Kevin Stead explains (cost) effective blood glucose monitoring.

With the rising cost of living in South Africa, it is imperative that we realise value in every rand spent. Especially when it comes to treatment and control of diabetes.

This becomes clear when reviewing the cost of healthy living and medication. It’s therefore important to understand why it is so essential to know and understand blood glucose control and why monitoring is so crucial to reduce cost, as well as prevent complications.

The situation in South Africa

Seven percent of South Africans, between the ages of 21 and 79, have diabetes. This means that 3,85 million South Africans in this age group may have diabetes.

The prevalence of diabetes in South Africa, in 2010, was estimated at 4,5% – a 155% increase in six years. The International Diabetes Federation (IDF) Diabetes Atlas indicates that the uncertainty range is between 3,6 and 14%. Data suggests that 630 000 to 2, 394 million people are undiagnosed in South Africa.

Financial implications

Cost per person per annum was approximately R5 000 in 2010 and R26 743,69 in 2015.

Sixty to 80% of people with diabetes in South Africa die before the age of 60 (loss of manpower).

The World Bank suggests that no more than 5% of a country’s gross domestic profit should be spent on health. In South Africa, 8,9% GDP is spent on health.

What is the solution?

What of glycaemic control? Complications? Education? Dr Shaukat Sadiko, IDF president, said, “Big talk and quoting statistics have little value if we do not do initiatives which improve the lives of all our people with diabetes.”

Testing in pairs

The average cost of a glucose strip is R3,76 (R188 medical aid reimbursement rate). So, testing can be expensive and seemingly worthless, especially in people living with diabetes who don’t understand how to use the information from their meter to control their glucose levels.

For example: A Type 2 diabetes patient will test their glucose level in the mornings only (fasting), only to discover six months later that their HbA1c levels are high (above 6,5%). So, where is the problem?

The blood glucose peaks are not being pinpointed, i.e. the after-meal glucose levels which only peak from 1,5 to 2 hours after meals.

If testing is performed in pairs, before and after meals, an accurate and immediate benefit is that the patient will see the effect that a meal has on their glucose levels. This in turn leads to an action to either reduce food intake, exercise, or increase medication to address the ‘spike’.

By alternating testing times (breakfast, lunch and supper), very soon a clear picture will emerge and a better understanding of the effect that testing with a purpose has on food and medication.

Yes, testing in the morning is important but testing in pairs on alternate days and alternate meals will provide a clear understandable picture of overall control.

A tin of 50 strips will be sufficient in most Type 2 diabetes patients to test 12 times a week. And, if utilised correctly, will result in the healthcare provider to easily access and manage diabetes patients effectively.

Education is the key. Many diabetes patients need to be educated on why monitoring is important as well as an understanding of the effects that food and medication has on blood glucose.

How does this make sense?

It seems nonsensical to cut down cost by testing in pairs. That means more glucose strips are used, right?

Yes, indeed. But, a random test means nothing to you, the patient, as well as your doctor. If random tests are done, they are a complete waste of money and strips.

Once your diabetes is controlled and you are on the correct dosage, etc. then and only then will testing protocol’s as per Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) apply.

However, usually diabetes patients that get one tin of strips per month, on medical aid, never uses them. So, by the year end, they end up with lots of unused, expired strips that are a complete waste of money.

On the other hand, if all 50 strips are used in a month, a comprehensive trend pattern is formed allowing the patient and doctor to intervene much sooner.

In effect, the question really is: Do I only test once a week in the mornings (complete waste of a strip) or do I use what the medical aid is paying for to get as much data per month on my “actual” glucose control?

Regardless, if patients test in pairs, even minimally (three times a week) then at least test with a purpose (before meals and after meals and a fasting).

What is the real issue?

The real issue is: do you, the diabetes patient, know what a Sunday lunch does to your glucose level? Do you know what effect the six beers you drank last night has on your glucose level? Or what the effect of exercising was? What happens to your glucose when you are sick?

Often than not, most don’t know and wonder why their HbA1c levels are so high, or suddenly get an abnormal high and don’t know why?

Another main issue is morbidity and the result of developing the complications. The cost of treatment is exorbitant so as the old adage goes, prevention is better than cure.

So, when we step back and look at the entire picture, isn’t it good sense to monitor effectively and prevent complications, or simply test at random, waste strips, be blissfully ignorant of glucose changes and hope for the best?

