Suboptimal control and failure to intensify therapy for South Africans with type 2 diabetes: an audit of diabetes management at primary health care facilities

The management of people living with type 2 diabetes (T2D) in primary care in a South African district was audited, focusing on glycaemic, cholesterol, and blood pressure (BP) control to identify gaps in care and evidence of clinical inertia. A cross-sectional retrospective review was conducted of medical records belonging to patients with T2D seen at 23 primary health care facilities between February and May 2019. Fieldworkers collected patient demographics, BP, laboratory measurements such as HbA1c (two most recent values), total cholesterol (TC) and LDL cholesterol (LDL-C), and which glucose-lowering drug each patient was on, as well as the dosage. The mean (SD) age of patients was 58 (11.8) years and 64% of them were women. Most patients had hypertension (83%) and were using statins (78%). Most patients (46%) were on second-line therapy and less than a quarter of patients were on insulin (22%). Only 23% (CI: 18.9-27.9%) of patients met the HbA1c target of < 7% with a mean HbA1c of 8.8%. Over half of patients (56%) had achieved the BP target (< 140/90 mmHg) and only 15% (CI: 8.1-23.9%) of the 88 patients with LDL-C values met the LDL target. Healthcare providers failed to intensify oral treatment for most patients who had suboptimal glycaemic control, and most patients who were on maximum oral drugs were not initiated on insulin. In most patients, diabetes control targets were not met, and treatment was not intensified when needed, suggesting clinical inertia.