Indicator of diabetes care – can we measure it?
The SA NCD Alliance calls for the HBA1c test to be used as a major indicator blood sugar control.
By Dr Vicki Pinkney-Atkinson
By 2020 The National Department of Health’s (NDoH) target is to have 30% more people with controlled diabetes. However, it is not clear what is meant by control as there are no indicators or measuring it or any of the in theNCDs in the National NCDs Plan.
The 2012 type2 diabetes guideline is a comprehensive evidence-based primary care level tool noted that:
“The Department of Health, through its Non-Communicable Disease Directorate, has committed to utilising and implementing this Guideline. It is hoped that private health-sector funders also use this Guideline to establish minimum care standards for type 2 diabetes. Systems will need to be in place to measure appropriate Guideline usage and outcomes. If this should happen, SEMDSA would have achieved its objective of ensuring adequate care for all South Africans with type 2 diabetes.”
What is “controlled diabetes”?
Controlled diabetes includes blood sugar levels (HBA1c) and the extent to which complications are prevented and managed. Debilitating complications like heart and kidney disease and leg amputations. The UK’s National Institute for Health and Care Excellence (NICE) diabetes quality standard for adults includes other important aspects of care like medication, education for self-management and many more issues. NICE recommends that people with diabetes should receive annual health checks to monitor and manage their condition. A series of 8 activities (test or measures) performed and recorded over 12 months are considered best practice indicators:
- Body mass index (BMI)
- Blood pressure
- HBA1c (blood test)
- Cholesterol blood test (SA guidelines recommend triglycerides in addition)
- Record of smoking status
- Foot examination
- Albumin: creatinine ratio (urine)
- Serum creatinine measurement (blood test).
The HBA1c blood test is essential to accurately measure diabetes control, adherence and care. Remember that good control = fewer debilitating complications. The HBA1c, shows the average blood glucose levels over the last 8-12 weeks and is not comparable to a blood sugar that measures only one point in time. Blood sugars go up and down throughout the day and each day can vary depending on food, activity and, well, life. It is an outdated measure of diabetes control.
The SA type 2 diabetes guideline clearly supports the same approach:
“Early good control of glycaemia, blood pressure and dyslipidaemia, together with regular examinations for microvascular and macrovascular complications with appropriate and timely interventions, is the only way to prevent or reduce morbidity and mortality.” (page S1)
However, at a primary health care level most South Africans sector don’t have access to the HBA1c test because of cost and length of time it takes to get results. Can it be compared to the challenge of TB diagnosis in SA? Probably. In this case a solution was found for rapid TB diagnosis using the Gene Xpert machine. It has revolutionised SA TB management and is now part of the health budget.
Diabetes, like most NCDs is not well managed, with poor blood sugar control even in developed countries. Audits of care in the UK suggest that <10% of people are being offered the full series of recommended tests. If we had to measure the same factors in SA what would the results be like? The trouble is, as long as we don’t measure it comprehensively we, the citizens, will never know.