What it boils down to

It really boils down to the value you are spending on strips against the value of saving a few strips that would be better utilised. And, at the same time prevent a stroke, heart attack, kidney failure, blindness, amputations, etc.

SEMDSA guidelines

The diagnosis of diabetes is confirmed¹

1. In patients with symptoms of hyperglycaemia (excessive urination, rxcess thirst, blurred vision, weight loss) or metabolic decompensation (diabetic ketoacidosis or hyperosmolar non-ketotic state), when any one single test confirms that the:

•  Random plasma glucose is ≥ 11,1 mmol/L
•  Fasting plasma glucose is ≥ 7,0 mmol/L
•  HbA1c is ≥ 6.5%
• 2-hour post-load glucose is ≥ 11,1 mmol/L.

However, a glucose tolerance test is rarely needed in this category of patient.

1. In an asymptomatic individual, when any one of the following tests, repeated on separate days within a two-week period confirms that the:

• •  Fasting plasma glucose is ≥ 7,0 mmol/L
  • 2 hr-post load glucose (OGTT) is ≥ 11, 1 mmol/L
  • HbA1c is ≥ 6,5%

If the diagnosis of diabetes is not confirmed with the repeated test, institute lifestyle modification and retest in three to six months.

References:

1. SEMDSA guidelines 2018
2. Centre for Diabetes and Endocrinology clinical guidelines 2018
3. IDF IDF Diabetes Atlas. Seventh edition Brussels, IDF 2015, IDF Atlas Sixth edition, Brussels IDF. 2013
4. Statistics South Africa. Midyear population estimates 2015 htpp://www.statssa.gov.za/publications/P0302/P03022015.pdf
5. World Bank. Health expenditure, total (% GDP) 2016 htpp://data.worldbank.org/indicator/SH.XPD.TOTL.ZS 

MEET OUR EXPERT

Kevin Stead is a professional representative specialising in diabetes and diabetes management.

Header image credit by Freepik 

People living with diabetes may suffer from an array of movement disorders that can cause pain and dysfunction. Physiotherapist, Saadia Jantjes, tells us more.

In the last issue, I discussed the importance of getting active and incorporating more movement into your daily life. But what if you’re experiencing joint or bone pain, discomfort or just have difficulty moving?

One of the barriers preventing people living with diabetes from implementing exercise into their daily routine is movement or musculoskeletal disorders that develop due to diabetes.

Diabetic patients may suffer from an array of musculoskeletal disorders that can cause pain and dysfunction. This could result in a negative effect on the management of their diabetes, stress and a decrease the quality of life.

Common examples of such movement disorders

Frozen shoulder

Frozen shoulder is frequently on both sides in diabetic patients. It’s characterised by severe pain, increased tightening, stiffness, and restricts the range of motions of the shoulder. It has an incidence of 10 – 20% in Type 1 diabetes patients and 7 – 32% in Type 2 diabetes patients. Other risk factors include past shoulder trauma, cardiac-, respiratory- and cerebral diseases. 

Carpal tunnel syndrome

This is a neuropathy that occurs frequently in the wrist and hand. Diabetes is the most common metabolic disease that causes carpal tunnel syndrome, found in 14 – 16% of patients. It is also seen more frequently in women than in men.

Symptoms include paresthesia (abnormal sensation) that worsens in the evenings in the thumb, index, and middle fingers of the hands, which wakes the person up from sleep.

Pain in the wrist and hand can cause clumsiness and poor control of hand movements. It can cause a decrease in work production as well as pain in manual workers, office workers and drivers.

Diabetic peripheral neuropathy (DPN)

Peripheral neuropathy is nerve damage which leads to numbness, loss of sensation, pain or impaired sensation in hands, feet and legs.

The dangers of having neuropathy include loss of balance and poor control of extremities which could result in falls and further injury.

The prevalence of numbness and poor sensation means that bruises, cuts and abrasions are usually gone unnoticed and untreated, leading to ulcers which could result in amputation if infected. It is the most common complication of diabetes; about 60 to 70% of people with diabetes will eventually develop peripheral neuropathy.

However, studies have shown that diabetic patients can reduce their risk of nerve damage by controlling their blood glucose levels through correct nutrition and exercise.

Charcot arthropathy

This is a result of diabetic peripheral neuropathy. It is a progressive and degenerative disease of the foot and ankle joints, which causes damage and deformities of the joint if left untreated. Charcot’s joints are typically seen in patients over the age of 50 who have had diabetes for many years and have existing neuropathic complications.

