Compliance with local diabetic guidelines at a district hospital in KwaZulu-Natal, South Africa
Compliance with local diabetic guidelines at a district hospital in
KwaZulu-Natal, South Africa
K Rampersad* , S Rangiah and M Kendon
Department of Family Medicine, University of KwaZulu-Natal, Durban, South Africa
*Corresponding author, email: kamalrampersad4@gmail.com
Background: Diabetes mellitus (DM) represents a major health-related problem in South Africa and throughout the world. The
management goals of diabetes are first to maintain normal blood glucose levels and second to prevent the development of
complications. Local guidelines developed by the Society for Endocrine Metabolism and Diabetes South Africa (SEMDSA) have
shown that tight glycaemic control and appropriate monitoring can prevent or delay the development of diabetic
complications. The demographic profile of patients with type 2 DM and the compliance of doctors to the guidelines were
determined.
Methods: Five hundred records of patients with type 2 DM were selected from the medical outpatients’ department (MOPD) by
systematic sampling. Demographic information on age, sex and ethnicity was obtained. The performance and timing of
recommended investigations were recorded and compared with the 2012 SEMDSA guidelines.
Results: The mean age of patients was 61 years. Black and Indian patients formed the majority, comprising 44.4% and 43.0%
respectively. Glycated haemoglobin was measured in 29.2% of patients once and 13.2% of patients twice in the past year.
Lipid studies were done on 40.4% of patients. A serum creatinine (sCr), estimated glomerular filtration rate (eGFR) and serum
potassium were done on 38.2% of patients. Eye examinations were done on 13.60% patients and examination of the foot was
done on 7.8% of patients. Some 15% had a urine dipstick test done at least once in the past year and 10.4% had a urine
albumin/creatinine ratio (ACR) requested. Only 21 patients (4.2%) were compliant with the SEMDSA guidelines. Measurements
of blood pressure and blood glucose were 100% compliant. Anthropometric measurements (height, weight and body mass
index), dietitian referral and foot examinations were the least compliant, being performed 4.2%, 5.0% and 7.8% of the time
respectively.
Conclusion: Black and Indian patients formed the majority of the study population. The screening for chronic complications of
type 2 DM was poor in the majority of patients. Evaluation of selected records demonstrated compliance with the SEMDSA
guidelines in only 4.2% of patients. There is an urgent need to review barriers to the implementation of guidelines in South Africa.
Key words: Diabetes mellitus, adherence, guidelines
Introduction
Diabetes mellitus (DM), like many other non-communicable dis-
eases, represents a major health-related problem throughout
the world.1 The 2015 report released by the International Dia-
betes Federation (IDF) showed that there are currently around
451 million people affected with diabetes worldwide and this
is predicted to increase to over 693 million by 2045.2
Type 2 DM is the most commonly diagnosed form of diabetes and
accounts for more than 90% of people living with diabetes.3 His-
torically DM was thought to be very uncommon in Africa,
however some epidemiologists predict that the economic
impact of diabetes, as well as the consequent death toll, will
surpass the ravages of HIV and AIDS in the near future.4
Currentlymorethan22millionpeoplewithinAfricahavediabetes.3
In South Africa there were 2.3 million cases of diabetes in 2015
with a national prevalence of 7.0%.5 DM is common amongst all
race groups with the highest prevalence amongst the Indian
population (15.8%), followed by the Black (4.8%) and White
(3.5%) populations.3,6
Long-term cardiovascular, renal, neurological and retinal compli-
cations of type 2 DM are major causes of morbidity and mor-
tality.1–6 These complications impact negatively on the patient,
his/her family and the community in which he/she resides and
works.
Diabetes is the fourth leading cause of death in the world.3,6,7 In
2015 approximately 5.0 million people died from diabetes
worldwide. The 2015 IDF estimated that there were 57 319 dia-
betic-related deaths in the South Africa.2 The mean health
expenditure per person was approximately US$ 918.9.5
The primary goals in the management of type 2 DM are first to
maintain normal blood glucose levels throughout the day and
second to prevent the development of complications by a sys-
tematic and standardised screening programme.5,7
DM is a major concern for National Health Systems worldwide
because of its impact on morbidity and mortality. Routine
measurements such as blood glucose, haemoglobin A1c
(HbA1c), lipid determination, blood pressure measurement,
annual eye and albuminuria screening have proved to be effec-
tive in identifying and treating patients at risk.3,5,7
The Society for Endocrine Metabolism and Diabetes of South
Africa has developed guidelines based on a number of local
and international trials, which showed that tight glycaemic
control leads to a reduction in the development of diabetic
South African Family Practice 2019; 61(2):60–64
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complications.5,7 These guidelines are targeted at the resource-
limited South African context and all required tests and examin-
ations are readily available in both the public and private sector.
