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ABSTRACT
UNIVERSA MEDICINA
Diabetes mellitus patients in Indonesia: management in
a tertiary hospital compared to primary health care
Hikmat Permana1, Raspati Cundarani Koesoemadinata2,3*, Nanny Natalia Mulyani
Soetedjo1,2, Nury Fitria Dewi2, Novi Jayanti2, Sofia Imaculata2, Rovina Ruslami2,4,
Bachti Alisjahbana1,2, and Susan Margaret McAllister5
BACKGROUND
The increasing prevalence of diabetes mellitus (DM) requires that patients
have greater access to care, which is yet lacking in many low- and middle-
income countries and the quality of which varies between health care
facilities. We compare the characteristics, complications, and risk profile of
diabetes in patients receiving care in primary and tertiary level health facilities
in Bandung, Indonesia.
METHODS
Adult DM patients were recruited from 25 community health centres (CHCs)
and the outpatient clinic at one referral hospital. Key data collected and
compared to national guidelines were DM history, treatment, complications,
blood pressure, height, weight, and laboratory examinations on glycated
haemoglobin (HbA1c), lipid profile, and creatinine. Data analyses were
conducted using Chi-square or Fisher's exact test for categorical variables
and Student's t-test or Mann-Whitney test for numerical variables.
RESULTS
Of the 809 DM patients (median age 59 years, 63% female, 98% type 2 DM),
318 (39%) were from CHCs and 491 (61%) from the hospital. Overall median
HbA1c was 8.3%, with no difference between CHC and hospital patients.
Only 32% of patients with HbA1c 10% were on insulin (CHCs 5.9%,
hospital 42.9%), and only 18% of those on insulin had a good glycaemic
control (<7%). Hypertension was common (CHCs 62%, hospital 51%,
p<0.001), and only 44% of CHC and 34% of hospital patients received
antihypertensive therapy. Among those with macrovascular complications,
only 32% (CHCs) and 26% (hospital) were receiving aspirin. The numbers
reaching the treatment targets were low for those on antihypertensives
and lipid-lowering medications (80/251 and 11/105, respectively).
CONCLUSION
Glycaemic control and management of complications of DM patients at
both health care levels need considerable improvement.
ORIGINAL ARTICLE
pISSN: 1907-3062 / eISSN: 2407-2230
DOI: http://dx.doi.org/10.18051/UnivMed.2022.v41.157-168
Copyright@Author(s) - https://univmed.org/ejurnal/index.php/medicina/article/view/1313
Cite this article as: Permana H, Koesoemadinata RC, Soetedjo NNM, Dewi NF, Jayanti N,
Imaculata S, Ruslami R, Alisjahbana B, McAllister SM. Diabetes mellitus patients in Indone-
sia: management in a tertiary hospital compared to primary health care. Univ Med 2022;41:
157-68. doi: 10.18051/UnivMed.2021.v40.157-168.
1Department of Internal Medicine,
Faculty of Medicine, Universitas
Padjadjaran/Dr Hasan Sadikin General
Hospital, Bandung, Indonesia
2Research Center for Care and Control
of Infectious Disease, Universitas
Padjadjaran, Bandung, Indonesia
3Department of Internal Medicine,
Radboud Institute for Health Sciences,
Radboud University Medical Center,
Nijmegen, The Netherlands
4Department of Biomedical Sciences,
Faculty of Medicine, Universitas
Padjadjaran, Bandung, Indonesia
5Centre for International Health,
Department of Preventive and Social
Medicine, University of Otago
Medical School, Dunedin, New
Zealand
Correspondence:
*Raspati Cundarani Koesoemadinata
Research Center for Care and Control
of Infectious Disease
Universitas Padjadjaran, Bandung,
Indonesia 40161
Phone/Fax: 022-2044128
Email: r.c.koesoemadinata@unpad.ac.id
ORCID ID: 0000-0002-3817-4589
Date of first submission, April 25, 2022
Date of final revised submission, July
26, 2022
Date of acceptance, August 1, 2022
This open access article is distributed
under a Creative Commons Attribution-
Non Commercial-Share Alike 4.0
International License
May-August 2022 Vol.41 No.2
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Permana, Koesoemadinata, Mulyani , et al Diabetes mellitus management, Indonesia
INTRODUCTION
Diabetes mellitus (DM) is one of the most
extensive global health problems of the 21st
century. In 2019, there were 463 million adults
estimated to be living with DM. This number is
predicted to increase to 700 million by 2045.(1)
An estimated 79% of these people are thought
to be living in low- or middle-income countries,
the majority of whom have type 2 diabetes.(2)
Patients with DM o ften present with
cardiovascular and other complications that
require more careful and often specialist care.(3)
Diabetes mellitus and its complications often
constitute a significant financial burden to patients
and their families.(4) The care of DM patients in
low-resource countries is challenging as health
care systems are less equipped to manage people
with chronic conditions.
