During our time in Kenya, I made a number of observations about diabetes care:
- There is a lot of “treatment inertia” with inadequate implementation of treat-to-target goals and timing of dose escalations/follow-up;
- Lack of utilization of urine glucose testing, since fingerstick blood testing is so expensive (although a reliable in-country source of inexpensive urine glucose testing strips would need to be found);
- General lack of use of NPH in the hospital (even "sliding scale" regular insulin is inconsistent and often only performed twice daily due to nursing challenges), even though it is generally available at approximately the same cost as human regular insulin;
- Lack of initiation of insulin in T2D pts using NPH at bedtime (which could be quite amenable to patient self-titration in capable patients even using second voided morning fasting urine tests)—human premixed 70/30 insulin is often used BID or with breakfast regardless of which meal is largest (usually supper);
- Major challenges in providing adequate diabetes education for all patients (there are in-country resources available including eg, an excellent compilation of teaching materials by Roche, Sanofi and Merck);
- Lack of use of lab confirmation of diagnosis of T2D after fingerstick screening and complete absence of 75g post glucose confirmatory testing;
- High expense of A1C testing and in some places a lot of wastage of patient money to get the A1C when the clinician already knows the A1C will be way high (cost efficient practice needs to be provided particularly in low resource settings);
- Potential benefit of simple checklist for routine annual assessment in all patients with diabetes (could be incorporated as an electronic reminder for hospitals with electronic medical record capability;
- Lack of fingerstick point-of-care blood ketone testing which would be very helpful on the wards (and the few ICUs) where DKA patients are managed;
- Management of T1D is particularly challenging; and,
- The need for availability of remote email or tele-consultations regarding challenging patients with diabetes/endocrinology problems [among others].
Please feel free to contact me at firstname.lastname@example.org or 317-644-9248 if you are interested in discussing this.
In His name,
Jeff Jackson, MD