Clinical audit of diabetes management can improve the quality of care in a resource-limited primary care setting

A realist synthesis of multicentre comparative audit implementation: exploring what works and in which healthcare contexts

BACKGROUND

Multicentre comparative clinical audits have the potential to improve patient care, allow benchmarking and inform resource allocation. However, implementing effective and sustainable large-scale audit can be difficult within busy and resource-constrained contemporary healthcare settings. There are little data on what facilitates the successful implementation of multicentre audits. As healthcare environments are complex sociocultural organisational environments, implementing multicentre audits within them is likely to be highly context dependent.

OBJECTIVE

We aimed to examine factors that were influential in the implementation process of multicentre comparative audits within healthcare contexts-what worked, why, how and for whom?

METHODS

A realist review was conducted in accordance with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards reporting standards. A preliminary programme theory informed two systematic literature searches of peer-reviewed and grey literature. The main context-mechanism-outcome (CMO) configurations underlying the implementation processes of multicentre audits were identified and formed a final programme theory.

RESULTS

69 original articles were included in the realist synthesis. Four discrete CMO configurations were deduced from this synthesis, which together made up the final programme theory. These were: (1) generating trustworthy data; (2) encouraging audit participation; (3) ensuring audit sustainability; and (4) facilitating audit cycle completion.

CONCLUSIONS

This study elucidated contexts, mechanisms and outcomes influential to the implementation processes of multicentre or national comparative audits in healthcare. The relevance of these contextual factors and generative mechanisms were supported by established theories of behaviour and findings from previous empirical research. These findings highlight the importance of balancing reliability with pragmatism within complex adaptive systems, generating and protecting human capital, ensuring fair and credible leadership and prioritising change facilitation.

Improving quality of non-communicable disease services at primary care facilities in middle-income countries: A scoping review

Health systems in middle-income countries face important challenges in managing the high burden of Non-Communicable Diseases (NCD). Primary health care is widely recognized as key to managing NCDs in communities. However, the effectiveness of this approach is limited by poor quality of care (QoC), among others. This scoping review identifies the types of interventions that have been used in middle-income countries to improve the quality of NCD services at primary care facilities. Further, it identifies the range of outcomes these quality interventions have influenced. This scoping review covered both the grey and peer-reviewed literature. The 149 articles reviewed were classified into four domains - governance, service-delivery systems, health workforce, and patients and communities. There was a remarkable unevenness in the geographic distribution of studies - lower middle-income countries and some regions (Middle East, North Africa, and South East Asia) had a scarcity of published studies. NCDs such as stroke and cardiovascular disease, mental health, cancer, and respiratory disorders received less attention. The thrust of quality interventions was directed at the practice of NCD care by clinicians, facilities, or patients. Few studies provided evidence from interventions at the organizations or policy levels. Overall, effectiveness of quality interventions was mixed across domains. In general, positive or mixed effects on provider clinical skills and behavior, as well as, improvements in patient outcomes were found across interventions. Access to care and coverage of screening services were positively influenced by the interventions reviewed. This review shows that quality improvement interventions tried in middle-income countries mostly focused at the provider and facility level, with few focusing on the organizational and policy level. There is a need to further study the effectiveness of organizational and policy level interventions on the practice and outcomes of NCD care.

Outcomes and Challenges in Noncommunicable Disease Care Provision in Health Facilities Supported by Primary Health Care System Strengthening Project in Sri Lanka: A Mixed-Methods Study

The Primary Healthcare System Strengthening Project in Sri Lanka focuses on improving noncommunicable disease (NCD) care provision at primary medical care institutions (PMCIs). We conducted an explanatory mixed-methods study to assess completeness of screening for NCD risk, linkage to care, and outcomes of diabetes/hypertension care at nine selected PMCIs, as well as to understand reasons for gaps. Against a screening coverage target of 50% among individuals aged ≥ 35 years, PMCIs achieved 23.3% (95% CI: 23.0-23.6%) because of a lack of perceived need for screening among the public and COVID-19-related service disruptions. Results of investigations and details of further referral were not documented in almost half of those screened. Post screening, 45% of those eligible for follow-up NCD care were registered at medical clinics. Lack of robust recording/tracking mechanisms and preference for private providers contributed to post-screening attrition. Follow-up biochemical investigations for monitoring complications were not conducted in more than 50% of diabetes/hypertension patients due to nonprescription of investigations by healthcare providers and poor uptake among patients because of nonavailability of investigations at PMCI, requiring them to avail services from the private sector, incurring out-of-pocket expenditure. Primary care strengthening needs to address these challenges to ensure successful integration of NCD care within PMCIs.

