3. Electronic Theses and Dissertations (ETDs) - All submissions
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Item A comparison of diabetes care of patients attending Charlotte Maxeke Johannesburg Academic Hospital and Houghton centre for diabetes & endocrinology(2018) Pinchevsky, YacobIntroduction: With the realities of resource constraints existing in South Africa’s public sector and evidence of disparities in healthcare between populations, the study sought to compare aspects of quality of diabetes care and Health Related Quality Of Life (HRQoL) in patients with Type 2 Diabetes Mellitus (T2DM) receiving care within two specialised settings, one in the public sector (Charlotte Maxeke Johannesburg Academic Hospital - CMJAH) and the other in the private sector (Centre for Diabetes and Endocrinology - CDE). Particular emphasis was placed on complication rates at the two sites. Methods: Quantitative data were collected between June and October 2016 from existing patients at each setting. Data collected included patient demographics, potential barriers to accessing care, medical history, laboratory results, pharmacological treatment, and diabetesrelated clinical, biochemical and HRQoL outcomes. With outcome measurements being the priority, methodology incorporated the Donabedian Model in which ‘structure’ of the health systems, access to care and processes of care are key to determining outcomes. Results: Two-hundred ninety T2DM patients were enrolled. Analysis revealed that CDE patients were predominantly Caucasian with higher socioeconomic indicators (p<0.01) and education levels (p<0.0001), and experienced fewer access barriers to clinical services/care (p<0.0001). They also had more-frequent consultations with dieticians (p<0.0001), podiatrists (p<0.0001) and biokineticists (p<0.0001) compared to patients attending the CMJAH. Multivariate analysis of the complete sample showed that outcomes were related to factors other than the setting in which care was provided. Some outcomes were related to demographic factors e.g. higher risk of macrovascular disease in Caucasian and Asian patients, while others were related to difficulties in accessing care, patients’ education, and/or T2DM duration and disease severity. In the important area of complications, which ultimately determine the course of T2DM, rates of micro- and macrovascular disease were similar between the sites, as were HRQoL scores and subscores as measured by the EQ-5D-5L assessment tool. However, site-related data suggest that a) identification of early microvascular complications may vary between the sites, and b) while care at CMJAH may be equivalent in terms of the outcomes of interest, the clinic is treating a smaller number of patients than would be ideal in terms of the public sector burden of T2DM. Conclusions: Despite differences in patient demographics and resources, the HRQoL and T2DM-related complications were found to be similar across the two settings. Attention should be directed towards identification of modifiable factors that would be of benefit to patients at the two sites and possibly beyond.Item The implementation of current guidelines regarding the treatment of cardiovascular risk in type 2 diabetics(2012-01-10) Pinchevsky, YacobBackground: Type 2 diabetes mellitus (T2DM) is defined by an increase in serum glucose, however, this leads to the belief that only the serum glucose levels need be monitored and treated. Hence many other risk factors such as obesity, lipids and blood pressure which increase the risk of coronary heart disease, myocardial infarction, stroke and peripheral vascular disease are neglected. Consequently, T2DM patients that are at greater risk of developing cardiovascular disease (CVD), are often not receiving optimal comprehensive care. Aims: To identify the treatment gaps of cardiovascular risk factors in patients with T2DM using both national and international current treatment guidelines. Methods: Using a public sector database, data was obtained on the treatment of 666 T2DM patients. Records of patients were selected on the basis of established T2DM diagnoses, receiving oral hypoglycaemic and/or insulin therapy. The following patient data was recorded: demographics (age, gender, ethnicity), systolic blood pressure (SBP), diastolic blood pressure (DBP), glycated haemoglobin (HbA1c), total cholesterol (TC), triglycerides (TG), HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C) , family history, cardiovascular history and all chronic medications. The following parameters were applied to the cohort: SBP <130 mmHg, DBP <80 mmHg. In the event of proteinuria: SBP ≤120 mmHg, DBP ≤70 mmHg. HbA1c <7.0%, TC <4.5 mmol/L, LDL-C <2.5 mmol/L, HDL-C >1.0 mmol/L (males), HDL-C >1.2 mmol/L (females) and TG <1.7 mmol/L. In patients with established CVD, LDL-C target: ≤1.8 mmol/L. Results: The study cohort consisted of 666 T2DM-patients. 55% females. Mean age was 63 years (SD: 11.8), mean HbA1c was 8.7% (SD: 2.4). The mean SBP and DBP readings for the cohort were 133.66 (SD: 19.9) and 78.07 mmHg (SD: 11.6), respectively. Mean LDL-cholesterol was 2.6 mmol/L (SD: 0.9). 26.2% reached HbA1c of ≤7%, 45.8% reached ≤130/80 mm Hg blood pressure targets, 53.8% reached LDL-C of ≤2.5mmol/L and all 3 were reached by 7.5% of the cohort. TC ≤4.5 mmol/L was reached by 53.8%, 60.2% reached TG ≤1.7mmol/L, 58.6% males and 52.8% females reached HDL-C targets of ≥1.0 mmol/L and ≥1.2 mmol/L, respectively. There were 17.9% of patients with CVD reaching targets of LDL-C ≤1.8 mmol/L whilst 16.4% of patients with nephropathy reaching targets of ≤120/70 mm Hg. Almost half (48.2%) were not receiving lipid-lowering therapy, yet would be deemed eligible for therapy. Blood pressure targets may have been better reached with appropriate dosage reductions in addition to the introduction of further antihypertensive combination therapy. CVD was present in 15.5%. Conclusions: T2DM patients are at high-risk for CVD. Many trials have demonstrated the benefits of targeting CVD risk factors (HbA1c, blood pressure, serum lipids) in T2DM. Less than 10% of CVD risk factor targets were reached by the study cohort despite treatment guideline recommendations. The data from the study suggests poor control of modifiable cardiovascular risk factors and significant under treatment of T2DM in clinical practice. Whether improvement lies in the form of therapeutic titration adjustment or an increase in patient education, there needs to be a more aggressive multi-factorial therapeutic approach to treating this high risk group of patients in order to reduce overall morbidity, mortality and improve patient outcomes.