Key message 2: diabetes and its consequences are costly to patients and economies We estimate that, in 2015, the overall cost of diabetes in sub-Saharan Africa was US$19•45 billion or 1•2% of cumulative gross domestic product (GDP). Around $10•81 billion (55•6%) of this cost arose from direct costs, which included expenditure on diabetes treatment (eg, medication, hospital stays, and treatment of complications), with out-of-pocket expenditure likely to exceed 50% of the overall health expenditure in many countries. We estimate that the total cost will increase to between $35•33 billion (1•1% of GDP) and $59•32 billion (1•8% of GDP) by 2030. Putting in place systems to prevent, detect, and manage hyperglycaemia and its consequences is therefore warranted from a health economics perspective. Key message 3: health systems in countries in sub-Saharan Africa are unable to cope with the current burden of diabetes and its complications By use of information from WHO Service Availability Readiness Assessment surveys and World Bank Service Delivery Indicator surveys and the local knowledge of Commissioners, we found inadequacies at all levels of the health system required to provide adequate management for diabetes and its associated risk factors and sequelae. We found inadequate availability of simple equipment for diagnosis and monitoring, a lack of sufficiently knowledgable health-care providers, insufficient availability of treatments, a dearth of locally appropriate guidelines, and few disease registries. These inadequacies result in a substantial dropoff of patients along the diabetes care cascade, with many patients going undiagnosed and with those who are diagnosed not receiving the advice and drugs they need. We also noted scarce facilities to manage the microvascular and macro vascular complications of diabetes. Additionally, despite calls for adding the care of diabetes and other cardiovascular risk factors onto existing infectious disease programmes (such as those for HIV), we found little evidence that such combined programmes are successful at improving outcomes.

BackgroundValue-based health care aims to optimize the balance of patient outcomes and health care costs. To improve value in perinatal care using this strategy, standard outcomes must first be defined. The objective of this work was to define a minimum, internationally appropriate set of outcome measures for evaluating and improving perinatal care with a focus on outcomes that matter to women and their families.MethodsAn interdisciplinary and international Working Group was assembled. Existing literature and current measurement initiatives were reviewed. Serial guided discussions and validation surveys provided consumer input. A series of nine teleconferences, incorporating a modified Delphi process, were held to reach consensus on the proposed Standard Set.ResultsThe Working Group selected 24 outcome measures to evaluate care during pregnancy and up to 6 months postpartum. These include clinical outcomes such as maternal and neonatal mortality and morbidity, stillbirth, preterm birth, birth injury and patient-reported outcome measures (PROMs) that assess health-related quality of life (HRQoL), mental health, mother-infant bonding, confidence and success with breastfeeding, incontinence, and satisfaction with care and birth experience. To support analysis of these outcome measures, pertinent baseline characteristics and risk factor metrics were also defined.ConclusionsWe propose a set of outcome measures for evaluating the care that women and infants receive during pregnancy and the postpartum period. While validation and refinement via pilot implementation projects are needed, we view this as an important initial step towards value-based improvements in care.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3732-3) contains supplementary material, which is available to authorized users.

Aims To select a core list of standard outcomes for diabetes to be routinely applied internationally, including patientreported outcomes. Methods We conducted a structured systematic review of outcome measures, focusing on adults with either type 1 or type 2 diabetes. This process was followed by a consensus-driven modified Delphi panel, including a multidisciplinary group of academics, health professionals and people with diabetes. External feedback to validate the set of outcome measures was sought from people with diabetes and health professionals. Results The panel identified an essential set of clinical outcomes related to diabetes control, acute events, chronic complications, health service utilisation, and survival that can be measured using routine administrative data and/or clinical records. Three instruments were recommended for annual measurement of patient-reported outcome measures: the WHO Well-Being Index for psychological well-being; the depression module of the Patient Health Questionnaire for depression; and the Problem Areas in Diabetes scale for diabetes distress. A range of factors related to demographic, diagnostic profile, lifestyle, social support and treatment of diabetes were also identified for case-mix adjustment. Conclusions We recommend the standard set identified in this study for use in routine practice to monitor, benchmark and improve diabetes care. The inclusion of patient-reported outcomes enables people living with diabetes to report directly on their condition in a structured way.

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High blood pressure is the leading modifiable risk factor for mortality, accounting for nearly 1 in 5 deaths worldwide and 1 in 11 in low-income countries. Hypertension control remains a challenge, especially in low-resource settings. One approach to improvement is the prioritization of patient-centered care. However, consensus on the outcomes that matter most to patients is lacking. We aimed to define a standard set of patient-centered outcomes for evaluating hypertension management in low- and middle-income countries. The International Consortium for Health Outcomes Measurement convened a Working Group of 18 experts and patients representing 15 countries. We used a modified Delphi process to reach consensus on a set of outcomes, case-mix variables, and a timeline to guide data collection. Literature reviews, patient interviews, a patient validation survey, and an open review by hypertension experts informed the set. The set contains 18 clinical and patient-reported outcomes that reflect patient priorities and evidence-based hypertension management and case-mix variables to allow comparisons between providers. The domains included are hypertension control, cardiovascular complications, health-related quality of life, financial burden of care, medication burden, satisfaction with care, health literacy, and health behaviors. We present a core list of outcomes for evaluating hypertension care. They account for the unique challenges healthcare providers and patients face in low- and middle-income countries, yet are relevant to all settings. We believe that it is a vital step toward international benchmarking in hypertension care and, ultimately, value-based hypertension management.