Making the most of audit and feedback to improve diabetes care: a qualitative study of the perspectives of Australian Diabetes Centres

BACKGROUND

Diabetes has high burden on the health system and the individual, and many people living with diabetes struggle to optimally manage their condition. In Australia, people living with diabetes attend a mixture of primary, secondary and tertiary care centres. Many of these Diabetes Centres participate in the Australian National Diabetes Audit (ANDA), a quality improvement (QI) activity that collects clinical information (audit) and feeds back collated information to participating sites (feedback). Despite receiving this feedback, many process and care outcomes for Diabetes Centres continue to show room for improvement. The purpose of this qualitative study was to inform improvement of the ANDA feedback, identify the needs of those receiving feedback and elicit the barriers to and enablers of optimal feedback use.

METHODS

Semi-structured interviews were conducted with representatives of Australian Diabetes Centres, underpinned by the Consolidated Framework for Implementation Research (CFIR). De-identified transcripts were analysed thematically, underpinned by the domains and constructs of the CFIR.

RESULTS

Representatives from 14 Diabetes centres participated in this study, including a diverse range of staff typical of the Diabetes Centres who take part in ANDA. In general, participants wanted a shorter report with a more engaging, simplified data visualisation style. Identified barriers to use of feedback were time or resource constraints, as well as access to knowledge about how to use the data provided to inform the development of QI activities. Enablers included leadership engagement, peer mentoring and support, and external policy and incentives. Potential cointerventions to support use include exemplars from clinical change champions and peer leaders, and educational resources to help facilitate change.

CONCLUSIONS

This qualitative study supported our contention that the format of ANDA feedback presentation can be improved. Healthcare professionals suggested actionable changes to current feedback to optimise engagement and potential implementation of QI activities. These results will inform redesign of the ANDA feedback to consider the needs and preferences of end users and to provide feedback and other supportive cointerventions to improve care, and so health outcomes for people with diabetes. A subsequent cluster randomised trial will enable us to evaluate the impact of these changes.

A reflective process led by a family physician to develop a renal-protection surveillance tool for HIV patients newly started on dolutegravir

A group of Vanguard Community Health Centre doctors embarked on a Health System's Improvement (HSI) project with the aim of reducing harm to renal function in patients who were either commenced on or switched to a dolutegravir (DTG)-based antiretroviral therapy (ART) regimen since 2019, when the usual monitoring and evaluation of ART-regimen switches were disrupted by the coronavirus disease 2019 (COVID-19) pandemic. This intended harm-reduction exercise, involving a reflective process that was facilitated by the family physician, led to the development of a Vanguard Renal Protection Surveillance tool, which is now used at Vanguard to detect and prevent renal decline.

Risk factors for COVID-19 hospitalisation and death in people living with diabetes: A virtual cohort study from the Western Cape Province, South Africa

BACKGROUND

COVID-19 outcomes and risk factors, including comorbidities and medication regimens, in people living with diabetes (PLWD) are poorly defined for low- and middle-income countries.

METHODS

The Provincial Health Data Centre (Western Cape, South Africa) is a health information exchange collating patient-level routine health data for approximately 4 million public sector health care seekers. Data from COVID-19 patients diagnosed between March and July 2020, including PLWD, were analysed to describe risk factors, including dispensed diabetes medications and comorbidities, and their association with COVID-19 outcomes in this population.

