Is screening for microalbuminuria in type 2 diabetic patients feasible in the public sector primary care context : a cost and consequence study in Elsies River community health centre
Background: The epidemic of type 2 diabetes poses an enormous and growing burden on health care globally. While the prevalence of diabetes is increasing worldwide, the developing countries will bear the greatest burden of this disease. Diabetes is one of the most common causes of kidney failure and nephropathy is a strong predictor of cardiovascular complications and death in these patients. Microalbuminuria represents a latent and early pre-symptomatic phase of nephropathy which can be stopped from progressing to an advanced stage if detected and treated early. The cost effectiveness of this screening and intervention has been researched and proven in the developed world, however similar studies in developing countries are non-existent. Microalbuminuria is not currently tested for in the public primary care sector. Aim and objectives: The aim was to assess the feasibility of introducing a screening test for microalbuminuria and the associated costs and consequences at Elsies River Community Health Centre (CHC) in the Metropolitan District of Cape Town. The objectives of the study are to assess the feasibility of implementing the test in our context, to assess any additional cost to the health services, to assess any measurable benefits in the quality of care for the patients, to extrapolate the likely long term consequences in terms of health outcomes, use of resources and costs and to make a policy recommendation to the Department of Health. Method: A cost and consequence study that describes the introduction of microalbuminuria testing in a cohort of type 2 diabetic patients at Elsies River Community Health Centre, Metro District Health Services, Cape Town, South Africa. Point of care status analyser microalbuminuria screening was introduced to the CHC after training of the chronic care team, and their fidelity to the protocol measured. All patients who met the inclusion criteria were screened. Patients whose first results were abnormal had a repeat test after 3-6 months, if both results were abnormal patient was diagnosed microalbuminuria positive, however a patient with a second normal result required a third test. Interventions included addition of an Angiotesin Converting Enzyme inhibitor to their treatment, more intensive glycaemic, blood pressure or lipid control via medication or lifestyle changes and treatment adherence health education. Field notes were taken by the researcher during visits and a recorded focus group interview conducted with the health workers to explore their views on the feasibility of the screening and intervention. Cost was assessed by the estimation of the additional resources required and the likely long term health outcomes extrapolated from available data and literature. Results: 15.2% of the sample population was noted to be microalbuminuria positive and they all received interventions. Additional cost required to screen a cohort of 100 patients was R1,109.40 per annum, out of which 15 patients at risk of developing nephropathy were identified and the cost of treating these patients was R1,393.20 for the first year. Qualitative data revealed that the test and interventions are feasible with an additional cost of staff time, medication and other materials which have been included in the cost above. Conclusion: This study represents the first attempt to successfully introduce screening for microalbuminuria in our public primary health care context. The chronic care team showed reasonable fidelity to the protocol and demonstrated the feasibility of screening and treating patients. The balance of costs and long term benefits suggests that this represents excellent value for money in a South African primary care setting.