Understanding the diagnostic delays and pathways for diabetes in eastern Uganda: A qualitative study

Glycated haemoglobin versus fasting plasma glucose for type 2 diabetes point of care screening: a decision model cost-effectiveness analysis

INTRODUCTION

Whereas fasting plasma glucose (FPG) is cheaper, the glycated haemoglobin (HBA1c) test, which does not require fasting, is more convenient for diabetes screening and could be available to patients throughout the day. In this study, we compared the cost effectiveness of the HBA1c test to that of the FPG test when used for point-of-care (POC) screening of type 2 diabetes in a low-resource setting in Uganda.

METHODS

A cost-effectiveness analysis from a societal perspective was conducted for a single screening cycle of 1659 adults aged 35-70 years receiving care at the outpatient department of a general hospital. We constructed a decision analysis model using TreeAge Pro Healthcare v2023, with the cost estimated using an ingredient approach and the effectiveness measured based on the proportion of patients correctly diagnosed with diabetes.

RESULTS

The unit cost was US$ 6.48 for the HBA1c test and US$ 8.39 for the FPG test. However, a marginally greater percentage of patients were correctly diagnosed according to the FPG test (96.3%) than the HBA1c test (96.2%). The cost-effectiveness ratio was $6.74 for the HBA1c test and $8.39 for the FPG test. The incremental cost effectiveness ratio was $989.06 per additional patient correctly diagnosed with diabetes.

CONCLUSION

HBA1c POC testing could be a more cost-effective alternative to the FPG POC test for the screening of diabetes in under-served outpatient populations in Uganda and similar contexts.

Non-Alcoholic Fatty Liver Disease Among Newly Diagnosed Type 2 Diabetes Mellitus in North Bihar and Missed Opportunities for Early Diagnosis

BACKGROUND

There are no studies investigating missed opportunities for earlier diagnosis in newly/recently detected Type 2 Diabetes Mellitus and Non-alcoholic Fatty Liver Disease in the region of Bihar, India.

METHODS

This study is a single-center cross-sectional study undertaken at the Research Centre for Diabetes Hypertension and Obesity, Samastipur, Bihar, India. The study collected data from newly/recently diagnosed persons with T2DM. The study was conducted between December 2022 and May 2023.

RESULTS

A total of 148 people with newly diagnosed T2DM were included (median age 47, 46.6% female), and 109 patients with liver disease on ultrasound evaluation. The majority of the persons detected with diabetes were symptomatic. The commonest group of typical symptoms were excessive hunger, urinary frequency, excessive thirst, and evening fatigue, which were present in 46 individuals with liver disease. The best pathway includes a group of persons who visited specialists and MBBS doctors once they felt their symptoms should be evaluated by them and diagnosed within two months of their symptom onset. Unfavorable pathways causing delays in diagnosis and hindering efficient care involve individuals with diabetes seeking help from village doctors, pharmacists, and Aayush doctors, thereby contributing to missed opportunities.

CONCLUSION

NAFLD is prevalent in new T2DM, especially among those with high fat intake and obesity markers. This study could initiate future research aiming to improve NAFLD management and decrease associated complications in newly diagnosed persons with T2DM.

"These are just finishing our medicines": older persons' perceptions and experiences of access to healthcare in public and private health facilities in Uganda

BACKGROUND

There is limited research on the experiences of access to medicines for non-communicable diseases (NCDs) in health facilities among older persons in Uganda. This paper explores the perspectives of older persons and healthcare providers concerning older persons' access to essential medicines in Uganda.

METHODS

It is based on qualitative data from three districts of Hoima, Kiboga, and Busia in Uganda. Data collection methods included seven (07) focus group discussions (FGDs) and eighteen (18) in-depth interviews with older persons. Nine (9) key informant interviews with healthcare providers were conducted. Deductive and inductive thematic analysis (using Health Access Livelihood Framework) was used to analyze the barriers and facilitators of access to healthcare using QSR International NVivo software.

RESULTS

The key facilitators and barriers to access to healthcare included both health system and individual-level factors. The facilitators of access to essential medicines included family or social support, earning some income or Social Assistance Grants for Empowerment (SAGE) money, and knowing a healthcare provider at a health facility. The health system barriers included the unavailability of specialized personnel, equipment, and essential medicines for non-communicable diseases, frequent stock-outs, financial challenges, long waiting times, high costs for medicines for NCDs, and long distances to health facilities.

CONCLUSION

Access to essential medicines for NCDs is a critical challenge for older persons in Uganda. The Ministry of Health should make essential drugs for NCDS to be readily available and train geriatricians to provide specialized healthcare for older persons to reduce health inequities in old age. Social support systems need to be strengthened to enable older persons to access healthcare.

