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Chronic diseases are not being managed effectively in either high-risk or low-risk populations in South Africa
1 Department of Surgery, School of Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
2
Cardiovascular Pathophysiology and Genomics
Research Unit, School of Physiology, Faculty of Health
Sciences, University of the Witwatersrand, Johannesburg, South
Africa
Background. Primary healthcare is the foundation of a country’s healthcare system. Without an efficient and cost-effective programme, the level of healthcare offered across all levels of health management is adversely affected.
Objective. To analyse the effectiveness of the management of hypertension and diabetes mellitus (DM) among two distinct patient populations, one with significant cardiovascular risk factors and the other without.
Method. We performed a case control study of a high-risk group of patients presenting with chronic critical limb ischaemia (CLI) to the Divisions of Vascular Surgery at Charlotte Maxeke Johannesburg Academic Hospital and Chris Hani Baragwanath Academic Hospital, and a randomly selected group of ‘healthy’ community participants from Johannesburg’s South Western Townships (Soweto).
Results. We assessed 217 patients with CLI and 1 030 participants from the community. We assessed the number of patients who were not achieving their therapeuatic targets, among those known to be hypertensive (CLI: 44.7%; community: 59.9%) and diabetic (CLI: 83.5%; community: 66%). Undiagnosed diabetes affected 10.8% of patients with CLI and 11% of the community sample.
Conclusion. Traditional vascular risk
factors are managed poorly at both primary healthcare and at
tertiary care levels. There is a need to identify factors that
will address this issue.
S Afr Med J 2013;103(12):938-941.
DOI:10.7196/SAMJ.6018
Groups of black African descent living in South Africa (SA) are a population on the brink of an epidemiological health transition.1 This population, which already bears a quadruple disease burden (HIV/AIDS; tuberculosis (TB); violence and injury; and poor maternal and child health)2 now faces an increasing prevalence of degenerative and lifestyle disease.
In 2008 the World Health Organization (WHO) emphasised
that, especially in developing countries, effective primary
healthcare (PHC) systems are essential to ensuring effective
national healthcare. 3 This is the challenge
facing our already strained public health system, which is
already hampered by lack of infrastructure, dwindling numbers
of medical professionals and inadequate resources. Is there
evidence that we are managing chronic diseases adequately, or
is there room for improvement?
Methods
We performed a case-controlled cross-sectional study in the Divisions of Vascular Surgery at Charlotte Maxeke Johannesburg Academic Hospital and Chris Hani Baragwanath Academic Hospital, Johannesburg, SA. We recruited consecutive patients referred with chronic critical limb ischaemia (CLI), defined as ischemic rest pain present for >2 weeks; ulcers; or gangrene attributable to arterial occlusive disease.4
Using an existing database, 1 030 participants were drawn from randomly selected families of black African descent (Nguni and Sotho chiefdoms) from Johannesburg’s South Western Townships (Soweto)5 and enrolled as a control group. Only adults were recruited, with siblings older than 16 years.
The database was the product of the African Project on Genes in Hypertension (APOGH). The APOGH group consists of randomly selected participants representing a community – some with hypertension, some diabetic, some with no comorbidities – and follows these patients over years to monitor disease progression and/or stability. Therefore, the APOGH group served as the ideal control group with which to compare a group of end-stage vascular disease patients.
The study was conducted according to the principles of the Declaration of Helsinki. The University of the Witwatersrand’s Committee for Research on Human Subjects had previously approved the APGH protocol (approval number M02-04-72 and renewed as M07-04-69) as well as the current study (approval number M11-08-29). Participants gave written, informed consent.
A questionnaire obtained each participant’s medical history, use of medication and smoking habits. Height and weight were measured with participants in a standing position, and body mass index (BMI) was calculated. A fasting lipid profile (cholesterol:high density lipoprotein (HDL) cholesterol ratio) and glycosylated haemoglobin (HbA1c) were measured as biochemical indicators of the risk factors of hyperlipidaemia and diabetes mellitus (DM).
Participants rested for 10 minutes in the supine position, after which 3 brachial blood pressure readings were obtained using an appropriately sized cuff. The mean of the 3 readings was calculated and used as the patient’s blood pressure for that occasion. Hypertension was defined as either a systolic blood pressure >130 mmHg or diastolic blood pressure >80 mmHg in the CLI group, and either a systolic blood pressure >140 mmHg or diastolic blood pressure >90 mmHg in the community sample. Any patient taking anti-diabetic medication was considered to be diabetic.
Statistical analysis and
database management were performed using SAS software version
9.3 Student t-tests were used to calculate p-values.
Results
Participant characteristics
A total of 217 patients with CLI were referred to our clinic, 78 (36%) from secondary level facilities and 139 (64%) from PHC clinics. Table 1 shows the demographic and clinical characteristics of the study samples. Patients with CLI were, on average, older, suffered from concomitant DM, were smokers and used alcohol more frequently. The majority were males. Of the community sample more were obese, with a higher mean BMI; their total cholesterol:HDL cholesterol ratio was higher.
In the CLI group, 18 patients had suffered a previous ischemic
coronary event and 9 had suffered a cerebrovascular accident. No
participants in the community sample gave a significant
cardiovascular or cerebrovascular history.
Blood pressure
Mean blood pressure was higher in the community sample, and
both means were significantly higher than the recommended target
blood pressure for their group. Table 2 shows the
comparison of blood pressure control between the two groups for
their respective targets. A total of 154 CLI patients were
hypertensive, of whom 139 were on treatment, 28 with monotherapy
and 111 with polytherapy. In the community sample 268
participants were on treatment, 180 with monotherapy and 88 with
polytherapy.