They were first published in 2009 with the aim of providing gui-
dance on the most appropriate management for people with
diabetes mellitus and its complications at primary health care
level. They are reviewed regularly at 3–4-year intervals and the
information is freely available to healthcare professionals by
means of journal publications such as the Journal of Endocrin-
ology, Metabolism and Diabetes of South Africa, various online
publications and seminar presentations.
Several studies, however, both in developed and developing
countries, have shown poor compliance with local guidelines
by doctors caring for patients with diabetes.1,6,7 A study con-
ducted in Italy in 2003 reviewed 31 104 persons with diabetes
and concluded that only 20% of patients received adequate
screening for complications as per their recommended local
guidelines.1 Uganda, a low-income developing country,
reported only 14% of patients had their lipid profiles done
annually. In addition only 12.4% of patients were screened for
diabetic nephropathy, no patient was assessed for microalbumi-
nuria and similar poor results of screening for retinopathy, per-
ipheral vascular disease and cardiac complications were
identified.8 Two studies published in 2013 conducted in the
North West province and KwaZulu-Natal reported similar poor
compliance with the locally recommended SEMDSA guide-
lines.9,10 Studies conducted at district hospitals providing gener-
alist services, which remain the entry point for the majority of
patients to primary health care, are severely lacking.
A large number of patients with diabetes are seen at Northdale
Hospital (NH) medical outpatients’ department (MOPD) for
review and prescribing of their chronic medication. They are
seen at six-monthly intervals or more often as requested by
the MOPD doctors. There are no statistics available on the demo-
graphic profile of these patients. NH has an on-site laboratory,
dietetics department and an eye clinic. Many patients,
however, are admitted from the MOPD or the emergency depart-
ment with complications arising from type 2 DM such as strokes,
heart attacks and renal failure. Many other patients are referred
to the ophthalmologist with advanced stages of diabetic retino-
pathy. The high occurrence of potentially preventable compli-
cations has prompted this study to assess the compliance of
healthcare providers with local diabetic guidelines. Observa-
tional analysis has shown that recommended screening linked
with a reduction in the HbA1c resulted in several benefits. For
every 1% reduction in the HbA1c, there was a 14% reduction
in myocardial infarction, a 37% reduction in microvascular com-
plications and a 21% reduction in deaths related to DM.5
The objectives of the study were to review the demographic
profile of patients with type 2 DM presenting to an MOPD at a
district hospital and to review compliance of doctors with the
2012 SEMDSA guidelines in terms of performing recommended
examinations and investigations.
Methods
The study was performed in a large district hospital in the
uMgungundlovu health district, KwaZulu-Natal. The hospital
provides medical services to a predominantly low-to-middle
income population with a high prevalence of diabetes and
hypertension. The MOPD sees approximately 2 450 patients
with diabetes per year and receives referrals from 12 clinics. It
is staffed mainly by medical interns and junior medical officers.
A study sample of 500 patients’ charts was reviewed, represent-
ing 20% of the 2 450 patients. This is a descriptive study that
does not test any statistical hypothesis; the issue of power was
not considered. This study included patients who were diag-
nosed with type 2 DM and were attending the MOPD for
more than one year. Patients with type 1 DM or gestational dia-
betes were excluded from the study due to differing monitoring
practices and a lower prevalence in the community.
Systematic random sampling was achieved by randomly assign-
ing a number between 1 and 5 to the charts. Every fifth record
was chosen until 500 charts were selected. These records were
subsequently assessed against the 2012 SEMDSA guidelines.