With an estimated 10.7 million people with
DM, Indonesia is ranked 7th in the world.(1) The
provision of quality care for DM patients, from
early diagnosis to treatment, and prevention of
complications, is hampered by a fragile and poorly
resourced health system. Currently, only 113
endocrinologists provide specialist care for DM
patients, mainly concentrated at secondary and
tertiary care levels in the main urban centres.(5)
At the primary level, there is one community
health centre (CHC) for every 27,000 people.(6)
However, the number of general physicians is
3.8 per 10,000 population, far below the world
average of 17.4,(7) and there is a significant
geographical variation with poorer access and a
limited number of general practitioners and nurses
in remote areas. DM patients are primarily
managed in CHCs, where they can be diagnosed
through random or fasting blood glucose, treated
with oral DM medications, and receive regular
monitoring. In 2014, the Indonesian government
started an insurance system to enable universal
health coverage to strengthen primary care
capacity, particularly in chronic diseases –
including DM. (3 ) Since then, it has been
recommended that patients with DM who have
no uncontrollable hype rglyc aemia or
complications should be referred to a secondary
or tertiary hospital. While the Indonesian Society
of Endocrinology has established guidelines for
the management of DM patients,(8) the definitions
and processes for referral are not always clear
or easy to understand. Further studies urgently
need to be carried out in Indonesia because
current DM therapy is focused almost solely on
the clinical aspects. Furthermore, the present
study can be used as a scientific base for the
government of Indonesia in organizing DM
programs, especially in supporting the government
program to strengthen the primary service in
Indonesia.
Our study aims to describe the severity and
complications of DM, the risk factors for
cardiovascular disease, and the medication
management of DM patients, and to investigate
any difference in these characteristics between
patients cared for at the tertiary level hospital
compared to primary health care level.
METHODS
Research design
This cross-sectional study was part of the
TANDEM research project on tuberculosis and
diabetes (www.tandem-fp7.eu) (9) and was
conducted at Dr Hasan Sadikin General Hospital
and Community Health Centres (CHCs) situated
throughout the city between December 2013 and
February 2015.
Study participants
A total of 809 DM patients were eligible and
consented to participate in this study, consisting
of 491 subjects from the hospital and 318 subjects
from the CHCs). Patients eligible to participate
were aged 18 years and over with known DM
(either under care for DM or on DM medication).
Patients who had gestational or steroid-induced
diabetes were excluded. Recruitment was
conducted among patients from the outpatient
endocrine clinic of Dr Hasan Sadikin General
Hospital – a tertiary level public referral hospital
for the West Java region of Indonesia, located in
159
Bandung City, or from 25 CHCs situated
throughout the city.
Data collection
The research physicians interviewed each
patient asking about their socio-demographic
characteristics (age, gender, and education),
behavioural characteristics such as smoking
status and alcohol consumption, and diabetic
characteristics such as DM history, complications,
medication, and management. The research
nurses followed a standard operating procedure
measuring height, weight (using digital scales),
and waist circumference to calculate body mass
index (BMI) and central obesity. Patients’ weight
and height were classified based on the Asia
Pacific BMI criteria,(10) namely underweight
(<18.5 kg/m2); normal (18.5-22.9 kg/m2);
overweight (23.0-24.9 kg/m2); obese I (25.0-29.9
kg/m2); obese II (30 kg/m2). Central obesity was
categorized as a waist circumference (WC) of
80 cm for females and 90 cm for males.
