Economic evaluation of a novel community-based diabetes care model in rural Mexico: a cost and cost-effectiveness study.

OBJECTIVES: Diabetes is the leading cause of disability-adjusted life years in Mexico, and cost-effective care models are needed to address the epidemic. We sought to evaluate the cost and cost-effectiveness of a novel community-based model of diabetes care in rural Mexico, compared with usual care. DESIGN: We performed time-driven activity-based costing to estimate annualised costs associated with typical diabetes care in Chiapas, Mexico, as well as a novel diabetes care model known as Compañeros En Salud Programa de Enfermedades Crónicas (CESPEC). We conducted Markov chain analysis to estimate the cost-effectiveness of CESPEC compared with usual care from a societal perspective. We used patient outcomes from CESPEC in 2016, as well as secondary data from existing literature. SETTING: Rural primary care clinics in Chiapas, Mexico. PARTICIPANTS: Adults with diabetes. INTERVENTIONS: CESPEC is a novel, comprehensive, diabetes care model that integrates community health workers, provider education, supply chain management and active case finding. OUTCOME MEASURE: The primary outcome was the incremental cost-effectiveness of CESPEC compared with care as usual, per quality-adjusted life year (QALY) gained, expressed in 2016 US dollars. RESULTS: The economic cost of the CESPEC diabetes model was US$144 per patient per year, compared with US$125 for diabetes care as usual. However, CESPEC care was associated with 0.13 additional years of health-adjusted life expectancy compared with usual care and 0.02 additional years in the first 5 years of treatment. This translated to an incremental cost-effectiveness ratio (ICER) of US$2981 per QALY gained over a patient's lifetime and an ICER of US$10 444 over the first 5 years. Findings were robust to multiple sensitivity analyses. CONCLUSIONS: CESPEC is a cost-effective, community-based model of diabetes care for patients in rural Mexico. Given the high prevalence and significant morbidity associated with diabetes in Mexico and other countries in Central America, this model should be considered for broader scale up and evaluation.

Ectopic ACTH- and/or CRH-Producing Pheochromocytomas.

CONTEXT: The characteristics of catecholamine-secreting pheochromocytomas have been well studied. However, less is known about the characteristics, management and outcome in patients with ectopic adrenocorticotropic hormone (ACTH) and/or corticotrophin-releasing hormone (CRH)-secreting pheochromocytomas. OBJECTIVE: To review the characteristics and outcomes of ACTH- and/or CRH-secreting pheochromocytomas. DATA SOURCE: A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 February 2020. STUDY SELECTION: Original articles, including case reports and case series, reporting individual patient data from patients with ACTH- and/or CRH-secreting pheochromocytomas. DATA EXTRACTION: Information on sex, age, symptoms at presentation, comorbidities, biochemistry, imaging, histopathology, and outcomes was extracted. DATA SYNTHESIS: We identified 91 articles reporting on 99 cases of ACTH- and/or CRH-secreting pheochromocytomas (CRH-secreting n = 4). Median age at diagnosis was 49 years (interquartile range 38-59.5) with a 2:1 female to male ratio. Most patients presented with clinical Cushing syndrome (n = 79; 81%), hypertension (n = 87; 93%), and/or diabetes (n = 50; 54%). Blood pressure, glucose control, and biochemical parameters improved in the vast majority of patients postoperatively. Infections were the most common complication. Most cases (n = 70, 88%) with reported long-term outcome survived to publication (median follow-up 6 months). CONCLUSION: Ectopic ACTH- and/or CRH-secreting pheochromocytoma should be considered in patients presenting with ACTH-dependent Cushing syndrome and adrenal mass. Despite the challenge in diagnosis, patient outcomes appear favorable.

Depression in Rural Communities and Primary Care Clinics in Chiapas, Mexico.

Depression is a leading cause of disability worldwide and can be diagnosed and treated in primary care clinics. No studies to date have demonstrated the prevalence of depression in rural, primary care settings in Mexico. The objective of this study is to describe the prevalence of visits for depression in primary care settings in one group of rural communities within Chiapas, Mexico. We performed a cross-sectional, retrospective study of depression prevalence in primary care clinics in the Sierra region of Chiapas, Mexico during the calendar year of 2014. We determined the average depression prevalence is 7.9% (6 community clinics, n = 4555). The prevalence of depression in rural Chiapas, Mexico is much higher than the Mexican national average of 4.0-4.5% found in a home-based survey. Further efforts to understand the causes, develop improved mental health services in primary care, and reduce the higher burden of depression in rural communities in Mexico are urgently needed.

