Optimising insulin use in people living with type 2 diabetes at primary healthcare facilities: The Tshwane Insulin Project
DOI:
https://doi.org/10.7196/SAMJ.2025.v115i6.2551Keywords:
Type 2 diabetes, Primary care, Insulin, Community health worker, telehealth, mobile app, Glycaemic controlAbstract
Background. In South Africa (SA), glucose control for individuals with type 2 diabetes follows a stepwise approach. According to the guidelines, insulin therapy is started after using two oral agents. However, various challenges may delay the initiation of insulin.
Objectives. To implement a nurse-led, telehealth-assisted programme to address these challenges, aiming to transition patients to insulin safely to achieve better glycaemic control.
Methods. From 2021 to 2023, we conducted a single-arm, unblinded before-and-after study in primary care facilities in Tshwane District, Gauteng Province, SA. Participants were on insulin or two oral agents at maximum doses. Study nurses monitored glycated haemoglobin (HbA1c) results, and participants with HbA1c levels of ≥8% (≥10% during the COVID-19 pandemic) were counselled about insulin use. During an initiation visit, participants received demonstrations and education on using insulin and glucose meters. The participants then tested their glucose levels at home according to a fixed schedule. Over 14 weeks, we implemented monthly clinic visits supplemented by home visits facilitated by community healthcare worker teams. During these visits, glucose results were communicated to the clinic physician via the Vula mobile app, allowing timely adjustments to insulin therapy.
Results. Of the 293 participants, 65% (n=192) were women and 35% (n=101) were men. The mean (standard deviation (SD)) age was 53 (10) years, with a baseline mean (SD) HbA1c level of 12.1% (1.7%). Of those initiated, 169 (58%) were on oral agents and 124 (42%) were on insulin. Biphasic mixed human insulin was prescribed to 185 participants (63%) and intermediate human neutral protamine Hagedorn (NPH) insulin to 108 (37%). Immediately after baseline assessment and during the 14-week study period, 72 participants (23%) were lost to follow-up, and seven were hospitalised during the study period. Glucose values decreased over 14 weeks, with approximately one-third of participants having no insulin adjustments, one-third having one adjustment, and one-third having more than one adjustment. The mean (SD) HbA1c level decreased from 12.1% (1.6%) to 8.8% (1.6%) over the 14 weeks in 240 paired samples (p<0.001). Ten percent of these participants achieved HbA1c levels <7%, and 34% had levels <8%.
Conclusion. The nurse-led, telehealth-supported intervention successfully transitioned participants onto twice-daily mixed insulin or night-time intermediate NPH insulin, resulting in a significant decrease in HbA1c from 12.1% to 8.8%. However, clinics will require additional resources to initiate or intensify insulin therapy in primary care settings.
References
1. International Diabetes Federation. IDF Diabetes Atlas. 10th ed. Brussels, Belgium: IDF, 2021. https:// www.diabetesatlas.org (accessed 30 May 2024).
2. Statistics South Africa. Mortality and causes of death in South Africa, 2016: Findings from death notification. Statistical release P0309.3. Pretoria: Stats SA, 2018. https://www.statssa.gov.za/ publications/P03093/P030932016.pdf (accessed 30 May 2024).
3. Khunti K, Millar-Jones D. Clinical inertia to insulin initiation and intensification in the UK: A focused literature review. Prim Care Diabetes 2017;11(1):3-12. https://doi.org/10.1016/j.pcd.2016.09.003
4. Aschner P, Gagliardino JJ, Ilkova H, et al. Persistent poor glycaemic control in individuals with type 2 diabetes in developing countries: 12 years of real-world evidence of the International Diabetes Management Practices Study (IDMPS). Diabetologia 2020;63(4):711-721. https://doi.org/10.1007/ s00125-019-05078-3
5. Webb EM, Rheeder P, van Zyl DG. Diabetes care and complications in primary care in the Tshwane district of South Africa. Prim Care Diabetes 2015;9(2):147-154. https://doi.org/10.1016/j. pcd.2014.05.002
6. Bulbulia S, Variava F, Bayat Z. Are type 2 diabetic patients meeting targets? A Helen Joseph Hospital diabetic clinic audit. J Endocrinol Metab Diabetes South Afr 2019:25(1):12-17. https://doi.org/10.108 0/16089677.2019.1692471
7. Govender RD, Gathiram P, Panajatovic M. Poor control and management of type 2 diabetes mellitus at an underresourced South African hospital: Is it a case of clinical inertia? S Afr Fam Pract 2017;59(5):154-159. https://doi.org/10.1080/20786190.2017.1307909
8. Kok A, Hariram A, Webb D, Amod A. Patterns of diabetes management in South Africa: Baseline and 24-month data from the South African cohort of the DISCover study. J Endocrinol Metab Diabetes South Afr 2021;26(2):60-65. https://doi.org/10.1080/16089677.2021.1897227
9. Khunti K, Davies MJ. Clinical inertia – time to reappraise the terminology? Prim Care Diabetes 2017;11(2):105-106. https://doi.org/10.1016/j.pcd.2017.01.007
10. Penfornis A, San-Galli F, Cimino L, Huet D. Current insulin therapy in patients with type 2 diabetes: Results of the ADHOC survey in France. Diabetes Metab 2011;37(5):440-445. https://doi. org/10.1016/j.diabet.2011.03.001
11. Hanefeld M. Use of insulin in type 2 diabetes: What we learned from recent clinical trials on the benefits of early insulin initiation. Diabetes Metab 2014;40(6):391-399. https://doi.org/10.1016/j. diabet.2014.08.006
12. National Department of Health, South Africa. Standard Treatment Guidelines and Essential Medicines List for South Africa: Primary Healthcare Level. 7th ed. Pretoria: NDoH, 2020. https://knowledgehub. health.gov.za/system/files/elibdownloads/2023-04/Primary%2520Healthcare%2520STGs%2520and% 2520EML%25207th%2520edition%2520-%25202020-v2.0.pdf (accessed 11 June 2024).