FINDINGS

There were 64,476 COVID-19 patients diagnosed. Of 9305 PLWD, 44.9% were hospitalised, 4.0% admitted to ICU, 0.6% received ventilation and 15.4% died. In contrast, proportions of COVID-19 patients without diabetes were: 12.2% hospitalised, 1.0% admitted, 0.1% ventilated and 4.6% died. PLWD were significantly more likely to be admitted (OR:3.73, 95 %CI: 3.53, 3.94) and to die (OR:3.01, 95 %CI: 2.76,3.28). Significant hospitalised risk factors included HIV infection, chronic kidney disease, current TB, male sex and increasing age. Significant risk factors for mortality were CKD, male sex, HIV infection, previous TB and increasing age. Pre-infection use of insulin was associated with a significant increased risk for hospitalisation (OR:1·39, 95 %CI:1·24,1·57) and mortality (OR1·49, 95 %CI:1·27; 1·74) and metformin was associated with a reduced risk for hospitalisation (OR:0·62,95 %CI:0·55, 0·71) and mortality (OR 0·77, 95 %CI:0·64; 0·92).

INTERPRETATION

Using routine health data from this large virtual cohort, we have described the association of infectious and noncommunicable comorbidities as well as pre-infection diabetes medications with COVID-19 outcomes in PLWD in the Western Cape, South Africa.

FUNDING

This research was funded in part, by the Wellcome Trust 203135/Z/16/Z, through support of NT. For the purpose of open access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission. The Wellcome Centre for Infectious Diseases Research in Africa is supported by core funding from the Wellcome Trust [203135/Z/16/Z]. NT receives funding from the CIDRI-Africa Wellcome Trust grant (203135/Z/16/Z), and NT and TT receive funding from the NIH H3ABioNET award (U24HG006941). NT receives funding from the UKRI/MRC (MC_PC_MR/T037733/1).

Clinical audit on assessment of non-glycemic parameters in diabetic patients by physicians

BACKGROUND

Diabetes mellitus (DM) is a major health problem in family practice causing multiple micro and macrovascular complications; the prevention of which should be the main aim of treating physicians. Lack of proper assessment can hasten the complications and a meticulous screening system is a prerequisite in every diabetic patient's evaluation.

OBJECTIVE

The aim of this study was to assess the pattern of screening for non-glycemic parameters in type 2 DM patients by physicians in an outpatient setting.

METHODS

A cross-sectional study was conducted in a teaching hospital during December 2019. A total of 254 patients with type 2 DM without any complications were randomly selected for screening as per the criteria developed by RSSDI [Research Society for the Study of Diabetes in India].

RESULTS

Complete history and physical examination were done by physicians in all the participants. Measurement of blood pressure at every visit was done in about 95% of patients and 90% of them were counseled for cessation of smoking. But only about 60% or less of patients were screened for microalbuminuria, diabetic retinopathy, and peripheral neuropathy. Advice on comprehensive foot care was also not a regular practice among physicians.

CONCLUSION

This clinical audit showed that 90% of the patients had undergone only 4 of the 9 RSSDI recommended screening. The other parameters had been carried out in only among 40 to 60% of the patients. Thus, primary care physicians have to emphasize on the subtle but important criteria like ophthalmic examination, peripheral neuropathy and microalbuminuria during regular outpatient visits.

Use of a simplified clinical audit tool to evaluate hypertension and diabetes management in primary care clinics in Jamaica

This study evaluates a simple clinical audit tool for assessing quality of care and blood pressure control among persons with hypertension in primary care clinics. A systematic random sampling of persons with diabetes mellitus (DM) and hypertension (HTN) attending five health centers in Kingston, Jamaica, was conducted. A modified Ministry of Health paper-based audit tool captured quality of care and outcome indicators (blood pressure and glycemic control). Additional chart audits were conducted by a physician and nurse to assess reliability. One hundred and forty-nine charts were audited between January and September 2017. One hundred and thirty-eight persons (92.6%) had hypertension (27 men and 111 women); 77 persons (51.7%) had DM (14 men and 63 women). The median age was 64 years old. Approximately two-thirds of persons with HTN and DM had electrolytes, lipid profile, and ECG done within the last year. One-fifth of persons with hypertension (18.5% men and 19.8% women, P = 1.000) had adequate blood pressure control with greater control among persons with HTN only compared to persons with both DM and HTN. Poor glycemic control was recorded for 69% of persons with DM (57% men and 71% women, P = .297). Moderate to substantial inter-rater agreement was observed for quality of care indicators. Our findings confirmed that hypertension and glycemic control are inadequate among persons attending primary care clinics in Jamaica's capital city. Simplified clinical audits can provide important quality of care and outcome indicators without losing the meaningfulness of the data collected.