Laboratory analysis
The research nurses followed a standard
operating procedure for taking patients’ blood
pressure using a digital device. Blood was taken
for laboratory glycated haemoglobin (HbA1c)
examinations and urine for albumin creatinine
ratio (ACR) examinations. Lipid profile and
creatinine concentrations, tested in Dr Hasan
Sadikin General Hospital laboratory, as the most
recent test undertaken within the previous month,
were obtained from electronic medical records
for a subset of patients under regular care in the
endocrine clinic.
Laboratory HbA1c was categorized into
three groups: <7.0%; 7.0-9.9%; and 10% for
analysis and also dichotomized into two groups:
<10% and 10%. Albumin creatinine ratio
categories were: n ormal (<30 mg/g) ;
micr oalbuminuria ( 30-300 mg/g) , and
macroalbuminuria (>300 mg/g).(8,11) Low-density
lipoprotein (LDL) was categorized as uncontrolled
if the result was 100 mg/dL.(8,11) Estimated
glomerular filtration rate (eGFR) was calculated
according to the CKD-EPI creatinine equation
2009 (12) which was then categorized according
to the US National Kidney Foundation guidelines
for chronic kidney disease (CKD): stage 1 (eGFR
90), stage 2 (eGFR 60-89), stage 3 (eGFR 30-
59), stage 4 (eGFR 15-29), stage 5 (eGFR
<15).(13)
Key measures
Key mea sures sought are r elate d to
guidelines set by the Indonesian Society of
Endocrinology as follows: 1) patients with HbA1c
10% should have insulin added to their
medications; 2) patients with systolic blood
pressure 140 mmHg or diastolic blood pressure
90 mmHg should be managed with anti-
hypertensive medication; 3) patients with
macrovascular complications should be managed
with aspirin; and 4) patients with LDL 100 mg/
dL should be managed with statin therapy.(8)
Blood pressure was categorized according
to the Indonesian guidelines (Box 1) and also the
JNC VII(14) i.e. normal (systolic and diastolic
<120/80 mmHg); pre-hypertension (systolic 120-
139 or diastolic 80 -89 mmHg) ; stage I
hypertension (systolic 140-159 or diastolic 90-99
mmHg); stage II hypertension (systolic 160 or
diastolic 100 mmHg).
Complications
Complications were self-reported by patients
and cross-checked for patients who had a medical
record in the hospital. Complications were then
classified according to the Charlson Morbidity
Index (CMI).(15) Macrovascular complications
included a history of heart disease: heart attack,
angina pectoris, coronary artery bypass grafting
(CABG), percutaneous transluminal coronary
intervention (PTCI), history of cardiovascular
disease, or history of other vascular diseases.
Microvascular complications included a history
of renal disease or eye problems (blindness,
decreased visual acuity, cataract operation or laser
treatment, glaucoma).
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Permana, Koesoemadinata, Mulyani , et al Diabetes mellitus management, Indonesia
A B
Data management
Demographic and clinical data were entered
onto a case report form and then into a secure,
centr ally mana ged e lectronic database
(REDCap).(16) Data such as laboratory results,
diabetes history, smoking status, and complications
were entered directly into REDCap. Data quality
was checked monthl y for acc uracy and
completeness.
Statistical analysis
Descriptive data are presented as mean and
standard deviation for normally distributed data,
median and inter-quartile range (IQR) for
abnormally distributed data, and proportions for
categorical data. Chi-square or Fisher’s exact
tests of association were used to compare groups
where appropriate, and Student’s t-test was used
to compare mean values. Statistical analyses were
performed using Stata v13 (StataCorp, College
Station, TX, USA).
Ethical considerations
All patients provided written informed
consent prior to inclusion. Ethical approval was
received from the Observational/Interventions
Research Ethics Committee, London School of
Hygiene and Tropical Medicine on 18 December
2013 (LSHT M ethics ref : 6449, LSHT M
amendment no: A473) and from the Health
Research Ethics Committee, Faculty of Medicine,
Universitas Padjadjaran, Bandung on 5 February
2014 (No: 05/UN6.C2.1.2/KEPK/PN/2014).