13. Mollentze WF. Insulin therapy in South Africa: Barriers, dilemmas and paradoxes. S Afr J Diabetes Vasc Dis 2011;8(1):4.
14. Haque M, Navsa M, Emerson SH, Dennison CR, Levitt NS. Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town. J Endocrinol Metab Diabetes South Afr 2005;10(3):94-99.
15. Ngassa Piotie P, Wood P, Webb EM, Hugo JFM, Rheeder P. Designing an integrated, nurse-driven and home-based digital intervention to improve insulin management in underresourced settings. Ther Adv Endocrinol Metab 2021;12:20420188211054688. https://doi.org/10.1177/20420188211054688
16. ElSayed NA, Aleppo G, Aroda VR, et al. Pharmacologic approaches to glycemic treatment: Standards of care in diabetes – 2023. Diabetes Care 2023;46(Suppl 1):S140-S157. https://doi.org/10.2337/ dc23-S009
17. Wright A, Burden ACF, Paisey RB, Cull CA, Holman RR; U.K. Prospective Diabetes Study Group. Sulfonylurea inadequacy: Efficacy of addition of insulin over 6 years in patients with type 2 diabetes in the U.K. Prospective Diabetes Study (UKPDS 57). Diabetes Care 2002;25(2):330-336. https://doi. org/10.2337/diacare.25.2.330 (erratum in: Diabetes Care 2002;25(7):1268. https://doi.org/10.2337/ diacare.25.7.1268).
18. Ngassa Piotie P, Webb EM, Rheeder P. Suboptimal control and failure to intensify therapy for South Africans with type 2 diabetes: An audit of diabetes management at primary health care facilities. J Endocrinol Metab Diabetes South Afr 2024;29(1):37-42. https://doi.org/10.1080/16089677.2024.231 1497
19. Nichols GA, Koo YH, Shah SN. Delay of insulin addition to oral combination therapy despite inadequate glycemic control: Delay of insulin therapy. J Gen Intern Med 2007;22(4):453-458. https:// doi.org/10.1007/s11606-007-0139-y
20. Ghosal S, Sinha B, Majumder A, et al. Consensus on ‘Basal insulin in the management of type 2 diabetes: Which, when and how?’ J Assoc Physicians India 2017;65(7):51-62.
21. Mohan V, Kalra S, Kesavadev J, et al. Consensus on initiation and intensification of premix insulin in type 2 diabetes management. J Assoc Physicians India 2017;65(4):59-73.
22. Beran D, Lazo-Porras M, Mba CM, Mbanya JC. A global perspective on the issue of access to insulin. Diabetologia 2021;64(5):954-962. https://doi.org/10.1007/s00125-020-05375-2
23. Johns Hopkins Bloomberg School of Public Health. Eli Lilly lowers insulin prices. Baltimore, Md: Johns Hopkins University, 1 March 2023. https://publichealth.jhu.edu/2023/eli-lilly-lowers-insulin- prices (accessed 27 May 2025).
24. Levy NK, Orzeck-Byrnes NA, Aidasani SR, et al. Transition of a text-based insulin titration program from a randomised controlled trial into real-world settings: Implementation study. J Med Internet Res 2018;20(3):e93. https://doi.org/10.2196/jmir.9515
25. Médecins Sans Frontières. Novo Nordisk’s insulin pen shortage impacts thousands in South Africa. 16 May 2024. https://www.msf.org.za/news-and-resources/press-release/novo-nordisks-insulin-pen- shortage-impacts-thousands-south-africa (accessed 11 June 2024).
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Copyright (c) 2025 P Rheeder, G Botha, G M Mohlala, O Eales, D van Zyl, P Ngassa Piotie
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