Interventions targeting hypertension and diabetes mellitus at community and primary healthcare level in low- and middle-income countries:a scoping review

BACKGROUND

Hypertension (HTN) and diabetes mellitus (DM) are highly prevalent in low- and middle-income countries (LMIC) and a leading cause of morbidity and mortality. Recent evidence on effectiveness of primary care interventions has attracted renewed calls for their implementation. This review aims to synthesize evidence pertaining to primary care interventions on these two diseases, evaluated and tested in LMICs.

METHODS

Two reviewers conducted an electronic search of three databases (Pubmed, EMBASE and Web of Science) and screened for eligible articles. Interventions covering health promotion, prevention, treatment, or rehabilitation activities at the PHC or community level were included. Studies published in English, French, Portuguese and Spanish, from January 2007 to January 2017, were included. Key extraction variables included the 12 criteria identified by the Template for Intervention Description and Replication (TIDieR) checklist and guide. The Innovative Care for Chronic Conditions Framework (ICCCF) was used to guide analysis and reporting of results.

RESULTS

198 articles were analyzed. The strategies focused on healthcare service organization (76.5%), community level (9.7 %), creating a positive policy environment (3.6%) and strategies covering multiple domains (10.2%). Studies included related to the following topics: description or testing of interventions (n=81; 41.3%), implementation or evaluation projects (n=42; 21.4%), quality improvement initiatives (n=15; 7.7%), screening and prevention efforts (n=26; 13.2%), management of HTN or DM (n=13; 6.6%), integrated health services (n=10; 5.1%), knowledge and attitude surveys (n=5; 2.5%), cost-effective lab tests (n=2; 1%) and policy making efforts (n=2; 1%). Most studies reported interventions by non-specialists (n=86; 43.4%) and multidisciplinary teams (n=49; 25.5%).

CONCLUSION

Only 198 articles were found over a 10 year period which demonstrates the limited published research on highly prevalent diseases in LMIC. This review shows the variety and complexity of approaches that have been tested to address HTN and DM in LMICs and highlights the elements of interventions needed to be addressed in order to strengthen delivery of care. Most studies reported little information regarding implementation processes to allow replication. Given the need for multi-component complex interventions, study designs and evaluation techniques will need to be adapted by including process evaluations versus simply effectiveness or outcome evaluations.

Ten-Year Follow-Up of Clinical Governance Implementation in Primary Care: Improving Screening, Diagnosis and Control of Cardiovascular Risk Factors

Current improvement strategies for the control of cardiovascular risk factors (CRFs) in Europe are based on quality management policies. With the aim of understanding the effect of interventions delivered by primary healthcare systems, we evaluated the impact of clinical governance on cardiovascular health after ten years of implementation in Catalonia. A cohort study that included 1878 patients was conducted in 19 primary care centres (PCCs). Audits that comprised 13 cardiovascular health indicators were performed and general practitioners received periodic (annual, biannual or monthly) feedback about their clinical practice. We evaluated improvement in screening, diagnosis and control of the main CRFs and the effects of the feedback on cardiovascular risk (CR), incidence of cardiovascular disease (CVD) and mortality, comparing baseline data with data at the end of the study (after a 10-year follow-up). The impact of the intervention was assessed globally and with respect to feedback frequency. General improvement was observed in screening, percentage of diagnoses and control of CRFs. At the end of the study, few clinically significant differences in CRFs were observed between groups. However, the reduction in CR was greater in the group receiving high frequency feedback, specifically in relation to smoking and control of diabetes and cholesterol (Low Density Lipoprotein (LDL) and High Density Lipoprotein (HDL)). A protective effect of having a cardiovascular event (hazard ratio (HR) = 0.64, 95% confidence interval (CI) = 0.44-0.94) or death (HR = 0.55, 95% CI = 0.35-0.88) was observed in patients from centres where general practitioners received high frequency feedback. Additionally, these PCCs presented improved cardiovascular health indicators and lower incidence and mortality by CVD, illustrating the impact of this intervention.