Table 1. Patient characteristics according by recruitment site
Abbreviations: CHC=community health center; DM=diabetes mellitus; ND=no data; SD=standard deviation
ï DM type was only recorded from medical records for 491 patients recruited in the hospital
*Chi-square test; # Independent-t-test
Characteristics
Total
n=809
n (%)
Recruitment site
p-value* CHC
n=318
n (%)
Hospital
n=491
n (%)
Sex, Female 511 (63.2) 231(72.6) 280 (57.0) <0.001
Mean age (SD) – years# 59 (10) 60 (9) 58 (11) 0.006
Age group (years)
<40 33 (4.1) 8 (2.5) 25 (5.1) 0.008
40-49 100 (12.4) 32 (10.0) 68 (13.9)
50-59 285 (35.2) 101 (31.8) 184 (37.5)
60-69 276 (34.1) 129 (40.6) 147 (29.9)
≥70 115 (14.2) 48 (15.1) 67 (13.6)
Education
No formal education/ primary 249 (30.8) 105 (33.0) 144 (29.3) 0.64
Junior high school 153 (18.9) 58 (18.2) 95 (19.3)
Senior high school 229 (28.3) 84 (26.4) 145 (29.5)
Higher education 178 (22.0) 71 (22.3) 107 (21.8)
Smoking status
Current 117 (14.5) 43 (13.5) 74 (15.1) 0.003
Past 235 (29.0) 73 (23.0) 162 (33.0)
Never 457 (56.5) 202 (63.5) 255 (51.9)
Alcohol consumption (current/past) 17 (2.1) 3 (0.9) 14 (2.8) 0.114
Duration of diabetes (years)
<1 144 (17.8) 58 (18.2) 86 (17.5) 0.191
1-5 311 (38.4) 134 (42.1) 177 (36.0)
6-15 286 (35.4) 105 (33.0) 181 (36.9)
>15 68 (8.4) 21 (6.6) 47 (9.6)
DM type ϯ
Type 1 ND 12 (2.4)
Type 2 ND 479 (97.6)
161
RESULTS
Description of study participants
The mean age was 59 ± 10 years, and 63.2%
were female. The majority of patients had type 2
DM (97.6%) and had DM for more than one year
(82.2%). A total of 491 (61%) patients were
recruited in the hospital and 318 (39%) from
CHC. Patients recruited in the hospital were
slightly younger (58 vs. 60 years (p=0.006), a
smaller proportion were females (57.0% vs.
72.6%, p<0.001), and had never smoked (51.9%
vs. 63.5%, p=0.003) (Table 1).
DM severity and complications
The overall median HbA1c was 8.3% (IQR
6 .8 -1 0. 3) , a n d t h e r e w a s n o si gni f i c a nt
difference according to the recruitment site. A
history of any macrovascular complications was
r ep o r te d b y 20 .3% of p at i ent s , a nd t hi s
proportion was higher in patients recruited in
the hospital than in CHCs (23.2% vs 15.7%,
p=0.010). The most common macrovascular
compl ica tion re ported wa s hear t disease
(34.1%). Fifteen (1.9%) patients had undergone
foot amputation (Table 2).
Table 2. Diabetes severity and complications according by recruitment site
Abbreviations: CHC=community health center; ACR=Albumin to creatinine ratio; CABG=Coronary artery bypass
grafting; eGFR=Estimated glomerular filtration rate; IQR=interquartile range; ND=no data; PTCI=Percutaneous
transluminal coronary intervention
a eGFR mL/min/1.73 m2
*Chi-square-test; ¶ Mann-Whitney test
Univ Med Vol. 41 No. 2
Characteristics
Total
N=809
n (%)
Recruitment site
p-value*
CHC
N=318
n (%)
Hospital
N=491
n (%)
Median HbA1c (IQR) - %¶ 8.3 (6.8-10.3) 8.4 (6.9-10.3) 8.2 (6.7-10.2) 0.663
History of macrovascular complications
Any macrovascular complications 164 (20.3) 50 (15.7) 114 (23.2) 0.010
Heart disease:
Myocardial infarction 110 (13.6) 27 (8.5) 83 (16.9) 0.001
CABG or PTCI 35 (4.3) 4 (1.3) 31 (6.3) 0.001
Angina pectoris or heart failure 131 (16.2) 33 (10.4) 98 (20.0) 0.001
Stroke 80 (9.9) 27 (8.5) 53 (10.8) 0.284
Foot amputation 15 (1.9) 6 (1.9) 9 (1.8) 0.956
History of microvascular complications
Any microvascular complications 542 (67.0) 218 (68.6) 324 (66.0) 0.448
Renal failure 28 (3.5) 4 (1.3) 24 (4.9) 0.022
Eye problems:
Blindness 34 (4.2) 5 (1.6) 29 (6.0) 0.003
Decreased visual acuity 232 (28.7) 113 (35.6) 119 (24.2) 0.001
Cataract operation/laser treatment 130 (16.1) 45 (14.2) 85 (17.3) 0.349
Glaucoma 7 (0.9) 2 (0.6) 5 (1.0) 0.439
Chronic kidney disease classification
