Design and validation of indicators for the comprehensive measurement of quality of care for type 2 diabetes and acute respiratory infections in ambulatory health services.

Developing ambulatory health services (AHS) of optimal quality is a pending issue for many health systems at a global level, especially in middle- and low-income countries. An effective health response requires indicators to measure the quality of care that are context-specific and feasible for routine monitoring. This paper aimed to design and validate indicators for assessing the technical and interpersonal quality dimensions for type 2 diabetes (T2D) and acute respiratory infections (ARI) care in AHS. The study was conducted in two stages. First, technical and user-centered-based indicators of quality of care for T2D and ARI care were designed following international recommendations, mainly from the American Diabetes Association standards and the National Institute for Health and Care Excellence guidelines. We then assessed the validity, reliability, relevance, and feasibility of the proposed indicators implementing the modified Delphi technique. A panel of 17 medical experts from five countries scored the indicators using two electronic questionnaires, one for each reason for consultation selected, sent by email in two sequential rounds of rating. We defined the levels of consensus according to the overall median for each performance category, which was established as the threshold. Selected indicators included those with scores equal to or higher than the threshold. We designed 36 T2D indicators, of which 16 were validated for measuring the detection of risks and complications, glycemic control, pharmacological treatment, and patient-centered care. Out of the 22 indicators designed for ARI, we validated 10 for diagnosis, appropriate prescription of antimicrobials, and patient-centered care. The validated indicators showed consistency for the dimensions analyzed. Hence, they proved to be a potentially reliable and valuable tool for monitoring the performance of the various T2D and ARI care processes in AHS. Further research will be needed to verify the applicability of the validated indicators in routine clinical practice.

Diabetes care innovation in the Mexican Institute for Social Insurance: Scaling up the preventive chronic disease care model to address critical coverage constraints.

BACKGROUND: With diabetes prevalence in Mexico at 11.3% of adults, the Mexican Institute of Social Insurance (IMSS) is piloting the Chronic Disease Preventive Model (CDPM). CDPM includes intensive patient education, care by multidisciplinary teams and risk management in primary care. The objective of this article is to determine CDPM coverage bottlenecks and to explore facilitators and barriers to implementation. METHODS: The National Health and Nutrition Survey 2018 was processed to identify key diabetes prevalence, coverage, quality and outcome indicators. Key IMSS informant interviews and document content analyses were undertaken following the Tanahashi coverage decay model and the Consolidated Framework for Implementation Research (CFIR). RESULTS: IMSS screens 49% of adult beneficiaries for diabetes but only 26% with presumptive diagnosis proceed to confirmation. Out of 4.1 million adults with diabetes, IMSS diagnoses 94% and treats 85%. Medications are received by 90% of patients but only 63% of those requiring insulin receive it. The overall quality of care indicator attains 37% of potential. Coverage of diabetes education, monitoring with HbA1c and interdisciplinary care are 20%, 15% and 3%, respectively. Among IMSS beneficiaries treated by the institute 38.1% have HbA1c levels below 7% and 26.1% have levels above 9%. CDPM facilitators are the perceived threat of uncontrolled diabetes, compatibility of innovation values and willingness for institutional learning. Barriers are centralized decision making, functional differentiation across managers and practitioners and lack of incentives, resource shortages and the lack of measures to ensure fidelity. CONCLUSIONS: CDPM scale-up has to address organizational and process barriers while ensuring the necessary resources for sustainability.