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REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
70
VOLUME 12 NUMBER 2 • NOVEMBER 2015
Discussion
The quality of diabetes care cannot simply be measured across
proportions of patients achieving guideline targets. However, a broad
overview of the quality of care can be gauged when comparing target
adherence across different countries, especially with adequately sized
samples of patients. Hence the reason for this review, where countries
from various economies were compared, according to achievement
of modifiable risk factors against the guidelines. Based on the results
of other studies, this review set out to establish the achievement of
major risk-factor targets (HbA
1c
, BP and LDL-C levels) in the treatment
of DM patients in different parts of the world.
Given the increasing prevalence of T2DM, effective management
of critical diabetes risk factors can significantly contribute towards
improved outcomes. Attaining targets requires improved methods
to increase adherence to lifestyle (exercise/diet) and pharmacological
interventions. From this review, it was evident that certain studies
appeared to be more successful at managing patients’ risk factors
than others.
Practitioners achieving better guideline adherence should
be encouraged to share their management strategies for
implementation with other healthcare facilities. Hermans
et al.
found that by benchmarking the level of care of ‘three paramount
cardiovascular risk factors’ in a primary care setting has in itself led
to a clinically significant improvement in T2DM care over time.
13
There is also evidence to suggest that performance with regard to
management of a disease, when compared between a physician
and his/her colleagues, has brought about an intellectual, emotional
and competitive incentive for change.
23
The most critical ways of reducing T2DM complications is by
collectively managing HbA
1c
, BP and LDL-C levels. More patients
achieved LDL-C than HbA
1c
targets in the studies reviewed,
potentially owing to the progressive nature of the disease, where
β
-cell function gradually declines over time. BP control was the least-
achieved risk factor across all the studies, and according to McLean
et al.
, may have occurred due to the ‘inadvertent under emphasis’
of treating T2DM-associated risk factors (such as hypertension,
when there is strong emphasis on glucose control).
24
Perhaps it was
due to inadequate dosages, poor adherence to medication, poor
access to follow-up care or a combination of these. A well-designed,
randomised, controlled trial may help address these questions.
Once considered rare in sub-Saharan Africa, the prevalence of
T2DM is rapidly increasing. As many as four out of every five diabetics
reside in LMICs, many of whom remain undiagnosed.
1
T2DM is a
complex, resource-intensive disease requiring multifactorial yet
individually tailoured, lifelong treatment.
Most of the studies found and included in this review were from
higher-income countries. However patterns of poor control rates
were common across all settings. For instance, less than 40% of
patients from the USA, Europe (specifically Italy) and the UK studies
(all high-income countries) achieved HbA
1c
levels (< 7%) comparable
with those of lower- to upper-middleincome countries (Uganda
and South Africa, respectively).
14,17-20
Similarly, the combined results
of six European countries, and other individual studies, had less
than half of patients at LDL-C target, as seen in two separate non-
high-income countries.
13,14,20
Yet on the other hand, and possibly as
expected from moredeveloped nations, two to three times more
patients from separate European (specifically the Netherlands) and
a USA study achieved HbA
1c
(< 7%) and LDL-C (< 2.6mmol/l) targets
in comparison with a lower-income country, respectively.
14,19,22
The differences across the sites in their abilities to achieve guideline
targets may be attributed to socio-economic reasons. In resource-rich
settings, where patients supposedly receive the extra time required
for diabetes care through more regular physician interactions
or appointments, appropriate reminder systems and adherence
monitoring, this may improve the standards of diabetes care received.
Lower-income countries face the realities of inadequate healthcare
infrastructure, regular medication stock outs, few educational
programmes and minimal healthcare facilities/professionals.
25
This
literature review covered the influences of multiple background factors
occurring across healthcare systems in different countries, hence the
differences in targets achieved across the environments studied.
As described above, Africa faces many healthcare challenges,
both within and between countries. Despite resource constraints,
by targeting the modifiable risk factors associated with DM, there
is still the potential for improvement, and better patient outcomes.
This review serves to highlight the proportion of patients achieving
guideline targets across different settings. The aim of this review
was to serve as a benchmark for those countries selected, in order
to measure their performance against each other in terms of
achieving guideline targets.
By recognising those healthcare settings with increased patient
numbers achieving guideline targets, this could allow for future
studies to identify the mechanisms and processes used to achieve
their targets. Areas of interest for the improvement of diabetes
care could include: organisational characteristics such as improved
implementation of adherence to clinical guidelines (evidence-
based), identification of individuals to act as guideline champions
to deliver more performance measures, and feedback to healthcare
providers on progress made. Perhaps, once identified, the settings
achieving less-favourable control of modifiable risk factors may
begin to explore approaches used in the more successful settings.
In addition, given the chronic progressive nature of DM, it is hoped
that attention will be prioritised not just on treatment but also on
prevention strategies in those settings wishing to improve their
level of diabetes care offered.
It has been predicted that the ageing populations of LMICs will
face a significant increase in mortality rate due to NCDs over the next
25 years.
26
Although not included in this review, a previous South
African study revealed that only 30.4% of the 899 patients achieved
HbA
1c
levels < 7%, which is similar to the three studies included in
this review from the same locale.
27
The three South African studies
included in this review had noticeably fewer patients at HbA
1c
goal
in comparison with other countries. One of the reasons for this may
have been that all the South African studies included in this review
were from the public sector, which has often been described as
‘overburdened’, and due to resource constraints, cannot always offer
appropriate levels of healthcare or access to the most modern of
diabetes treatments currently available in South Africa’s private sector
or in those high-income countries included in this study. Furthermore,
many of the patients serviced in South Africa’s public sector settings
originate from a lower socioeconomic background, which may
indicate lower educational levels or limited access to healthier lifestyle
choices. Perhaps HbA
1c
level is still the most challenging of risk factors
to control, especially in less-developed economies.
Study limitations
Studies included in this review differed with regard to guidelines
or targets, however, we tried to overcome this by consistently
capturing and comparing similar risk factors using standardised