(n=301)
Stage 1 (eGFRa ≥90) ND 217 (44.2)
Stage 2 (eGFRa 60-89) ND 147 (29.9)
Stage 3 (eGFRa 30-59) ND 91 (18.6)
Stage 4 (eGFRa 15-29) ND 30 (6.0)
Stage 5 (eGFRa <15) ND 6 (1.3)
Albuminuria
Normal (ACR <30 ug/mg) 402 (49.7) 160 (50.3) 242 (49.3) 0.746
Micro-albuminuria (ACR 30-300 ug/mg) 241 (29.8) 97 (30.5) 144 (29.3)
Macro-albuminuria (ACR >300 ug/mg) 166 (20.5) 61 (19.2) 105 (21.4)
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Permana, Koesoemadinata, Mulyani , et al Diabetes mellitus management, Indonesia
Microvascular complications were reported
by 67% of patients, with similar proportions in
patients in the hospital and CHCs (66.0% vs
68.6%, p=0.448). T he most common
microvascular complication reported was
decreased visual acuity (28.7%). Even though
only 3.5% of patients reported renal failure,
29.8% patients had microalbuminuria, and 20.5%
had macroalbuminuria. There was no significant
dif ference between r ecruitment sites for
albuminuria (p=0.746). The mean eGFR was
78.24 ± 30.05 for the 491 patients recruited in
the hospital. Almost half of the patients had a
normal eGFR indicating preserved kidney
function (stage 1 CKD classification). Patients
indicated for dialysis or kidney replacement
Table 3. Cardiovascular risk profile and medication management of
patients according by recruitment site
Abbreviations: CHC=community health centre; BMI=body mass index; DM=diabetes mellitus; WC=waist
circumference; HDL=high density lipoprotein; LDL=low density lipoprotein; ND=no data
Data were complete (n=809) except for LDL /HDL, only measured in 272 patients recruited in the hospital.
a Blood pressure classification according to JNC VII:
Normal = systolic and diastolic <120/80 mmHg;
Pre-hypertension = systolic or diastolic 120/80-139/89 mmHg;
Stage I hypertension = systolic or diastolic 140/90-159/99 mmHg;
Stage II hypertension = systolic or diastolic e”160/100 mmHg
b Twenty-three patients with no medication (35.4%) had been diagnosed within the last 12 months.
c Using sulfonylurea, thiazolidinediones, acarbose, or DPP-4 inhibitors
d Using metformin, sulfonylurea, thiazolidinediones, acarbose, and/or DPP-4 inhibitor besides insulin
e Using sulfonylurea, thiazolidinediones, acarbose, and/or DPP-4 inhibitor beside using metformin
*Chi-square test
Characteristics
Total
n=809
n (%)
Recruitment site
p-value*
CHC
n=318
n (%)
Hospital
n=491
n (%)
Body Mass Index (BMI, kg/m2)
Under weight (<18.5) 29 (3.6) 7 (2.2) 22 (4.5) 0.145
Normal (18.5-22.9) 205 (25.3) 75 (23.6) 130 (26.5)
Overweight (23.0-24.9) 150 (18.5) 68 (21.4) 82 (16.7)
Obese I (25.0-29.9) 312 (38.6) 128 (40.2) 184 (37.5)
Obese II (≥30) 113 (14.0) 40 (12.6) 73 (14.9)
Central Obesity
Females WC ≥80 cm - yes 352 (68.9) 156 (67.5) 196 (70.0) 0.549
Males WC ≥90 cm - yes 110 (36.9) 30 (34.5) 80 (37.9) 0.577
Blood pressure classificationa
Normal 123 (15.2) 29 (9.1) 94 (19.1) <0.001
Pre-hypertension 237 (29.3) 92 (28.9) 145 (29.5)
Stage I hypertension 242 (29.9) 94 (29.6) 148 (30.1)
Stage II hypertension 207 (25.6) 103 (32.4) 104 (21.2)
Hyperlipidemia (mg/dL)
LDL ≥100 ND 222 (81.9)
HDL ≤40 (male); ≤50 (female) ND 124 (45.6)
Diabetes medication
No medicationb 65 (8.0) 28 (8.8) 37 (7.5) <0.001
Insulin alone 172 (21.3) 10 (3.1) 162 (33.0)
Insulin & any oral DM drugsd 58 (7.2) 9 (2.8) 49 (10.0)
Metformin alone 166 (20.5) 96 (30.2) 70 (14.3)
Metformin & other oral DM drugse 233 (28.8) 111 (34.9) 122 (24.9)
Other oral DM drugs alonec 115 (14.2) 64 (20.1) 51 (10.4)
Anti-hypertensive drugs 251 (31.0) 114 (35.9) 137 (27.9) 0.017
Lipid-lowering drugs (statins) 194 (24.0) 55 (17.3) 139 (28.3) <0.001
Anti-platelet drugs (aspirin) 67 (8.3) 25 (7.9) 42 (8.6) 0.727
163
therapy (stages 4 and 5 CKD classification)
accounted for less than 10% (Table 2).