Many hops, many stops: care-seeking "loops" for diabetes and hypertension in three urban informal settlements in the Mumbai Metropolitan Region

Background

The burden of Non-Communicable Diseases (NCDs) in urban informal settlements across Lower and Middle Income Countries is increasing. In recognition, there has been interest in fine-tuning policies on NCDs to meet the unique needs of people living in these settlements. To inform such policy efforts, we studied the care-seeking journeys of people living in urban informal settlements for two NCDs-diabetes and hypertension. The study was done in the Mumbai Metropolitan Region, India.

Methods

This qualitative study was based on interviews with patients having diabetes and hypertension, supplemented by interactions with the general community, private doctors, and public sector staff. We conducted a total of 47 interviews and 6 Focus Group Discussions. We synthesized data thematically and used the qualitative software NVivo Version 10.3 to aid the process. In this paper, we report on themes that we, as a team, interpreted as striking and policy-relevant features of peoples' journeys.

Results

People recounted having long and convoluted care-seeking journeys for the two NCDs we studied. There were several delays in diagnosis and treatment initiation. Most people's first point of contact for medical care were local physicians with a non-allopathic degree, who were not always able to diagnose the two NCDs. People reported seeking care from a multitude of healthcare providers (public and private), and repeatedly switched providers. Their stories often comprised multiple points of diagnosis, re-diagnosis, treatment initiation, and treatment adjustments. Advice from neighbors, friends, and family played an essential role in shaping the care-seeking process. Trade-offs between saving costs and obtaining relief from symptoms were made constantly.

Conclusion

Our paper attempts to bring the voices of people to the forefront of policies on NCDs. People's convoluted journeys with numerous switches between providers indicate the need for trusted "first-contact" points for NCD care. Integrating care across providers-public and private-in urban informal settlements-can go a long way in streamlining the NCD care-seeking process and making care more affordable for people. Educating the community on NCD prevention, screening, and treatment adherence; and establishing local support mechanisms (such as patient groups) may also help optimize people's care-seeking pathways.

Missed Opportunities in Type 2 Diabetes Mellitus: A Narrative Review

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a significant health problem around the world.

OBJECTIVE

This review aims to define missed opportunities and how they apply to patients with T2DM.

METHOD

This narrative review describes the natural history of T2DM and also describes where missed opportunities may arise.

RESULTS

Missed opportunities may relate to prevention, early detection, diagnosis, and treatment of diabetes. The cornerstone of T2DM prevention is the control of modifiable risk factors and lifestyle changes to potentially prevent diabetes. Early detection of T2DM is important as it is a chronic condition that can progress rapidly if untreated. Missed opportunities related to the diagnosis of T2DM draw attention to the heterogeneous presentation of diabetes. The condition can be incidentally identified in asymptomatic patients, so all healthcare professionals should be aware of the disease. Furthermore, it is not unexpected that patients with atypical symptoms may have a delay in diagnosis. The treatment-related missed opportunities in T2DM are broad and include self-care, education, remission of T2DM, risk factor management, prevention of complications, medication therapy and compliance, as well as individualized care. Considering patient pathways is a useful approach to evaluate missed opportunities in patient care.

CONCLUSION

Missed opportunities are a concept that is not often considered in diabetes care, which calls upon reflection of real-world activities and consideration of whether patient outcomes could have been improved with changes in decision-making. Future studies that aim to improve patient care should consider this concept.

Investigation of possible preventable causes of COVID-19 deaths in the Kampala Metropolitan Area, Uganda, 2020-2021

BACKGROUND

Identifying preventable causes of COVID-19 deaths is key to reducing mortality. We investigated possible preventable causes of COVID-19 deaths over a six-month period in Uganda.

METHODS

A case-patient was a person testing reverse transcription polymerase chain reaction-positive for SARS-CoV-2 who died in Kampala Metropolitan Area hospitals from August 2020 to February 2021. We reviewed records and interviewed health workers and case-patient caretakers.

RESULTS

We investigated 126 (65%) of 195 reported COVID-19 deaths during the investigation period; 89 (71%) were male, and the median age was 61 years. A total of 98 (78%) had underlying medical conditions. Most (118, 94%) had advanced disease at admission to the hospital where they died. A total of 44 (35%) did not receive a COVID-19 test at their first presentation to a health facility despite having consistent symptoms. A total of 95 (75%) needed intensive care unit admission, of whom 45 (47%) received it; 74 (59%) needed mechanical ventilation, of whom 47 (64%) received it.

CONCLUSION

Among hospitalized patients with COVID-19 who died in this investigation, early opportunities for diagnosis were frequently missed, and there was inadequate intensive care unit capacity. Emphasis is needed on COVID-19 as a differential diagnosis, early testing, and care-seeking at specialized facilities before the illness reaches a critical stage. Increased capacity for intensive care is needed.