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VOLUME 14 NUMBER 1 • JULY 2017
DIABETES CARE MODEL
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Integrating the pieces of a complex puzzle to achieve
a comprehensive approach towards optimal care of the
patient with diabetes
S PILLAY, C ALDOUS
Correspondence to: S Pillay
Department of Internal Medicine, Edendale Hospital, Pietermaritzburg,
South Africa
e-mail:
drspillay@iafrica.comC Aldous
School of Clinical Medicine, University of KwaZulu-Natal, Durban,
South Africa
S Afr J Diabetes Vasc Dis
2017;
14
: 18–23
Abstract
Background:
Diabetes mellitus (DM) is ravaging both
patients’ health and healthcare economies of countries
worldwide, especially in developing countries. Mitigation
of the diabetes-related tsunami of complications could occur
through optimal control of DM. Control of this disease begins
at our local healthcare facilities and requires a comprehensive,
standardised and holistic approach to care.
Methods:
The diabetes clinic at Edendale Hospital is a busy
regional clinic situated in Pietermaritzburg, KwaZulu-Natal.
In order to improve diabetes care, the following integrated
packageof changeswasmade to this resource-limitedclinic: (1)
introduction of a fully operational multidisciplinary treatment
team; (2) intensive nurse and clinician education on DM and
its management according to local South African diabetes
guidelines; (3) intensive patient education from all members
of the team; (4) introduction of essential basic equipment
into the clinic; (5) introduction of a patient clerking datasheet
to ensure standardisation and comprehensive diabetes care
for all patients visiting the clinic; and (6) development of a
customised computer program to audit and analyse data over
time in order to identify areas of poor performance within
the care of the patient, and to monitor patient progress.
Conclusion:
This article describes the development and
implementation of the above six steps as a holistic patient-
care package at the clinic. The overall management plan
of diabetes care proposed within the clinic could provide
the blueprint for other resource-limited diabetes clinics in
developing countries.
Introduction
Optimal control of diabetes mellitus (DM) ensures that the risk of
micro- and macrovascular complications are minimised or prevented.
1
Aside from patient-related complications, especially cardiovascular,
the economic burden of DM and its complications on the health
economies of countries is enormous.
2,3
The latest International
Diabetes Federation (IDF) estimates are that 77% of diabetic patients
live in low- to middle-income countries and that approximately 62%
of diabetic patients in Africa are undiagnosed.
4
The diabetes pandemic in Africa is putting an enormous strain
on a continent with limited resources and one that is already under
strain from communicable diseases such as HIV infection and
tuberculosis (TB). Coupled with the diabetes pandemic is obesity,
which is increasing at an alarming rate worldwide. South Africa has
the highest rates of obesity in females in sub-Saharan Africa, where
approximately 42% of females and 39% of males are classified as
obese.
5
Obesity is considered a risk factor for developing type 2
DM and is an important contributor to insulin resistance and poor
glycaemic control.
6
In South Africa, both in the private and state sectors, target
glycaemic control is not being achieved.
7,8
Patient education is an
essential first step towards diabetes control. This education process
should be present at every level of the multidisciplinary team and is
integral to achieving control.
9
The diabetes nurse-educator’s role is
pivotal in improving the quality of diabetes education imparted to
patients.
10
Dietary advice to diabetic patients has shown benefit in
improving glycaemic control.
11
Patients with DM are about 20 times more likely to have lower-
limb amputations compared with non-diabetics hence attention to
foot care is paramount in their overall care.
12
Diabetic retinopathy
accounts for the majority of cases of new onset of blindness in
adults between 20 and 74 years of age.
13
Annual eye assessments
form an essential component of optimal diabetes care. The risk of
developing cardiovascular disease is two to three times higher in
diabetic versus non-diabetic patients.
14
Routine electrocardiogram
assessments may help in detecting silent myocardial ischaemia or
infarctions among other abnormalities in diabetic patients.
DM is a chronic disease requiring the patient to take ownership
of it. A fundamental aspect of self-control entails being able to
manage diabetes at home. This requires self-monitoring of blood
glucose levels (SMBG) by the patient. Guerci
et al.
15
demonstrated
that SMBG improves metabolic control in diabetic patients.
The Society for Endocrinology, Metabolism and Diabetes in South
Africa (SEMDSA) 2012 diabetes guideline
16
provides direction for
clinicians dealing with diabetic patients. Real benefits can be achieved
by following these guidelines. However, studies have demonstrated
that clinician compliance with these guidelines is still poor and control
is sub-optimal.
7,17,18
Weingarten
et al.
,
19
in their meta-analysis of
interventions in chronic diseases, showed that patient education and
education of healthcare providers was associated with improvements
in adherence to clinical guidelines by providers and resulted in definite
improvements in patient disease control.
Organisational structural interventions within the clinic coupled
with patient, nurse and clinician education has been shown to improve
overall outcomes in diabetic patients.
20
One such intervention within