The following were assessed: demographic data, presence of
hypertension, height, weight, body mass index (BMI), waist cir-
cumference, blood pressure, comprehensive foot examination,
comprehensive eye examination, blood glucose, HbA1c, lipid
profile, sCr, eGFR, potassium, urine dipstick, urine albumin/crea-
tinine ratio (ACR), ECG, referral to dietitian and current therapy.
Results were recorded as either performed or not performed and
the number of times performed if applicable.
The data collected were captured on an Excel® spreadsheet
(Microsoft Corp, Redmond, WA, USA) and subsequently analysed
using the Statistical Package for the Social Sciences (SPSS; IBM
Corp, Armonk, NY, USA). Descriptive statistics such as percen-
tages were used to summarise categorical data.
Permission to conduct the study was obtained from the man-
agement of NH, UKZN Biomedical Research Ethics Committee
(BE551/16) and the KZN Department of Health. Confidentiality
of patients’ information was maintained by excluding their
names and file numbers during the processing of data.
Results
There were 296 females (59.20%) and 204 males (40.80%). The
mean age was 61 years (42–91 years), 222 (44.40%) of the
patients were Black, 215 (43%) were Indian, 34 (6.8%) were
Coloured and 29 (5.8%) were White. A total of 275 (55%) were
also receiving treatment for hypertension and 82 (16.2%)
patients were receiving insulin therapy (ActraphaneTM or Proto-
phaneTM), with the balance being managed with oral anti-dia-
betic agents (Metformin and Glibenclamide or Gliclazide)
(Table 1).
Screening tests for complications as per the guidelines were not
performed consistently (Table 2). Of the 500 patients, only 21
had a weight, height, BMI and waist circumference recorded.
The eye examination was done in only 68 (13.60%) patients. In
Table 1: Demographic profiles and disease characteristics
Parameter Categories N %
Sex Male
Female
204
296
40.8
59.2
Race Black
Indian
White
Coloured
222
215
34
29
44.4
43
6.8
5.8
Treatment Oral therapy only
Insulin therapy
418
82
83.8
16.2
Presence of hypertension Hypertension present
Hypertension not present
275
225
55
45
N: given as a number; %: percentage.
Compliance with local diabetic guidelines at a district hospital in KwaZulu-Natal, South Africa 61
addition, patients receiving insulin were more likely to be
referred for an annual eye examination (50 of the 68 patients)
compared with those on oral therapy only.
Examination of the foot was recorded in 39 (7.8%) patients.
Older patients with a mean age of 58.2 years were more likely
to have this examination performed.
An HbA1c was done on 146 (29.2%) patients once in the year
and only 66 (13.2%) patients had an HbA1c done twice in the
preceding year. Both males and females were equally likely to
have this test requested with a male:female ratio of 1:1.12. A
lipid analysis including total cholesterol, low density lipoprotein,
high density lipoprotein and triglycerides was done on 202
(40.4%) patients. A serum creatinine (SCr), eGFR and serum pot-
assium were done on 191 (38.2%) of patients.
Seventy-six (15.2%) had a urine dipstick test done at least once
in the past year and 52 (10.4%) had a urine ACR requested. An
ECG was done on 64 (13.2%) occasions and only 25 (5%) patients
had been reviewed by the dietitian.
There were no statistical differences in tests performed in
relation to age and sex (Tables 3 and 4).
All patients had their blood pressure and blood glucose checked
at every visit. The observations are routinely performed by
nurses prior to patients consulting with doctors.
Discussion
In this study, females formed the majority of the patients with a
female to male ratio of 1.45:1.
The overall mean age was 61 years. Black and Indian patients
represented the majority of the sample population at 44.4%
and 43% respectively.
This study demonstrated the poor adherence of medical person-
nel to the SEMDSA guidelines and poor screening of the long-
term complications of type 2 DM.
Nurse-driven examinations such as recording of blood pressure
and blood glucose were performed routinely. However, height,
weight, BMI, abdominal circumference and urine dipstick were
done with less frequency. This was surprising as these tests
require little time, equipment or skill. Other similar studies
showed varying results with a South African study reporting a
more than 90% compliance with these bedside tests whilst
another African study showed less than 50% compliance.10,11
There was no identifiable reason for their omission in this
study. It is possible that a lack of understanding of their signifi-
cance in the guidelines may have contributed to their omission.