Development and validation of a tool to measure patient experience in chronic disease care

BACKGROUND

 There is a global increase in the prevalence of non-communicable diseases and a growing understanding that patients need to be involved in their care. Patient experience should be assessed and the information used to improve on the planning and delivery of health services.

AIM

 This study described the development and validation of a patient-reported experience measure (PREM) tool which is appropriate for the South African context, to assess self-reported patient experience of chronic care.

SETTING

 The study was conducted at four primary health care facilities in the Cape Town Metropole.

METHODS

 This was a validity and reliability study with multiple phases to develop and determine the psychometric properties of a novel tool. It consisted of three phases, namely: Phase 1 - Consensus Validity; Phase 2 - Face Validity; Phase 3 - Reliability. Phase 1 consisted of an expert panel reaching consensus on a draft tool. Phase 2a consisted of qualitative semi-structured interviews and cognitive interviews. Phase 3 tested the internal consistency of the tool, the time necessary to complete, as well as floor and ceiling effects with 200 questionnaires.

RESULTS

 The process described resulted in a final questionnaire with n = 10 items in three languages that was easily understood by patients. Internal consistency was determined with the overall Cronbach's alpha 0.86. This PREM has been named Chronic Care Assessment of Patient Experience.

CONCLUSION

 Using best practice guidance in tool construction and validation, we delivered a PREM with the potential to improve the quality of care from the perspective of patients. Implementation studies are now required to determine how best to use this tool in routine practice.

A quality improvement project using statistical process control methods for type 2 diabetes control in a resource-limited setting

Quality issue

Quality improvement (QI) is a key strategy for improving diabetes care in low- and middle-income countries (LMICs). This study reports on a diabetes QI project in rural Guatemala whose primary aim was to improve glycemic control of a panel of adult diabetes patients.

Initial assessment

Formative research suggested multiple areas for programmatic improvement in ambulatory diabetes care.

Choice of solution

This project utilized the Model for Improvement and Agile Global Health, our organization's complementary healthcare implementation framework.

Implementation

A bundle of improvement activities were implemented at the home, clinic and institutional level.

Evaluation

Control charts of mean hemoglobin A1C (HbA1C) and proportion of patients meeting target HbA1C showed improvement as special cause variation was identified 3 months after the intervention began. Control charts for secondary process measures offered insights into the value of different components of the intervention. Intensity of home-based diabetes education emerged as an important driver of panel glycemic control.

Lessons learned

Diabetes QI work is feasible in resource-limited settings in LMICs and can improve glycemic control. Statistical process control charts are a promising methodology for use with panels or registries of diabetes patients.

The Influence of Family Physicians Within the South African District Health System: A Cross-Sectional Study

PURPOSE

Evidence of the influence of family physicians on health care is required to assist managers and policy makers with human resource planning in Africa. The international argument for family physicians derives mainly from research in high-income countries, so this study aimed to evaluate the influence of family physicians on the South African district health system.

METHODS

We conducted a cross-sectional observational study in 7 South African provinces, comparing 15 district hospitals and 15 community health centers (primary care facilities) with family physicians and the same numbers without family physicians. Facilities with and without family physicians were matched on factors such as province, setting, and size.

RESULTS

Among district hospitals, those with family physicians generally scored better on indicators of health system performance and clinical processes, and they had significantly fewer modifiable factors associated with pediatric mortality (mean, 2.2 vs 4.7, P =.049). In contrast, among community health centers, those with family physicians generally scored more poorly on indicators of health system performance and clinical processes, with significantly poorer mean scores for continuity of care (2.79 vs 3.03; P =.03) and coordination of care (3.05 vs 3.51; P =.02).