Cardiovascular risk profile and medication
management
Overall, more than half of the DM patients
were in the BMI obese I and II categories (38.6%
and 14.0%, respectively) and were centrally obese
(57.1%), and this was similar in people recruited
in both sites. In add ition, stage I and II
hypertension were similarly reported in more than
half of the patients (55.5%), with more CHC
patients having severe stage II hypertension
(p<0.001) (Table 3). Of all DM patients in this
study, half (56%) were on monotherapy for DM
control (insulin 21.3%; metformin 20.5%, other
oral DM medications 14.2%). Almost a third
(28.8%) were on combined therapy of metformin
with other oral DM medications, and 7.2% were
on insulin combination therapy. The proportion of
hospital patients on insulin was 43.0%, while most
CHC patients were on oral DM medication
(85.2%) (Table 3).
The Indonesian Treatment Guidelines
recommend that patients with HbA1c 10% have
insulin added to their medications, but in our study,
only 32.4% (n=77/238) of such patients were on
insulin. Of the patients who were considered
hypertensive according to guidelines, only 38.1%
(n=171/449) were receiving antihypertensive
therapy, and this proportion was higher in CHC
patients (43.6%) compared to hospital patients
(33.7%) (p=0.032). One hundred and sixty-four
(20.3%) patients reported macrovascular
complications, of whom only 28.1% (n=46/164)
were receiving aspirin. This proportion was higher
in CHC patients (32.0%) compared to hospital
patients (26.3%) but not statistically significant
(p=0.456). Of the patients with LDL 100 mg/
dL, 42.3% (n=94/222) were on statin (Figure 1).
Similarly, there were very small proportions
of patients on treatment who were achieving the
Figure 1. Treatment indication and actual treatment with insulin, antihypertensive, antiplatelet, and lipid-
lowering medication
The proportion of diabetes patients with an indication for insulin, antihypertensive, antiplatelet, and lipid-
lowering medication according to the Indonesian diabetes guideline. The grey bar represents those patients
with a treatment indication actually receiving insulin (32.4%), antihypertensive drugs (38.1%), aspirin (28.0%)
and statins (42.3%). Data were available for 809 patients, except for LDL (n=272)
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Permana, Koesoemadinata, Mulyani , et al Diabetes mellitus management, Indonesia
expected treatment targets. Of the 230 patients
on insulin, only 41 (17.8%) had an HbA1c of <7%.
Of the 251 patients on antihypertensive
medication, 80 (31.9%) reached the treatment
target of systolic and diastolic blood pressure of
<140 mmHg and <90 mmHg, respectively. Of
the 105 patients who were on statins and for
whom we had LDL information on, only 11
(10.5%) had an LDL <100 mg/dL (Figure 2).
DISCUSSION
In this study of patients under care for DM
in an urban setting in Indonesia, a large proportion
had uncontrolled blood glucose, macrovascular
and microvascular complications, risk factors for
cardiovascular disease, and unmet medication
needs. While blood glucose levels, microvascular
complications, and albuminuria in patients
recruited from the hospital and CHC were similar,
this was not so for macrovascular complications,
hypertension, and obesity which were more
common in patients recruited from the hospital.