Laboratory tests including HbA1c (29.2%), Scr, eGFR and potass-
ium (38.2%), and lipids (40.4%) were performed more frequently
but well below recommendations. Studies done in KwaZulu-
Natal (KZN) and North West province showed better results
with 30–90% of investigations being performed.9,10 The pres-
ence of an on-site laboratory and phlebotomist simplifies the
process for doctors to request blood tests. Doctors may not
always be familiar with the guidelines and thus not order rec-
ommended tests timeously.
Examinations requiring more clinical skills, including a compre-
hensive foot examination (7.8%) and eye examination (13.6%),
were done less frequently. These results mirrored the 2012
study in KZN, which showed only 6% of patients received a
foot exam.10 More specialised diabetic centres however, seem
to place greater emphasis on examination of the foot with a
Ugandan study reporting a 75% uptake of this test.8 Time con-
straints due to high patient load and uncertainty of clinical
skills may have contributed to these outcomes.
Systemic hypertension was common in this study sample with
55% of patients being managed for both their hypertension
and type 2 DM at the MOPD. Although this did not fall under
the specific objectives of this study, it is well documented that
hypertension is an important modifiable risk factor for both
microvascular and macrovascular disease.5,7,12 Patients with dia-
betes and hypertension are therefore more likely to develop
target organ damage.5,7,11,12
Table 3: Relationship between sex and tests performed
Parameter Males Females Chi-squared p-value
HbA1c 92 120 1.0646 0.5873
Lipogram 89 114 1.1062 0.2929
u-ACR 27 36 0.0476 0.8272
Eye test 33 36 1,.316 0.2513
u-ACR: urine albumin creatinine ratio.
HbA1c: Glycated haemoglobin.
Table 2: Screening tests for complications
Test performed
Compliance with the 2012
SEMDSA Guidelines
n %
Height 21 4.2
Weight 21 4.2
BMI 21 4.2
Waist circumference 21 4.2
Blood pressure 500 100
Blood glucose 500 100
Eye examination 68 13.6
Foot examination 39 7.8
HbA1c annually
HbA1c biannually
146
66
29.2
13.2
Lipids 202 40.4
sCr and eGFR 191 38.2
Urine dipstick 62 12.4
Urine ACR 52 10.4
ECG 64 13.2
Dietitian 25 5.0
n: given as a number; %: percentage.
Table 4: Relationship between age and tests performed
Parameter
40–59 years
n = 264
60 years
and more
n = 236 Chi-squared p-value
HbA1c 115 97 7.21 0.081
Lipogram 112 91 6.8551 0.0767
u-ACR 36 37 2.1887 0.5342
Eye test 35 34 2.1997 0.5546
n: number of patients.
HbA1c: glycated haemoglobin.
u-ACR: urine albumin creatinine ratio.
62 South African Family Practice 2019; 61(2):60–64
A 2009 study published in the Annals of African Medicine
showed that the major predictor of resource use in type 2 DM
patients in developing countries was the presence of compli-
cations as well as inadequate glycaemic control.11
Diabetic retinopathy is possibly the most common microvascu-
lar complication of diabetes and is responsible for approximately
10 000 new cases of blindness every year in the USA.9,12–14
Studies in Africa have recorded the prevalence of diabetic reti-
nopathy to range from 7% in Kenya to 63% in South
Africa.3,7,10 A 2010 survey conducted in Cape Town showed
that diabetic retinopathy was responsible for 8% of blindness
and 11% of severe visual impairment.15 Loss of vision in patients
with diabetes is disabling as it may impair their ability to self-
monitor blood glucose and administer insulin. In addition, it
puts them at greater risk of falling and leads to loss of indepen-
dence.5,7 Early identification of retinopathy and appropriate
management has been shown to prevent or slow the pro-
gression to visual impairment and blindness.7,15 Only 13.6% of
patients received an annual eye examination. This finding is
unexpected as there is an on-site eye clinic with a senior
medical officer in ophthalmology.
