The implementation of guidelines in a South African population with type 2 diabetes

Objective: The aim of this study was to identify the treatment gaps that pertain to risk factors in South African patients with type 2 diabetes mellitus, using national treatment guidelines.Design: Cross-sectional study.Setting and subjects: The study consisted of 666 patients with type 2 diabetes mellitus, attending a diabetes clinic at the Charlotte Maxeke Johannesburg Academic Hospital.Outcome measures: Using a public sector database, retrospective data were obtained on the treatment of type 2 diabetes mellitus participants. Patients were randomly selected on the basis of established type 2 diabetes mellitus diagnosis, and if they were receiving oral hypoglycaemic and/or insulin therapy. Age, gender, race, blood pressure, haemoglobin A1c (HbA1c) and fasting lipids were captured and measured. The history of patients’ previous coronary artery disease, strokes, nephropathy, neuropathy and retinopathy was recorded.Results: The mean age of the patients was 63 years [standard deviation (SD) 11.9], 55% of whom were females. The HbA1c was 8.8% (SD 2.5). 26.2% of patients attained HbA1c levels of < 7%. Of the total patients, 45.8% met a < 130/80 mmHg blood pressure target, and 53.8% a low-density lipoprotein (LDL) cholesterol of < 2.5 mmol/l. Only 7.5% obtained the combined target for HbA1c , blood pressure and LDL cholesterol.Conclusion: Traditionally, type 2 diabetes mellitus treatment has centred on correcting blood glucose levels. Yet, as many as 80% of people with type 2 diabetes mellitus die from some form of cardiovascular disease  (CVD). Many trials have demonstrated the benefits of targeting CVD risk factors (HbA1c, blood pressure and lipids) in patients with type 2 diabetes mellitus. Despite the wealth of evidence, our data suggest that significant undertreatment of risk factors in patients with type 2 diabetes mellitus remains.Keywords: diabetes mellitus, risk factors, targets, managemen

The Achievement of Glycaemic, Blood Pressure and LDL Cholesterol Targets in Patients with Type 2 Diabetes Attending a South African Tertiary Hospital Outpatient Clinic

Objectives: To determine differences in the control of multiple diabetes control parameters in a select group of subjects with type 2 diabetes (T2DM) after a four-year follow-up period.Design: Cross-sectional study.Setting and subjects: The initial 2009 study population consisted of 666 T2DM patients of whom only 261 (39.2%) were audited at the Charlotte Maxeke Johannesburg Academic Hospital. Outcome measures: Using a public sector database, retrospective data were obtained on the treatment of participants with T2DM attending a tertiary care setting and a descriptive analysis was done.Results: The mean age was 64 (SD 10.6) years, women represented 55% of the cohort and the mean duration of diabetes was 16 years (range 2–40 years) in 2013. Fewer patients achieved an HbA1c goal (of < 7%) in 2013 (15.5%) compared with 2009 (25.4%), whilst an additional 13.7% and 25.0% of the 261 patients reached blood pressure targets (< 140/80 mmHg) and LDL-C targets ( < 2.5 mmol/L), respectively.Conclusion: Overall, more patients in the study reached blood pressure and LDL-C targets but there were difficulties in achieving optimal glycaemic levels over the four-year period. This study highlights the complexities of managing risk factors in T2DM, especially glucose control.Keywords: Diabetes Mellitus, Management, Risk Factors, Target

Multi-ethnic differences in HbA1c, blood pressure, and low-density-lipid cholesterol control among South Africans living with type 2 diabetes after a 4-year follow-up