Implementation and clinical effectiveness of a community-based non-communicable disease treatment programme in rural Mexico: a difference-in-differences analysis.

Non-communicable diseases (NCDs) account for the five largest contributors to burden of disease in Mexico, with diabetes representing the greatest contributor. However, evidence supporting chronic disease programmes in Mexico is limited, especially in rural communities. Compañeros En Salud (CES) partnered with the Secretariat of Health of Chiapas, Mexico to implement a novel community-based NCD treatment programme. We describe the implementation of this programme and conducted a population-based, retrospective analysis, using a difference-in-differences regression approach to estimate the impact of the programme. Specifically, we examined changes in diabetes and hypertension control rates between 2014 and 2016, comparing CES intervention clinics (n = 9) to care-as-usual at non-CES clinics (n = 806), adjusting for differences in facility-level characteristics. In 2014, the percent of diabetes patients with this condition under control was 36.9% at non-CES facilities, compared with 41.3% at CES facilities (P > 0.05). For hypertension patients, these figures were 45.2% at non-CES facilities compared with 56.2% at CES facilities (P = 0.02). From 2014 to 2016, the percent of patients with diabetes under control declined by 9.2% at non-CES facilities, while improving by 11.3% at non-CES facilities where the Compañeros En Salud Programa de Enfermedades Crónicas intervention was implemented (P < 0.001). Among hypertension patients, those with the condition under control increased by 21.5% at non-CES facilities between 2014 and 2016, compared with 16.2% at CES facilities (P > 0.05). Introduction of the CES model of NCD care was associated with significantly greater improvements in diabetes management between 2014 and 2016, compared with care-as-usual. Hypertension control measures were already greater at CES facilities in 2014, a difference that was maintained through 2016. These findings highlight the successful implementation of a framework for providing NCD care in rural Mexico, where a rapidly increasing NCD disease burden exists.

Service, training, mentorship: first report of an innovative education-support program to revitalize primary care social service in Chiapas, Mexico.

BACKGROUND: The Mexican mandatory year of social service following medical school, or pasantía, is designed to provide a safety net for the underserved. However, social service physicians (pasantes) are typically unpracticed, unsupervised, and unsupported. Significant demotivation, absenteeism, and underperformance typically plague the social service year. OBJECTIVE: Compañeros en Salud (CES) aimed to create an education-support package to turn the pasantía into a transformative learning experience. DESIGN: CES recruited pasantes to complete their pasantía in CES-supported Ministry of Health clinics in rural Chiapas. The program aims to: 1) train pasantes to more effectively deliver primary care, 2) expose pasantes to central concepts of global health and social medicine, and 3) foster career development of pasantes. Program components include supportive supervision, on-site mentorship, clinical information resources, monthly interactive seminars, and improved clinic function. We report quantitative and qualitative pasante survey data collected from February 2012 to August 2013 to discuss strengths and weaknesses of this program and its implications for the pasante workforce in Mexico. RESULTS: Pasantes reported that their medical knowledge, and clinical and leadership skills all improved during the CES education-support program. Most pasantes felt the program had an overall positive effect on their career goals and plans, although their self-report of preparedness for the Mexican residency entrance exam (ENARM) decreased during the social service year. One hundred percent reported they were satisfied with the CES-supported pasantía experience and wished to help the poor and underserved in their careers. CONCLUSIONS: Education-support programs similar to the CES program may encourage graduating medical students to complete their social service in underserved areas, improve the quality of care provided by pasantes, and address many of the known shortcomings of the pasantía. Additional efforts should focus on developing a strategy to expand this education-support model so that more pasantes throughout Mexico can experience a transformative, career-building, social service year.

Community health workers, social support and cervical cancer screening among high-risk groups in rural Mexico.

BACKGROUND: Rural Mexico has a low screening prevalence and high burden of cervical cancer. One strategy to increase screening coverage utilizes community health workers (CHWs) to recruit high-risk women and address barriers. METHODS: We conducted a systematic cross-sectional survey of 196 women residing in Chiapas, Mexico who were recruited by either CHWs or traditional means for screening. This analysis compares 110 rural women's risk factors, attitudes and knowledge of cervical cancer and socioeconomic factors stratified by type of recruitment. RESULTS: Women who were informed of screening by CHWs were more likely to be of high risk sub-groups and report higher scores of social support but were also more likely to endorse difficulty with access and fatalistic attitudes about cancer. DISCUSSION: Utilizing CWHs results in increased screening among high-risk women and increased social support for screening among rural women, addressing a significant barrier, but may have limited effects on other barriers.