CONCLUSIONS

In this study, having family physicians on staff was associated with better indicators of performance and processes in district hospitals but not in community health centers. The latter was surprising and is inconsistent with the global literature, suggesting that further research is needed on the influence of family physicians at the primary care level.

The effect of phlebotomy training on blood sample rejection and phlebotomy knowledge of primary health care providers in Cape Town: A quasi-experimental study

BACKGROUND

There is an increasing amount of blood sample rejection at primary health care facilities (PHCFs), impacting negatively the staff, facility, patient and laboratory costs.

AIM

The primary objective was to determine the rejection rate and reasons for blood sample rejection at four PHCFs before and after a phlebotomy training programme. The secondary objective was to determine whether phlebotomy training improved knowledge among primary health care providers (HCPs) and to develop a tool for blood sample acceptability.

STUDY SETTING

Two community health centres (CHCs) and two community day centres (CDCs) in Cape Town.

METHODS

A quasi-experimental study design (before and after a phlebotomy training programme).

RESULTS

The sample rejection rate was 0.79% (n = 60) at CHC A, 1.13% (n = 45) at CHC B, 1.64% (n = 38) at CDC C and 1.36% (n = 8) at CDC D pre-training. The rejection rate remained approximately the same post-training (p > 0.05). The same phlebotomy questionnaire was administered pre- and post-training to HCPs. The average score increased from 63% (95% CI 6.97‒17.03) to 96% (95% CI 16.91‒20.09) at CHC A (p = 0.039), 58% (95% CI 9.09‒14.91) to 93% (95% CI 17.64‒18.76) at CHC B (p = 0.006), 60% (95% CI 8.84‒13.13) to 97% (95% CI 16.14‒19.29) at CDC C (p = 0.001) and 63% (95% CI 9.81‒13.33) to 97% (95% CI 18.08‒19.07) at CDC D (p = 0.001).

CONCLUSION

There is no statistically significant improvement in the rejection rate of blood samples (p > 0.05) post-training despite knowledge improving in all HCPs (p < 0.05).

Does audit improve diabetes care in a primary care setting? A management tool to address health system gaps

Introduction:

Diabetes mellitus is one of the emerging epidemics. Regular clinical and biochemical monitoring of patients, adherence to treatment and counseling are cornerstones for prevention of complications. Clinical audits as a process of improving quality of patient care and outcomes by reviewing care against specific criteria and then reviewing the change can help in optimizing care.

Objective:

We aimed to audit the process of diabetes care using patient records and also to assess the effect of audit on process of care indicators among patients availing diabetes care from a rural health and training center in Puducherry, South India.

Materials and Methods:

A record based study was conducted to audit diabetes care among patients attending noncommunicable disease clinic in a rural health center of South India. Monitoring of blood pressure (BP), blood glucose, lipid profile and renal function test were considered for auditing in accordance with standard guidelines. Clinical audit cycle (CAC), a simple management tool was applied and re-audit was done after 1-year.

Results:

We reviewed 156 and 180 patients records during year-1 and year-2, respectively. In the audit year-1, out of 156 patients, 78 (50%), 70 (44.9%), 49 (31.4%) and 19 (12.2%) had got their BP, blood glucose, lipid profile and renal function tests done. Monitoring of blood glucose, BP, lipid profile and renal function improved significantly by 35%, 20.7%, 36.4% and 56.1% over 1-year.

Conclusion:

CAC improves process of diabetes care in a primary care setting with existing resources.

Auditing chronic disease care: Does it make a difference?

Background

An integrated audit tool was developed for five chronic diseases, namely diabetes, hypertension, asthma, chronic obstructive pulmonary disease and epilepsy. Annual audits have been done in the Western Cape Metro district since 2009. The year 2012 was the first year that all six districts in South Africa's Western Cape Province participated in the audit process.

Aim

To determine whether clinical audits improve chronic disease care in health districts over time.

