Resumen de The classification and management of adult diabetes mellitus patients at dr george mukhari academic hospital, gauteng province, south africa. A pharmacist initiated retrospective review
Mahlalela Nombuyiselo Sizakele, Natalie Schellack, Andries Gous
Background: Diabetes is a major health problem in South Africa and throughout the world. According to the International Diabetes Federation there were 2.6 million cases of diabetes in South Africa in 2015. The treatment goals of patients with diabetes are to attain and maintain normoglycaemia, reduce the risk of microvascular and macrovascular complications, reduce mortality and improve the quality of life of the patients. A number of international trials have shown that strict glycaemic control and proper management of co-morbid conditions leads to a reduction in the development of diabetes complications. Several guidelines were formulated worldwide, however, many studies have shown poor adherence to national guidelines by health professionals caring for diabetic patients. The Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) formulated guidelines based on a number of international trials.
Objectives: The aim of the study was to categorise the different subtypes of diabetes in diabetic patients treated at Dr George Mukhari Academic Hospital (DGMAH), to assess and describe the treatment of these diabetic patients and to compare their treatment against the Standard Treatment Guidelines (STG) and Essential Medicines List (EML) (Hospital Level) (2012) and SEMDSA Guidelines (2012).
Method: The research study was a descriptive, retrospective cross-sectional study performed at the Diabetes Clinic and Out-patient Pharmacy Department at DGMAH. One hundred diabetic patient records met the inclusion criteria. Information for purposes of this research study was retrieved from the files of patients for a period of eight months. Files of patients were selected based on the inclusion criteria and all data were collected onto a data collection sheet.
Results: Of the 100 patients included, 12% had type 1 and 88% had type 2 diabetes. No other specific type was found. The two most common co-morbid conditions were hypertension (HTN) (diagnosed in 90 patients) and dyslipidaemia (diagnosed in 24 patients). Hypoglycaemic agents used were dominated by biguanides (41.5%), followed by insulin (39.9%) and sulphonylureas (16.4%). Metabolic control was suboptimal with a mean random blood glucose of 15 (±4.05) mmol/l. Glycosylated haemoglobin (HbA1c) was assessed in 65 patients, 84.6% of which had high HbA1c values with a mean of 9.89% (±2.79) and only 10 (15.4%) had HbA1c values <7%. A target blood pressure of <140/80 mmHg was achieved in 30% of the hypertensive patients. The mean systolic blood pressure (SBP) was 143.94 (±22.81) mmHg and the mean diastolic blood pressure (DBP) was 76.69 (±10.8) mmHg. Lipid-lowering drugs were mainly statins and prescribed in 85% of the patients. Lipid examinations were performed in 52 patients and only 14 (26.9%) had an LDL-cholesterol of <1.8mmol/l. Type 1 diabetes patients had an acceptable mean body mass index (BMI) of 25.51 (±5.41) kg/m2. Type 2 female patients were obese with a mean BMI of 34.41 (±6.44) kg/m2 and Type 2 males were overweight with a mean BMI of 28.6 (±3.67) kg/m2. Eye examinations were carried out in only 12% of the patients.
There was poor assessments or records of foot examinations. Only one patient had a foot examination done. Urine ACR, eGFR, serum creatinine and potassium were not done at all in 67, 30, 26 and 24 patients respectively.
Conclusion: This study demonstrates unsatisfactory compliance to processes of patient care with current diabetic guidelines. There were a high number of undocumented examinations. Metabolic and blood pressure control was suboptimal. Glycated haemoglobin was poorly controlled in a majority of the patients and poor glycaemic control was associated with poor patient outcomes and an increased risk of complications. These findings emphasise the importance of reviewing how guidelines are implemented in South African public sector hospitals, if evidence-based guidelines are to have any impact on patient care.
Recommendations: Recommendations from this study include the need to assess knowledge and provide continuous training of common guidelines amongst health care professionals working at specialised diabetes clinics and to encourage maximum involvement of pharmacists who can play an important role in the implementation of guidelines and overall patient care
