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 190 AFRICA
In the 11 studies (24 702 patients) that used LDL-C levels
of either 2.5 or 2.6 mmol/l (100 mg/dl or less) to define control,
51.4% (range 20.0–82.9%) of patients achieved goal.10-20 One
study (225 patients) with a total cholesterol target of < 200 mg/
dl (5 mmol/l) had 49.3% of patients at goal.21 Two studies (702
patients) did not measure lipid levels.9,22
In general, more patients reached target for LDL-C than
for HbA1c levels, with the poorest achievement of targets being
BP. The widest variability of target achievement was LDL-C
(variation of 62.9%), followed by BP and then HbA1c (least
variability). The highest and lowest achieved targets were those
by an American (LDL-C, 82.9%) and a German study (BP,
7.4%), respectively.18,19
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 (HbA1c, 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 HbA1c, BP and LDL-C levels. More
patients achieved LDL-C than HbA1c 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 HbA1c
levels (< 7%) comparable with those of lower- to upper-middle-
income 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 more-
developed nations, two to three times more patients from
separate European (specifically the Netherlands) and a USA
study achieved HbA1c (< 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 HbA1c levels < 7%, which is similar to the three