Diabetic nephropathy is the leading cause of renal failure in the
USA.3,5,7 The estimated prevalence in South Africa is 14–16%.4–6
As many as 7% of patients with type 2 DM may already have
microalbuminuria at the time of diagnosis.10 In the United
Kingdom Prospective Diabetes Study (UKPDS), the incidence
of microalbuminuria was 2% per year in patients with type 2
DM and the 10-year prevalence after diagnosis was 25%.16 Dia-
betic patients with microalbuminuria typically progress to pro-
teinuria and overt nephropathy if appropriate interventions
are not initiated early in the course of the disease.5,7,16,17 In a
resource-limited area such as South Africa, diabetic nephropathy
is a major concern as therapeutic options are limited once a
patient reaches the stage of renal failure. A urine dipstick,
urine ACR and Scr converted into an eGFR are the recommended
investigations by SEMDSA to screen for diabetic nephropathy.4,6
Only 15.2% of patients in this study had a urine dipstick done
once in the year, 10.4% had a urine ACR and 40.4% had a Scr
and eGFR done. A 2009 study conducted in a teaching hospital
in Nigeria showed similar poor results with urinalysis and serum
creatinine done only 50% of the time.11
Foot examinations and education on foot care is an essential step
in diabetic care. It is aimed at identifying persons at risk for ulcera-
tion and lower extremity amputation.5,7 A thorough examination
of the peripheries should be done initially and at least annually
thereafter.5,7,17 The skin, bones, nerves and vasculature should
be assessed. Screening for peripheral neuropathy is done with a
monofilament or 128 Hz tuning fork. It should include testing
for sensation to light touch, vibration and temperature. Abnorm-
alities in more than one test of peripheral sensation are > 87%
sensitive in detecting the presence of peripheral neuropathy.5,7,13
Patients who have lost 10-g monofilament sensation are at risk of
developing foot ulceration.5,7 In the NH MOPD, only 39 (7.8%)
patients had documentation of a foot examination being per-
formed. There was, however, no mention of the use of a monofi-
lament or tuning fork and no grading of risk documented. A 2008
study in the Western Cape and a 2011 study in KwaZulu-Natal
showed similar poor outcomes with 11.3% and 6% of records doc-
umenting foot examinations respectively.9,10
Routine measurements such as blood glucose, HbA1c, lipid
determination, blood pressure measurement, annual eye
examination and albuminuria screening have proved to be
effective in identifying and treating patients at risk, thereby pre-
venting or delaying the progression of target organ
damage.3,5,7,13 The early detection of abnormalities is crucial
and assists the healthcare provider to decide if treatment
needs to be modified, further investigations are warranted or
referral to a specialist is indicated. Overall, in this study,
compliance with the guidelines was disappointing, which puts
patients at a higher risk of developing potentially avoidable
complications.
Limitations of the study
This was a retrospective study with small numbers. The data
assessment tool only identified whether investigations were per-
formed; it did not comment on any specific values or appropri-
ateness of actions if results were found to be abnormal.
Conclusions and recommendations
Compliance with the SEMDSA guidelines for screening of
patients with type 2 DM was poor. This could lead to the late
identification of complications, resulting in poor outcomes for
the patient and an increased demand on health services.
Recommendations from this study are as follows:
. A quality improvement process should urgently be put in
place to identify the reason for the discrepancy between
current practice and recommended evidence-based
practice.
. Continuing medical education should be ensured with
emphasis on the SEMDSA guidelines to healthcare
workers managing patients with diabetes.
. A simplified data collection tool should be developed and
attached to the file of each patient being managed for DM.
This should specify the type and frequency of investigation
required to ensure that all processes of care are followed.
. With the high prevalence of type 2 DM in the community
being serviced by NH, a diabetic clinic in consultation
with all stakeholders should be implemented to further
improve care for patients with diabetes.
. Patients should be empowered through the principles of
Diabetes Self-Management Education and Support.
Acknowledgements – The authors thank Ms Fikile Nkwanyana for
statistical support and Dr T Nayager for support throughout the
entire study.
Disclosure statement – No conflict of interest was reported by the
authors.
Authors’ contribution – KR was responsible for the project design,
data collection and presentation of results. SR made major con-
tributions and corrections during the project design and writing
of the manuscript. MK made corrections during the writing of
the manuscript.
