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OBJECTIVES: Private managed healthcare organizations in South Africa (SA) use a capitation model of care for patients within their healthcare delivery systems for the optimal management of type 2 diabetes mellitus (T2DM) to reduce healthcare costs. Few studies have categorized healthcare costs at a patient level to determine the actual healthcare costs incurred by private insurers for T2DM in SA. This study estimated the direct medical costs of patients with T2DM registered with a private health insurer over a 5-year period between 2 funding models: a capitated risk-sharing model (CM) versus a traditional fee-for-service (FFS) model. METHODS: This population-based cohort study used retrospective claims data of patients with T2DM from 2012 to 2016 of a private medical scheme in SA. Annual healthcare costs of T2DM were assessed. RESULTS: During the 5-year period, most of the identified patients with T2DM were enrolled in CM-534 (64%) of 828 in 2012, which rose to 789 (81%) of 971 in 2016. The median annual healthcare costs of the treatment and management of the patients with T2DM was significantly higher in CM ($2002 [interquartile range (IQR) 2106] in 2012 to $1095 [IQR 1042] in 2016) than FFS ($582 [IQR 772] to $296 [IQR 507]) (P<.0001). A total of 46 patients with T2DM incurred hospitalization costs of ≥$24 243 for a T2DM or other event; 33 were enrolled on CM. CONCLUSIONS: The patients with T2DM on CM accrue significantly higher annual healthcare costs than patients on FFS. The greatest portion of the overall T2DM healthcare costs was associated with high-cost hospitalization of T2DM complications.

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Diabetes mellitus is a complex and chronic condition that requires lifelong management and interaction with a healthcare system. Failure to control risk factors through preventive care may lead to a host of diabetes-related complications. Underperforming healthcare systems and poor awareness among the general population/healthcare professionals has been suggested as reasons why so many patients remain undiagnosed. Due to the asymptomatic nature of early and even intermediate diabetes mellitus, several years may pass without any diagnosis before complications begin to manifest. Other factors include age, gender, ethnicity, education, marital and unemployment status which may also increase the risk of developing morbidity and mortality associated with diabetes mellitus. This review summarizes the current demographic risk factors and clinical characteristics associated with diabetes mellitus. A literature search was conducted using PubMed, MEDLINE, and Sabinet by using the following search terms: diabetes mellitus, risk factors, characteristics and complications.

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INTRODUCTION: In South Africa there is an easy access to over-the-counter (OTC) medicines and expenditure is high. Certain OTC products are available to the public in general stores, while others may only be available at pharmacies. It is also common for OTC medicines to be prescribed by a doctor for treatment of minor illnesses. Individuals with medical insurance usually have cover for these products, but typically only to a limited extent. AIM: To investigate the utilization patterns in two medical insurance schemes of OTC analgesic products in the Anatomical Therapeutic Chemical (ATC) category N02BE51 which includes medicines containing paracetamol and varying combinations of codeine, caffeine and antihistamines. METHODOLOGY: Data were obtained for two benefit plans, one with generous, high benefits (HI), the other with lower benefits (LO). Data covered utilization of OTC medicines in the N02BE51 group, indicating whether the medicines were purchased at a pharmacy or dispensed by a doctor. Doctors were further categorised as contracted/network or non-network providers. Product costs and volumes were analysed according to access directly by the beneficiary, recommendation by a pharmacist, or prescription from a doctor. RESULTS: Compared to doctors, pharmacists issued more-expensive products. Average costs were higher in the HI plan compared to the LO plan. Pharmacists showed a preference for dispensing larger and more expensive pack sizes. Doctors showed better cost containment: the average cost of products in HI was twice that of LO. Doctors dispensing directly to patients issued smaller pack sizes and lower-priced products. Contracted network doctors did not appear to impact on costs. CONCLUSION: Among the privately-insured individuals studied, the avaiIability, cost and formulation of N02BE51 OTC products appeared to be poorly regulated, whether by the consumer, pharmacist, medical insurance scheme or legislation. Doctors demonstrate better cost containment by prescribing less costly, smaller pack-size alternatives compared to pharmacists.