Medication management was also different in the
two recruitment sites, with fewer hospital patients
on antihypertensive medication and more on lipid-
lowering statins than patients from CHC.
The median HbA1c in our study was 8.3%,
with almost three-quarters of patients not reaching
the target set in the Indonesian Type 2 DM
Management Guidelines (8) of having an HbA1c
less than 7%. A similarly high mean HbA1c was
reported by Soewondo et al.(17) (mean HbA1c
8.1%) and Cholil et al.(18) (mean HbA1c 8.3%)
in their extensive studies of patients with diabetes
in Indonesia. There was no difference in median
HbA1c in hospital and CHC patients, despite
routine and regular HbA1c monitoring in the
hospital. However, in-depth reasons for this could
not be explored. Still, our results which showed
such a small number being on insulin as
recommended and then those on insulin not
achieving the treatment target, would indicate an
overall lack of blood glucose monitoring, referral,
and prescribing of appropriate medications from
the health system perspective. From the patients’
Figure 2. Patients receiving insulin, antihypertensives, and lipid-lowering medication and those who have
reached the treatment target
The proportion of diabetes patients receiving insulin, antihypertensives, and lipid-lowering medication. The
grey bar represents those patients who have reached the treatment target of HbA1c <7% (17.8%), systolic
blood pressure <140 mmHg and diastolic blood pressure <90 mmHg (31.9%), and LDL <100 mg/dL (10.5%).
Data were available for 809 patients, except for LDL (n=272)
165
perspective, further research is required to
understand and estimate their knowledge about
DM, medication adherence, and other barriers to
their DM care.
Similar poor glycaemic and metabolic
control among type 2 DM patients has also been
reported in South-East Asian countries.(19–21)
Misra et al.(22) categorized clinical management
challenges of type 2 DM as patient-related
challenges, physician-related challenges, and
health care, infrastructure, and drug-related
factors. Patient-related challenges included poor
awareness, unhealthy choice of food, and low
socioeconomic status. Physic ian-related
challenges were inadequate skills in chronic
disease management, poor communication with
patients, too few specialized diabetes nurses, and
the non-suitability of guidelines from high-income
countries. For many years, public health services
in many South Asian countries have primarily
been designed to focus on infectious diseases. It
is only recently that non-communicable conditions
have been consider ed and appr opriate
programmes created. Overcrowded facilities at
the primary health care level in Indonesia may
contribute to poor diabetes care, as is also seen
across the Western Pacific region.(23)
Almost a quarter of our patients had
macrovascular complications, the most prevalent
of which was heart disease, with a higher
prevalence than that reported in an earlier study
(2012) on DM patients in Indonesia.(18) Many
low- and middle-income countries, including
Indonesia, are undergoing a rapid transition in
lifestyle, including work patterns, diet, and eating
habits, with a subsequent increase in obesity,
heart disease, and other chronic conditions.(24–26)
A greater proportion of patients in the hospital
had a history of macrovascular complications than
did those in CHCs. This condition was expected
because diabetes patients with complications are
more likely to be referred to secondary and
tertiary hospitals. Despite the larger number of
patients with macrovascular complications, only
a small proportion was using antiplatelet drugs
(aspirin).
The high proportion of patients in our study
with microvascular complications such as
blindness, macro albuminuria, and
microalbuminuria is comparable to the 2012
Indonesian study. In addition,(18) microvascular
complications r equ ire more intensive
measurement by physicians, which is not routinely
carried out in either site. Hence there was no
difference between hospital and CHC patients.
Also, patients do not usually present with signs
and symptoms of microvascular complications,
especially for microalbuminuria.
More than half of the patients in our study
were obese, combined with hypertension and a
high LDL, which together increases the risk for
cardiovascular complications, with only a small
proportion receiving the relevant antihypertensive,
lipid-lowering (statin), or antiplatelet (aspirin)
drugs. This limited use of preventive therapy was
found at both hospital and CHC levels. At the
CHC level, there is often a limited supply of
medications which may contribute to this finding.
In the hospital, the national insurance system
requires that patients using insurance be referred
to the relevant clinic to obtain their medication.