What to do if one of these sound familiar?

Consult your GP and he/she will point you in the right direction. You may need further tests done to get a proper diagnosis and a consult with a specialist, like a neurologist, orthopaedist, or rheumatologist.

It is important to note that I have only highlighted a few and more common disorders. If you are feeling any pain during exercise or at rest, whether it is constant pain or intermittent pain, the best thing would be to consult your GP and get it checked out. Exercise should not be painful.

I’ve been diagnosed with a diabetes associated movement disorder, now what?

This is where your multi-disciplinary team becomes involved. Not only will you need regular check-ups with your GP, nurse and dietitian, but this is where physiotherapy and occupational therapy become an integral part of your management of your condition as well.

It may all seem incredibly daunting and scary. But keeping yourself informed is one of the best tools when managing your diabetes. The management of your condition is critical in preventing movement complications.

When the control of diabetes is poor, higher levels of diabetic complications result. Pharmacotherapy, diet, and a regular physiotherapy programme should be the cornerstone of diabetes management.

It is imperative to have an appropriate exercise programme, overseen by a GP, as an integral part of diabetes management to reduce the frequency and severity of complications.

MEET OUR EXPERT

Saadia Kirsten Jantjes is a physiotherapist with a passion for health and wellness. With a second degree in Sport Science, exercise is one of her favourite rehabilitation tools, to not only rehab injuries but prevent injuries too. Saadia has her own private practice in Morningside, Johannesburg, while working at a Sub-Acute Clinic and furthering her studies in Pilates.

Lisa Swaine gives us legal insight as to why doctors need to have a record of informed consent, and highlights that good clear communication is key.

1 April 2019 was certainly not a day for fools. The Supreme Court of Appeal gave judgment in the case of Beukes v Smith ((211/2018) [2019] ZASCA 48) for a surgeon whose information to his patient was called into question.

The decision highlights the value of keeping proper written records of explanations, discussions and advice leading to the informed consent to avoid protracted legal proceedings for both doctors and patients.

What is informed consent?

The introduction to the ethical guidelines published by the Health Professions Council of South Africa succinctly describes informed consent in this statement: “Successful relationships between healthcare practitioners and patients depend upon mutual trust. To establish that trust, practitioners must respect patients’ autonomy – their right to decide whether or not to undergo any medical intervention, even where a refusal may result in harm to themselves or in their own death. Patients must be given sufficient information in a way that they can understand, to enable them to exercise their right to make informed decisions about their care. This is what is meant by informed consent.”

Medical treatment cannot be provided in the absence of consent. Our courts have held that, to give proper informed consent, a patient must be informed of all material risks associated with the treatment.

What is material? If a reasonable person in the position of the patient, warned of the risk, would attach significance to the risk, it is material. To give proper informed consent, the patient must know, appreciate and understand the nature and extent of the harm or risk.

The claim in the proverbial nutshell

Dr Smith performed a laparoscopic (using multiple small incisions with ports to perform surgery with specialised instruments) hernia repair on Mrs Beukes. She sued him for damages alleging that he had negligently failed to provide her with sufficient information to enable her to give informed consent for the surgery.

Dr Smith’s alleged failure was to inform her that the hernia repair could have been done by way of a laparotomy procedure (older technique that relies on a single large incision, through which a surgeon uses his or her hands to directly perform the procedure).

His failure caused her to give uninformed consent to the laparoscopy during which her colon was perforated, resulting in her suffering complications and damages.

Mrs Beukes lost in the Gauteng Division of the High Court in Pretoria. The appeal was against that judgment.

Consultation, motivation, operation, complication

Against the backdrop of the surgery lay Mrs Beukes’ medical risk. She was a high-risk patient which meant that because of her health, lifestyle and medical history, the risk of her suffering complications related to surgery was high.

Mrs Beukes was referred to Dr Smith who consulted with her on 21 February 2012. He admitted her to the hospital as surgery was inevitable if she did not respond to conservative treatment. The issue would then be which surgery to perform.

After having consulted the referring doctor’s report and radiological reports, Dr Smith’s recommendation was that the laparoscopy would be the best option for Mrs Beukes in the circumstances.