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PURPOSE: With the realities of resource constraints existing in South Africa's public sector and the evidence of disparities in health care between populations, the study sought to compare the quality of diabetes care and health-related quality of life (HRQoL) in patients with type 2 diabetes mellitus (T2DM) receiving care within two specialized settings: one in the public and the other in the private sector. Particular emphasis was placed on complication rates at the two sites. PATIENTS AND METHODS: Quantitative and qualitative data were collected between June and October 2016 from existing patients' records at each setting. Data included patient demographics, potential barriers to accessing care, medical history, laboratory results, pharmacological treatment and diabetes-related clinical, biochemical and HRQoL outcomes. With outcome measurements being the priority, methodology incorporated the Donabedian model in which "structure" of health care systems, access to care and processes of care are key to determine outcomes. RESULTS: A total of 290 T2DM patients were enrolled. Analysis revealed that private 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<0.00001). Private patients also had more frequent consultations with dietitians (p<0.0001), podiatrists (p<0.0001) and biokineticists (p<0.0001). In the important area of complications, which ultimately determine the course of T2DM, rates of micro- and macrovascular disease as well as HRQoL scores and sub-scores were similar between the sites, which were measured by the EuroQoL-5 dimension (EQ-5D) assessment tool. While results indicated that public sector care may be equivalent in terms of the latter outcomes, a smaller number of patients are treated in the clinic than would be ideal in terms of the public sector burden of T2DM. CONCLUSION: Contrary to expectation, despite differences in patient demographics and resources, the HRQoL and quality of care, particularly in terms of T2DM-related complications, were found to be similar across the two settings.

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AIMS: The management of cardiometabolic goals or "ABCs" (HbA1c, blood pressure (BP), and cholesterol) ultimately determines the morbidity and mortality outcomes in patients with type 2 diabetes mellitus (T2DM). We sought to determine if patients with T2DM attending an urbanized public sector community health centre (CHC) were having their ABCs measured, were treated with appropriate cardioprotective agents and finally, were achieving guideline-based targets. METHODS AND RESULTS: A cross-sectional record review of 519 patients was conducted between May and August 2015. The mean age was 54 years (SD: ±11.5) and 54% (n = 280) were females. Testing of ABCs occurred in 68.8% (n = 357) for HbA1c, 95.4% (n = 495) for BP, and 58.6% (n = 304) for LDL-C. Achievement of ABC targets was as follows: 19.3% (HbA1c < 7%), 22.0% (BP < 140/80 mmHg), and 56.3% (LDL-C < 2.5 mmol/l). CONCLUSION: There were a significant number of patients who were not tested nor received adequate pharmacotherapy or achieved their ABC targets. This places these patients at an increased risk for the development of diabetes-related complications. Although the realities of resource constraints exist in South Africa's public sector settings, a wider implementation of evidence-based guidelines must be instituted in order to ensure better patient outcomes.

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PURPOSE: Our study set out to examine if disparities in control of glycated hemoglobin (HbA1c), blood pressure (BP), and low-density-lipoprotein cholesterol (LDL-C) existed among an urban multi-ethnic cohort of South Africans, living with type 2 diabetes mellitus (T2DM). PATIENTS AND METHODS: This longitudinal, retrospective study consisted of 261 men and women with previously diagnosed T2DM who attended Charlotte Maxeke Johannesburg Academic Hospital, South Africa across two time periods 2009 and 2013. Demographic and clinical data were extracted from consecutive medical records. The primary outcome was to determine achievements in HbA1c, BP, and LDL-C among ethnic groups using evidence-based goals. RESULTS: The mean age of the cohort was 64 (±10.6) years, females represented 55%, and the self-reported diabetes duration was 16 (±10.6) years as at 2013. Black Africans (42.9%, n=112 of 261) were more likely to reach the HbA1c target (<7%) and less likely to have had retinopathy, nephropathy, or cardiovascular disease. Over two-thirds of mixed-ancestry patients attained the BP target (<140/80 mmHg), while 90.2% of Caucasians achieved LDL-C goals (<2.5 mmol/L). Overall, across the ethnic groups studied, we found that HbA1c control deteriorated over time, although BP levels remained the same and LDL-C levels drastically improved. CONCLUSION: There was poor control of HbA1c, BP, and LDL-C across all ethnic groups. Although a minority achieved recommended targets, some ethnic groups appeared to have worse control than others. Timely aggressive actions in particularly high-risk ethnic groups will prevent/delay the complications commonly associated with T2DM.

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Sulphonylureas (SUs) are oral anti-diabetic drugs (OADs) that were introduced more than 60 years ago. Clinicians are familiar with their use and they remain extensively used. However, the SU class is associated with adverse effects of weight gain and hypoglycaemia. In addition, their effects on cardiovascular events remain contentious. Newer classes of anti-diabetic agents have been developed and these agents are weight neutral (di-peptidyl peptidase IV inhibitors), while others reduce weight (glucagon-like peptide analogues and sodium glucose co-transporter inhibitors). Furthermore, the newer agents are less likely to cause hypoglycaemia and have a potentially better cardiovascular safety profile. However, the newer agents are more costly than SUs and their long-term safety is unknown. It is therefore likely that SUs will continue to be used, and more so in resource-limited settings. One may mitigate the adverse effects of weight gain and hypoglycaemia associated with the SU class by using members within this class that are less probable to cause these adverse effects. Furthermore, the specific SU must be used at the lowest effective therapeutic dose. In patients at high risk of SU-induced hypoglycaemic episodes (frail, clinically significant renal impairment), or patients in whom hypoglycaemic episodes may have devastating effects (bus drivers), newer anti-diabetic agents may be a justifiable alternative option.