For example, those with hypertension are referred
to the renal and hypertension clinic to get
antihypertensive drugs, and those needing statins
as dyslipidaemia drugs must be referred to the
cardiology clinic. In each clinic, patients have to
queue, often for a long time which is likely to
impact their medication uptake and ongoing
adherence.
Of those receiving antihypertensive and
dyslipidaemia drugs, only a small proportion
reached the blood pressure control target
according to Indonesian Type 2 DM Management
Guidelines.(8) Reasons for this are unclear and
need to be explored further, but possible
explanations could be that medications are not
regularly taken because of their side effects, or
patients have too many drugs to take daily
(polypharmacy). Other reasons may be that in a
busy clinic, physicians may not be aware that the
dose they are prescribing is inadequate. In addition,
the number of drugs allowed to be prescribed at
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Permana, Koesoemadinata, Mulyani , et al Diabetes mellitus management, Indonesia
one time is limited by the insurance restrictions,
or there may be a limited drug supply.
In keeping with national guidelines, most of
the patients on insulin were under care in the
hospital. However, it appeared that more referrals
were necessary, with many of the patients with
an HbA1c 10% not being referred and not
receiving insulin. Introducing insulin is not an easy
task, with many patients being reluctant due to
the insulin needing to be injected. Even amongst
those receiving insulin, many did not achieve the
HbA1c target of below 7%. This is likely due to
a combination of patient, prescriber, and health
system management issues as mentioned earlier,
but requires further studies to explore this in more
detail. On the other hand, many patients with
HbA1c <7% and without complications were still
receiving their medication in the hospital while
they were supposed to be referred back to primary
care. This may cause an extra burden for
clinicians, preventing them from being focused
on individual treatment indicators of patients.
To our knowledge, this is the first study
comparing diabetes care in primary and tertiary
health care in Indonesia at the individual patient
level and with relatively large sample size.
However, the study’s limitation was that much of
the data was self-reported, particularly that of
DM complications, rather than having been
collected and confirmed from medical records.
Also, some data was only available for Also, some
data was only available for patients recruited in
the hospital and could not be compared to those
of CHC patients.
Based on the resul ts of this study,
complications in people living with DM may be
avoided by improving care, i.e., routine monitoring
of key laboratory indicators and medication
adjustments. Chronic disease management
trainings may be required for the physicians at
the primary health care levels.
Our study has identified gaps in care, but
further research is required to determine the gaps,
the key difficulties and barriers for patients and
those in the health care system, and how best to
address these gaps. Moreover, data obtained for
this study was from the early stages of the national
insurance scheme implementation. Since then,
several new regulations have been added,(27,28)
to ensure better treatment pathways. Further
evaluation should be done to see whether the
improvements have led to better patient care.
Regular auditing and benchmarking against
evidence-based guidelines will be essential to track
progress. (26)
CONCLUSIONS
Overall, the control of diabetes and its
complications appears to be poor for patients
cared for at both health care levels. Many
patients need to use insulin but have no access in
primary care, and even though hypertensive drugs
are more used in primary care, their blood pressure
control remained poor. These conditions suggest
a need for input and improvement within the health
system, and better integration of services both
within the hospital and between the primary and
tertiary levels of care, particularly for those using
national insurance.
CONFLICT OF INTEREST
All authors declare that there was no conflict
of interests relevant to the subject of this study.
ACKNOWLEDGEMENT
The authors would like to acknowledge the
assistance of the staff in the Endocrine Clinic at
Dr Hasan Sadikin General Hospital, of Dr Ahyani
Raksanagara at the Bandung City Health Office,
and of the staff at the Community Health Centres
for their role in patient recruitment. Prodia
Laboratory, Bandu ng, did the HbA1c
measurements.
FUNDING SOURCES
This study was part of the TANDEM
research proj ect (www.tande m-fp7.eu),
supported by the European Union’s Seventh
167
Framework Programme (FP7/2007-2013) under
Grant Agreement Number 305279.
CONTRIBUTORS
Conception or design: HP, NNMS, SMM
Acquisition, analysis, interpretation of data: NFD,
NJ, SI, NNMS, RCK, SMM
Writing – original draft: HP, RCK
Writing – review and editing: NNMS, SMM
Supervision: BA, RR
Project administration: BA, RCK
All authors have read and approved the final
manuscript.
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