Dr Smith wrote a detailed motivation for approval for the laparoscopy to Mrs Beukes’ medical aid in which the reason for his recommendation for the laparoscopy was stated and the general and specific advantages of the surgery were listed.

The laparoscopy was performed by Dr Smith on 23 February 2012. Mrs Beukes was discharged from hospital on 28 February 2012.

Three days’ post-discharge, Mrs Beukes was re-admitted to hospital with various complications associated with a perforation of her colon which included sepsis. She underwent three further surgical procedures and remained in hospital until 19 April 2012.

Trial and tribulation

The doctor’s version

According to Dr Smith, Mrs Beukes gave him informed consent orally on 22 February 2012, after he had consulted with her and explained the nature of each of the two options available, being the contemplated laparoscopic surgery and the laparotomy, and the material benefits and risks associated with both.

He had informed her that, in his opinion, the laparoscopy was the better option in the circumstances. He also testified that she had signed a written consent shortly before the operation on 23 February 2012, which formed part of the record and was a confirmation of the oral consent given the previous day following his explanation of both procedures.

The patient’s version

Mrs Beukes, on the other hand, denied that Dr Smith had explained both procedures to her. She insisted that, in her first consultation with Dr Smith on 21 February 2012, he told her that he would first consult with the radiologists on her scans and thereafter perform a “quick 15 to 20-minute operation” to repair her hernia with a mesh and in “two or three days” she would be home.

In her version, Dr Smith made the decision to do the laparoscopic hernia repair during the first consultation on 21 February 2012 before having consulted the radiologists. She also denied having signed the written consent. She testified that had she been informed that the hernia could also have been repaired through a laparotomy, she would have discussed her options with her family and would have opted for the less risky of the two procedures. But, she trusted Dr Smith and believed him when he told her that the laparoscopy was a simple procedure that would take 15 to 20 minutes and that she would be discharged from hospital in three days.

Expert opinions

The specialist surgeons who gave expert testimony on behalf of Mrs Beukes and Dr Smith agreed that Mrs Beukes was a high-risk patient, that under the circumstances, the laparoscopy was the better option; the procedure had been performed by Dr Smith without negligence; and that Dr Smith’s post-operative management of Mrs Beukes was acceptable.

Was informed consent obtained?

The only issue was whether informed consent had been obtained.

At the heart of Mrs Beukes’ contentions was the fact that there was no written record of the details of the informed consent discussion.

It was not disputed that no record had been made of the content of Dr Smith’s explanation to Mrs Beukes.

Mrs Beukes’ version was that, in the absence of evidence on the detail of her consultation with Dr Smith, the court had to conclude that Dr Smith had not given Mrs Beukes the necessary information as he alleged and further, even if he had given her some information, it was not sufficient to enable her to make an informed decision

Dr Smith’s evidence was entirely reliant on his memory of what had transpired over the relevant period. However, as found by the trial court, several aspects supported his version, such as his demeanour and diligence which were more consistent with his version that all had been sufficiently explained.

Added to this were the medical records which also supported his version as opposed to that tendered by Mrs Beukes. Mrs Beukes’ version was inconsistent with Dr Smith’s undisputed caring and diligent nature.

The medical records suggested that there had been a more substantive discussion between her and Dr Smith than she was willing to admit. The written representations made by Dr Smith to Mrs Beukes’ medical aid, after his consultation with her the morning before the laparoscopy, were consistent with his version and revealed that the material risks and benefits of the medical procedures occupied his mind. Nothing in the medical records contradicted Dr Smith’s evidence.

Judgment day

Fortunately for Dr Smith, the Appeal Court found no basis upon which to overturn the factual finding by the trial court that Dr Smith’s version was probable and that of Mrs Beukes was not.

The cost of not recording what is said

Unfortunately for Dr Smith, as it would appear from what was stated in the judgment, he was subjected to lengthy cross-examination from which he might have been spared had there been a written record or other record of his explanation, discussion and advice leading to the informed consent.

That is aside from the cost of the litigation to Dr Smith and by cost, I don’t just mean legal costs. Litigation is stressful and takes one out of one’s day-to-day professional practice. It comes with a high personal and economic price tag.

Keeping record not only protects the patient which is primary. It also protects the practitioner and may well avoid the risk of becoming embroiled in costly and lengthy ‘he said – she said’ debates.

MEET OUR EXPERT

Lisa Swaine is a partner at Webber Wentzel. She is a dispute resolution and litigation specialist.