Yacob Pinchevsky,1 Varada J Shukla,1 Neil Butkow,1 Tobias Chirwa,2 Frederick Raal3 1Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, 2Division of Epidemiology and Biostatistics, School of Public Health, 3Carbohydrate and Lipid Metabolism Research Unit, Division of Endocrinology and Metabolism, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Purpose: Our study set out to examine if disparities in control of glycated hemoglobin (HbA1c), blood pressure (BP), and low-density-lipoprotein cholesterol (LDL-C) existed among an urban multi-ethnic cohort of South Africans, living with type 2 diabetes mellitus (T2DM).Patients and methods: This longitudinal, retrospective study consisted of 261 men and women with previously diagnosed T2DM who attended Charlotte Maxeke Johannesburg Academic Hospital, South Africa across two time periods 2009 and 2013. Demographic and clinical data were extracted from consecutive medical records. The primary outcome was to determine achievements in HbA1c, BP, and LDL-C among ethnic groups using evidence-based goals.Results: The mean age of the cohort was 64 (±10.6) years, females represented 55%, and the self-reported diabetes duration was 16 (±10.6) years as at 2013. Black Africans (42.9%, n=112 of 261) were more likely to reach the HbA1c target (<7%) and less likely to have had retinopathy, nephropathy, or cardiovascular disease. Over two-thirds of mixed-ancestry patients attained the BP target (<140/80 mmHg), while 90.2% of Caucasians achieved LDL-C goals (<2.5 mmol/L). Overall, across the ethnic groups studied, we found that HbA1c control deteriorated over time, although BP levels remained the same and LDL-C levels drastically improved.Conclusion: There was poor control of HbA1c, BP, and LDL-C across all ethnic groups. Although a minority achieved recommended targets, some ethnic groups appeared to have worse control than others. Timely aggressive actions in particularly high-risk ethnic groups will prevent/delay the complications commonly associated with T2DM. Keywords: diabetes mellitus, ethnicity, HbA1c, blood pressure, LDL-

Quality of care delivered to type 2 diabetes mellitus patients in public and private sector facilities in Johannesburg, South Africa

Yacob Pinchevsky,1 Frederick Raal,2 Neil Butkow,1 Tobias Chirwa,3 Larry Distiller,4 Alan Rothberg5 1Department of Pharmacy and Pharmacology, School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 2Carbohydrate and Lipid Metabolism Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 3Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; 4Centre for Diabetes and Endocrinology, Johannesburg, South Africa; 5School of Therapeutic Sciences, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa Purpose: With the realities of resource constraints existing in South Africa’s public sector and the evidence of disparities in health care between populations, the study sought to compare the quality of diabetes care and health-related quality of life (HRQoL) in patients with type 2 diabetes mellitus (T2DM) receiving care within two specialized settings: one in the public and the other in the private sector. Particular emphasis was placed on complication rates at the two sites.Patients and methods: Quantitative and qualitative data were collected between June and October 2016 from existing patients’ records at each setting. Data included patient demographics, potential barriers to accessing care, medical history, laboratory results, pharmacological treatment and diabetes-related clinical, biochemical and HRQoL outcomes. With outcome measurements being the priority, methodology incorporated the Donabedian model in which “structure” of health care systems, access to care and processes of care are key to determine outcomes.Results: A total of 290 T2DM patients were enrolled. Analysis revealed that private patients were predominantly Caucasian with higher socioeconomic indicators (p<0.01) and education levels (p<0.0001) and experienced fewer access barriers to clinical services/care (p<0.00001). Private patients also had more frequent consultations with dietitians (p<0.0001), podiatrists (p<0.0001) and biokineticists (p<0.0001). In the important area of complications, which ultimately determine the course of T2DM, rates of micro- and macrovascular disease as well as HRQoL scores and sub-scores were similar between the sites, which were measured by the EuroQoL-5 dimension (EQ-5D) assessment tool. While results indicated that public sector care may be equivalent in terms of the latter outcomes, a smaller number of patients are treated in the clinic than would be ideal in terms of the public sector burden of T2DM.Conclusion: Contrary to expectation, despite differences in patient demographics and resources, the HRQoL and quality of care, particularly in terms of T2DM-related complications, were found to be similar across the two settings. Keywords: diabetes mellitus, quality, barriers, health-related quality of lif