Cardiovascular Journal of Africa: Vol 26 No 4 (July/August 2015)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 4, July/August 2015 AFRICA 189
reviews and hand-searched several medical journals.
Studies that reported achievement of guideline-recommended
targets of major risk factors for T2DM were included. The
primary objective of this review was to provide an overview
of achievement of major risk-factor targets (HbA1c, BP and
LDL-C) in the treatment of a sample of T2DM patients from
different parts of the world. Specifically, the objectives would
be addressed through comparison of the achievement of HbA1c,
BP and LDL-C targets, according to local or international
guidelines, across different study samples.
The following data were extracted from the studies: author
details, year of publication, study location, cohort size and
achievement of major risk factors (combined systolic and
diastolic BP, and HbA1c and LDL-C levels). As different
samples of study countries followed different guideline targets,
flexibilities around these differences was needed. Studies selected
for this article may have differed in the following parameters:
recruitment and randomisation methods, total number of study
participants recruited, study sites (e.g. single or multicentre),
gender ratios, ethnicity ratios, timelines of results presented (e.g.
single or longitudinal data) and periods of enrollment.
To compare results, we standardised (or converted or
conformed) certain measurement units in order to maintain
consistency (e.g. LDL-C in mmol/l instead of mg/dl). The
control or baseline results of studies were reported instead of
interventional group data. Only the latest data were selected
from studies with multiple time periods.
Studies excluded from the review had one or more of
the following characteristics: non-English language, studies
conducted before 2009, participating patients younger than 18
years of age, participants reported to have had any diabetes other
than T2DM (e.g. gestational, type 1 or steroid induced), studies
that reported insufficient data or less than two of the three major
risk factors being compared, and studies that consisted of large
HMO claims databases. The latter was chosen as an exclusion
criterion as larger-sized cohort studies would have biased the
results of this review.
Data presented in this article were collected from the results
of other studies and are limited to the authors’ definitions of
control. This review did not allow for the access of patient-level
data of different studies included in the review to be accessed.
It was assumed that all data extracted for this study were
collected from the medical records of patients who willingly
participated in the studies included in this review. The relevant
data were captured into a secure database using Microsoft Excel
2010. Ethical approval was obtained from the University of the
Witwatersrand Human Research Ethics Committee (Medical).
Results
The authors of this study set out to determine how diabetes
care compared across different settings, given the healthcare
challenges faced especially by under-resourced areas. Of the 511
(154 from Ovid MEDLINE + 32 Pubmed + 325 Sabinet) titles
initially identified between 2009 and 2014, 14 studies fulfilled the
inclusion criteria. These 14 studies originated from 19 different
countries (some studies included more than a single country) and
we enrolled a total of 25 629 patients.
There were 17 high-income, one upper-middle- (South
Africa) and one low-income (Uganda) country included in the
review (grouped according to the United Nations’ economies by
per-capita country classification).7 Cohort sizes ranged from 50
to 4 926 patients. Twelve studies contained results for all major
risk factors (HbA 1c, BP and LDL-C), while the rest included
at least two-thirds of the measured risk factors. There were
eight studies (57.1%) that defined treatment targets as per the
American Diabetes Association. 8 The characteristics of each
study are outlined in Table 1.
In 12 studies (25 354 patients) that used an HbA1c level of
7.0% or less to define control, 44.5% (range 19.2–70.5%) of
patients achieved target.9-20 In two studies (275 patients) where
HbA1c level was defined as < 6.5 and < 8.0%, respectively, 56.6
and 60.0% of patients reached their targets, respectively.21,22
In eight studies (18 089 patients), which had the definition
of target BP of 130/80 mmHg or less (systolic and diastolic
combined), 35.2% (range 7.4–66.3%) of patients achieved
target.9-11,16-19,21 In four studies (7 240 patients) where systolic BP
targets of 130 mmHg or less (alone) defined control, 32.7%
(range 21.3–50.0%) of the subjects achieved target.12,13,15,20 In
two studies (300 patients) with a BP target of either < 140/90
or < 140/80 mmHg, 24.0 and 56.0% of patients achieved goal,
respectively.14,22
Table 1. Study characteristics
First author
(reference)
Year of
publi-
cation Location
Cohort
size
(n)
Achievement of target
HbA1c
(< 7%)
BP (< 130/
80 mmHg)
LDL-C
(< 2.6mmol/l)
Al-Taweel9 2013 Kuwait 652 19.2 46.0 –
Braga10 2012 Canada 3002 52.6 53.6 64.2||
Casagrande11 2013 USA 4926 52.5 51.1 56.2
Goderis 12 2009 Belgium 2495 54.0 50.0‡ 42
Hermans13 2013 Belgium,
Greece,
Luxem-
bourg,
Portugal,
Spain,
UK
3996 49.2 27.3‡ 40.8
Kibirige14 2014 Uganda 250 20.8 56.0§ 20.0
Klisiewicz15 2009 South
Africa
150 30.7 21.3‡ 50.7||
Lee 16 2009 Korea 926 49.2 66.3 51.0
Morren21 2010 Trinidad 225 56.6† 53.6 49.3**
Pinchevsky 17 2013 South
Africa
666 26.2 45.8 53.8||
Sease18 2013 USA 95 35.8 62.1 82.9
Stone19 2013 Belgium 1044 59.7 27.6 49.7
Stone19 2013 France 1056 65.3 14.9 52.4
Stone19 2013 Germany 959 48.6 7.4 30.7
Stone19 2013 Ireland 950 53.4 24.9 76.9
Stone19 2013 Italy 984 35.7 20.8 40.4
Stone19 2013 Nether-
lands
1021 70.5 20.3 58.9
Stone19 2013 Sweden 550 56.5 27.1 47.3
Stone19 2013 UK 1033 39.1 25.0 74.5
Umar-
Kamara22
2011 USA 50 60.0* 24.0¶ –
Webb20 2014 South
Africa
599 27.0 32.0# 33.0||
Exceptions to the above targets are indicated by the following:
† HbA1c < 6.5%;*HbA1c < 8.0%;
‡ systolic blood pressure only < 130 mmHg;
§systolic/diastolic blood pressure < 140/80 mmHg; ¶systolic/diastolic blood pres-
sure < 140/90 mmHg;
||low-density lipoprotein cholesterol < 2.5 mmol/l;
**total cholesterol < 5.18 mmol/l.