Glycaemic control
In both the community sample and the CLI group with DM, the
mean HbA1c was significantly higher (>7.0%) (Table 2). In the
CLI group, 97 patients were diagnosed with diabetes. In the
control group, 103 participants were diagnosed with diabetes.
Only 35 (34.0%) patients in the community sample and 16 (16.5%)
in CLI group diagnosed with DM appeared to have achieved their
HbA1c therapeutic target. Of the 927 patients in the community
sample who did not have DM, 102 (11.0%) had an HbA1c >7.0%.
Of the 120 patients with CLI who were not diagnosed with DM, 13
(10.8%) had an HbA1c >7.0%.
Serum lipids
No patient in either sample was known to have
hypercholesterolaemia (Table 2). All patients in the CLI group
were on a statin as a component of their peripheral arterial
disease management and their cholesterol levels were within
accepted ranges.
Smoking
There was a high prevalence of smoking. The CLI group were more
likely to smoke, but the amount smoked was low (Table 1).
Indeed, for many the amount smoked was too irregular to
calculate a daily average, many patients smoking <5
cigarettes/day. Both groups demonstrated a decrease in smoking
from previous smoking, but current smoking levels remained
significant.
Discussion
We have studied risk factors for vascular disease and their management in patients with severe peripheral arterial disease, as well as in a randomly selected community sample. In SA, only 14 - 40% of patients achieve blood pressure control and 16 - 50% of diabetics currently achieve glucose control. 6 , 7 Our data was in line with these studies for our group of patients at high risk for adverse cardiovascular events. Blood pressure and glycaemic control is poor in both groups but significantly worse in the CLI group. We have also shown that approximately 10% of the population have not had their DM diagnosed and may present to hospitals with complications of their disease, such as CLI. Blood pressure and HbA1c values for the community sample are in keeping with other general SA community samples, as is their use of medication.8 , 9 The community sample was significantly more overweight than the CLI group, in keeping with other SA studies.9 , 10
In SA, clinical nurse practitioners are the main primary healthcare providers. From our study and several other community based studies in various provinces,6 , 9-11 it appears that the current healthcare system is failing to serve the greater public. SA is not the only country in which nurse-led PHC has not succeeded. In 2000 the Japanese instituted a nurse-led PHC initiative called ‘Kenko-Nippon-21’ (Healthy Japan 21).12 An audit of its treatment effects in 2004 showed that some outcomes for the population involved had worsened instead of improving. 8 In response, the Japanese began a new screening and intervention programme that identified individuals at risk, who were then referred to a doctor-supervised counselling or intervention programme.8 PHC should be doctor-led to improve quality of care.13 , 14
DM management can be significantly improved, even in resource-poor environments, through physician-patient contact, with up to 85% of patients achieving their glucose targets in diabetes-focused PHC clinics.15 The initiation and ongoing use of insulin is a stumbling block in non-hospital clinics, and non-specialist nurses cannot be expected to commence or monitor this therapy.16 , 17 On the other hand, specialist diabetic nurses working in PHC clinics do help patients achieve therapeutic targets.17
In Germany, disease-management programmes started in the 1990s and are run as secondary prevention programmes. Diagnosed patients are entered into specialist-led disease programmes in their area.18 This system has been shown to be effective and economical over the long term.19 Brazil has significantly improved its PHC system by developing a family-health programme, which runs clinics staffed by a doctor and nurse and linked to other clinics and regional medical centres through a comprehensive health-management information system.20 In situations where there are no doctors, nurse-led clinics have led to improvement in diabetic and hypertensive parameters, thanks to the information system and clear referral pathways to regional medical centers. While the values did not fall within recognised therapeutic targets, improvements did reach statistical significance.21
The SA Government’s Primary Healthcare Services Package was designed to create ‘one-stop public healthcare’ with a view to decreasing the burden on hospitals.22 It is evident from our study, as well as other community studies, that this policy has failed. If SA is to decentralise PHC, polyclinics with specialist nurses in chronic diseases such as DM and hypertension should be created.
Medical care in SA remains hospicentric. 1
,
23
Though there are initiatives in place to alleviate the burden
on hospitals (such as the National Strategic Plan on HIV,
sexually transmitted infections and TB 2012 - 2016, which was
launched on 1 April 2012,23 and the proposed
National Health Insurance (NHI) scheme), it will be several
years before they come to fruition. In the meantime, hospital
doctors should take every opportunity to provide PHC, and must
not assume that patients will automatically receive it outside
their hospital. A patient who is admitted for an inguinal
hernia repair who is hypertensive and diabetic should have
their blood pressure and diabetic management carefully
evaluated before discharge. Upon discharge, doctors must
carefully consider whether PHC or short-term hospital
out-patient follow-up is appropriate for that specific
patient. Once their comorbidities are well-controlled patients
can be managed peripherally, with clear channels and protocols
of referral back to the specialist clinic should the need
arise. Widespread specialist nurse-led polyclinics could
supplement the current PHC system by acting as an intermediate
step to tertiary care.
Conclusion
We have demonstrated poor cardiovascular risk-factor management
in high-risk and low-risk patient cohorts in Gauteng, both at
tertiary and primary care levels. Review of the SA literature
highlights the defects of the PHC system. In improving PHC in
SA, efforts should be made to learn from other PHC systems, such
as the Japanese, German and Brazilian systems. The district
clinical specialist teams that are planned for under the
forthcoming NHI system may promote improved cardiovascular
disease prevention and management. Until then, however, every
patient encounter at any level of care should be considered an
opportunity to prevent or manage chronic illnesses.
Acknowledgements. This work was
supported by the SA Medical Research Council, the Circulatory
Disorders Research Trust, the University Research Council of the
University of the Witwatersrand, the SA National Research
Foundation, and the Carnegie Trust. MB is a recipient of a
Carnegie Clinical Fellowship.
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Accepted 28
May 2013
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