Appropriateness of diabetic down-referral letters to primary healthcare clinics in the uMgungundlovu district municipality of KwaZulu-Natal

Keywords: diabetes mellitus, down-referral, community health clinics, primary health clinics, referral letters, referral pathways


Background: The majority of patients living with diabetes mellitus (PLWD) are diagnosed and managed at primary care level. Much research has focused on diabetes mellitus, its complications and the need for earlier referral from primary to higher levels of health care. Little research, however, has focused on down-referrals of PLWD.

Methods: This study assessed whether down-referral letters of PLWD to primary healthcare clinics (PHCs) and community healthcare centres (CHCs) in the uMgungundlovu district of KwaZulu-Natal contained adequate information, were legible, had a follow-up plan and whether national guidelines were adhered to. Questionnaires were distributed to nurses and doctors working in PHCs and CHCs to assess their opinions of appropriateness of down-referrals of PLWD during November and December 2019.

Results: A total of 127 referral letters and 55 questionnaires were assessed. Referral letter assessment revealed that 81.1% of PLWD had no glucose control and 85% had no renal function documented. Diabetic complications were recorded infrequently (3.94%). One-third (33.6%) of the PLWD over the age of 40 years were not down-referred on a statin while 6.3% were on a medication combination that was not in accordance with the South African Essential Medicines List. A significant number of referral letters had no clear management plan other than medications listed (96.1%), with no follow-up appointments documented (95.3%). Less than two-thirds (60%) of letters were easily legible. The most common down-referrals were from district hospitals (98.43%). Questionnaire respondents agreed that referral letters generally contained information on the patient’s medication and comorbidities but rarely contained information regarding glucose control or complications of diabetes, among which foot and eye complications were significantly omitted.

Conclusion: Analysis of down-referral letters identified many omissions, in both clinical and biochemical data, that are needed by clinicians working at both CHCs and PHCs to optimally manage PLWD. It is imperative that findings of studies like this be used in developing intervention strategies targeting this level of diabetes care.

Author Biographies

N G McGrath, University of the Witwatersrand

Division of Anatomical Pathology, University of the Witwatersrand, Johannesburg, South Africa

S Pillay, University of KwaZulu-Natal

Department of Internal Medicine, King Edward VIII Hospital and Nelson R Mandela School of Clinical Medicine, Durban, South Africa

Original Research