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Objective: The aim of this study was to identify the treatment gaps that pertain to risk factors in South African patients with type 2 diabetes mellitus; using national treatment guidelines.Design: Cross-sectional study.Setting and subjects: The study consisted of 666 patients with type 2 diabetes mellitus; attending a diabetes clinic at the Charlotte Maxeke Johannesburg Academic Hospital.Outcome measures: Using a public sector database; retrospective data were obtained on the treatment of type 2 diabetes mellitus participants. Patients were randomly selected on the basis of established type 2 diabetes mellitus diagnosis; and if they were receiving oral hypoglycaemic and/or insulin therapy. Age; gender; race; blood pressure; haemoglobin A1c (HbA1c) and fasting lipids were captured and measured. The history of patients' previous coronary artery disease; strokes; nephropathy; neuropathy and retinopathy was recorded.Results: The mean age of the patients was 63 years [standard deviation (SD) 11.9]; 55of whom were females. The HbA1c was 8.8 (SD 2.5). 26.2 of patients attained HbA1c levels of 7. Of the total patients; 45.8 met a 130/80 mmHg blood pressure target; and 53.8 a low-density lipoprotein (LDL) cholesterol of 2.5 mmol/l. Only 7.5 obtained the combined target for HbA1c ; blood pressure and LDL cholesterol.Conclusion: Traditionally; type 2 diabetes mellitus treatment has centred on correcting blood glucose levels. Yet; as many as 80

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Sulphonylureas (SUs) are oral anti-diabetic drugs (OADs) that were introduced more than 60 years ago. Clinicians are familiar with their use and they remain extensively used. However; the SU class is associated with adverse effects of weight gain and hypoglycaemia. In addition; their effects on cardiovascular events remain contentious. Newer classes of anti-diabetic agents have been developed and these agents are weight neutral (di-peptidyl peptidase IV inhibitors); while others reduce weight (glucagon-like peptide analogues and sodium glucose co-transporter inhibitors). Furthermore; the newer agents are less likely to cause hypoglycaemia and have a potentially better cardiovascular safety profile. However; the newer agents are more costly than SUs and their long-term safety is unknown. It is therefore likely that SUs will continue to be used; and more so in resource-limited settings. One may mitigate the adverse effects of weight gain and hypoglycaemia associated with the SU class by using members within this class that are less probable to cause these adverse effects. Furthermore; the specific SU must be used at the lowest effective therapeutic dose. In patients at high risk of SU-induced hypoglycaemic episodes (frail; clinically significant renal impairment); or patients in whom hypoglycaemic episodes may have devastating effects (bus drivers); newer anti-diabetic agents may be a justifiable alternative option

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type 2 diabetes mellitus is currently a global health problem. Although the armamentarium of oral hypoglycemic agents is continuously expanding, sulfonylureas (SUs) are still extensively used for the management of type 2 diabetes mellitus. However, despite decades of use, there is controversy as to the dosing of SUs. Despite many dose-response relationship studies indicating that SUs should be prescribed at lower doses, their dose recommendations remain unchanged. Moreover, studies have demonstrated that high doses of SUs may result in a deterioration of glycemic control and increased frequency of protracted hypoglycemic episodes. In view of the controversial dose-response relationship of SUs, it is suggested that the dose of SUs be titrated against glycemic parameters of blood glucose and glycated hemoglobin.

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We have investigated the effects of mepyramine, an H1 receptor antagonist, and lysine acetylsalicylate, a cyclo-oxygenase inhibitor, on post-ischaemic hyperalgesia in rats. We induced tail ischaemia in conscious rats by applying a tourniquet until the rats exhibited coordinated escape behaviour, when we released the tourniquet. We assessed hyperalgesia, by measuring tail flick latency following tail immersion in water at 49 degrees C, immediately after releasing the tourniquet and then at 30 min intervals for 2 h. After pretreatment with the drug vehicles, tail flick latency decreased significantly following ischaemia. Pretreatment with mepyramine maleate (3 mg/kg), or lysine acetylsalicylate (400 mg/kg), injected subcutaneously, abolished the decrease. We conclude that both histamine release and prostanoid synthesis are involved in the post-ischaemic hyperalgesia.

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