Setting

Western Cape Province, South Africa.

Methods

Internal audits were conducted of primary healthcare facility processes and equipment availability as well as a folder review of 10 folders per chronic condition per facility. Random systematic sampling was used to select the 10 folders for the folder review. Combined data for all facilities gave a provincial overview and allowed for comparison between districts. Analysis was done comparing districts that have been participating in the audit process from 2009 to 2010 (‘2012 old’) to districts that started auditing recently (‘2012 new’).

Results

The number of facilities audited has steadily increased from 29 in 2009 to 129 in 2012. Improvements between different years have been modest, and the overall provincial average seemed worse in 2012 compared to 2011. However, there was an improvement in the ‘2012 old’ districts compared to the ‘2012 new’ districts for both the facility audit and the folder review, including for eight clinical indicators, with ‘2012 new’ districts being less likely to record clinical processes (OR 0.25, 95% CI 0.21–0.31).

Conclusion

These findings are an indication of the value of audits to improve care processes over the long term. It is hoped that this improvement will lead to improved patient outcomes.

Quality of care for patients with non-communicable diseases in the Dedza District, Malawi

Introduction

In Malawi, non-communicable diseases (NCDs) are thought to cause 28% of deaths in adults. The aim of this study was to establish the extent of primary care morbidity related to NCDs, as well as to audit the quality of care, in the primary care setting of Dedza District, central Malawi.

Methods

This study was a baseline audit using clinic registers and a questionnaire survey of senior health workers at 5 clinics, focusing on care for hypertension, diabetes, asthma and epilepsy

Results

A total of 82 581 consultations were recorded, of which 2489 (3.0%) were for the selected NCDs. Only 5 out of 32 structural criteria were met at all 5 clinics and 9 out of 29 process criteria were never performed at any clinic. The only process criteria performed at all five clinics was measurement of blood pressure. The staff's knowledge on NCDs was basic and the main barriers to providing quality care were lack of medication and essential equipment, inadequate knowledge and guidelines, fee-for-service at two clinics, geographic inaccessibility and lack of confidence in the primary health care system by patients.

Conclusion

Primary care morbidity from NCDs is currently low, although other studies suggest a significant burden of disease. This most likely represents a lack of utilisation, recognition, diagnosis and ability to manage patients with NCDs. Quality of care is poor due to a lack of essential resources, guidelines, and training.

Effectiveness of a group diabetes education programme in under-served communities in South Africa: a pragmatic cluster randomized controlled trial

AIM

To evaluate the effectiveness of group education, led by health promoters using a guiding style, for people with type 2 diabetes in public sector community health centres in Cape Town.

METHODS

This was a pragmatic clustered randomized controlled trial with 17 randomly selected intervention and 17 control sites. A total of 860 patients with type 2 diabetes, regardless of therapy used, were recruited from the control sites and 710 were recruited from the intervention sites. The control sites offered usual care, while the intervention sites offered a total of four monthly sessions of group diabetes education led by a health promoter. Participants were measured at baseline and 12 months later. Primary outcomes were diabetes self-care activities, 5% weight loss and a 1% reduction in HbA(1c) levels. Secondary outcomes were self-efficacy, locus of control, mean blood pressure, mean weight loss, mean waist circumference, mean HbA1c and mean total cholesterol levels and quality of life.

RESULTS

A total of 422 (59.4%) participants in the intervention group did not attend any education sessions. No significant improvement was found in any of the primary or secondary outcomes, apart from a significant reduction in mean systolic (-4.65 mmHg, 95% CI 9.18 to -0.12; P = 0.04) and diastolic blood pressure (-3.30 mmHg, 95% CI -5.35 to -1.26; P = 0.002). Process evaluation suggested that there were problems with finding suitable space for group education in these under-resourced settings, with patient attendance and with full adoption of a guiding style by the health promoters.

CONCLUSION

The reported effectiveness of group diabetes education offered by more highly trained professionals, in well-resourced settings, was not replicated in the present study, although the reduction in participants' mean blood pressure is likely to be of clinical significance.