patients registered in the hypertension and/or diabetes programs

	Patients under care	Cumulative registered patients	Died^*
Hypertension-only	8,632	10,000	105
Both hypertension and diabetes	2,000	2,213	100
Diabetes-only	1,500	2,100	50
TOTAL	12,132	14,313	255

^*Deaths may be undercounted.

Comorbid patients with BP controlled

Patients with both hypertension and diabetes with BP controlled at latest visit in past 3 months

50%

1,000 patients with BP <140/90

Age and sex of patients under care for diabetes

3,500 patients under care

Age	Female (64%)	Male (36%)	Female and male
18-29	6%	4%	10%
30-49	28%	17%	45%
50-69	19%	6%	25%
70+	12%	8%	20%

Definitions

Clear definitions for all indicators will be included here

HEARTS360

River District

DM treatment outcomes

Blood sugar controlled at latest visit in past 3 months

Blood sugar not controlled at latest visit in past 3 months

No visit in past 3 months

Patients under care

12 month lost to follow-up

Diabetes treatment cascade

Opportunistic screening

Patients prescribed statins

Compare sub-regions

Quarterly cohort reports

Diabetes drug stock

Availability of blood glucose testing

Availability of HbA1c testing

Stock reporting by facility

Hypertension and diabetes comorbidity

Comorbid patients with BP controlled

Age and sex of patients under care for diabetes

Definitions