ORCID
K Rampersad http://orcid.org/0000-0003-1592-2975
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Received: 14-03-2018 Accepted: 31-07-2018
64 South African Family Practice 2019; 61(2):60–64
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Abstract
Introduction
Methods
Results
Discussion
Limitations of the study
Conclusions and recommendations
Acknowledgements
Disclosure statement
Authors’ contribution
ORCID
References
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/EmbedJobOptions true
/DSCReportingLevel 0
/EmitDSCWarnings false
/EndPage -1
/ImageMemory 524288
/LockDistillerParams true
/MaxSubsetPct 100
/Optimize true
/OPM 1
/ParseDSCComments false
/ParseDSCCommentsForDocInfo true
/PreserveCopyPage true
/PreserveDICMYKValues true
/PreserveEPSInfo false
/PreserveFlatness true
/PreserveHalftoneInfo false
/PreserveOPIComments false
/PreserveOverprintSettings false
/StartPage 1
/SubsetFonts true
/TransferFunctionInfo /Remove
/UCRandBGInfo /Remove
/UsePrologue false
/ColorSettingsFile ()
/AlwaysEmbed [ true
]
/NeverEmbed [ true
]
/AntiAliasColorImages false
/CropColorImages true
/ColorImageMinResolution 150
/ColorImageMinResolutionPolicy /OK
/DownsampleColorImages true
/ColorImageDownsampleType /Bicubic
/ColorImageResolution 300
/ColorImageDepth -1
/ColorImageMinDownsampleDepth 1
/ColorImageDownsampleThreshold 1.50000
/EncodeColorImages true
/ColorImageFilter /DCTEncode
/AutoFilterColorImages false
/ColorImageAutoFilterStrategy /JPEG
/ColorACSImageDict <<
/QFactor 0.90
/HSamples [2 1 1 2] /VSamples [2 1 1 2]
>>
/ColorImageDict <<
/QFactor 0.40
/HSamples [1 1 1 1] /VSamples [1 1 1 1]
>>
/JPEG2000ColorACSImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 15
>>
/JPEG2000ColorImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 15
>>
/AntiAliasGrayImages false
/CropGrayImages true
/GrayImageMinResolution 150
/GrayImageMinResolutionPolicy /OK
/DownsampleGrayImages true
/GrayImageDownsampleType /Bicubic
/GrayImageResolution 300
/GrayImageDepth -1
/GrayImageMinDownsampleDepth 2
/GrayImageDownsampleThreshold 1.50000
/EncodeGrayImages true
/GrayImageFilter /DCTEncode
/AutoFilterGrayImages false
/GrayImageAutoFilterStrategy /JPEG
/GrayACSImageDict <<
/QFactor 0.90
/HSamples [2 1 1 2] /VSamples [2 1 1 2]
>>
/GrayImageDict <<
/QFactor 0.40
/HSamples [1 1 1 1] /VSamples [1 1 1 1]
>>
/JPEG2000GrayACSImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 15
>>
/JPEG2000GrayImageDict <<
/TileWidth 256
/TileHeight 256
/Quality 15
>>
/AntiAliasMonoImages false
/CropMonoImages true
/MonoImageMinResolution 1200
/MonoImageMinResolutionPolicy /OK
/DownsampleMonoImages true
/MonoImageDownsampleType /Average
/MonoImageResolution 300
/MonoImageDepth -1
/MonoImageDownsampleThreshold 1.50000
/EncodeMonoImages true
/MonoImageFilter /CCITTFaxEncode
/MonoImageDict <<
/K -1
>>
/AllowPSXObjects true
/CheckCompliance [
/None
]
/PDFX1aCheck false
/PDFX3Check false
/PDFXCompliantPDFOnly false
/PDFXNoTrimBoxError true
/PDFXTrimBoxToMediaBoxOffset [
0.00000
0.00000
0.00000
0.00000
]
/PDFXSetBleedBoxToMediaBox true
/PDFXBleedBoxToTrimBoxOffset [
0.00000
0.00000
0.00000
0.00000
]
/PDFXOutputIntentProfile (None)
/PDFXOutputConditionIdentifier ()
/PDFXOutputCondition ()
/PDFXRegistryName ()
/PDFXTrapped /False
/Description <<
/ENU ()
>>
>> setdistillerparams
<<
/HWResolution [600 600]
/PageSize [595.245 841.846]
>> setpagedevice