Relationships between structure, process and outcome to assess quality of integrated chronic disease management in a rural South African setting: applying a structural equation model

Abstract

BackgroundSouth Africa faces a complex dual burden of chronic communicable and non-communicable diseases (NCDs). In response, the Integrated Chronic Disease Management (ICDM) model was initiated in primary health care (PHC) facilities in 2011 to leverage the HIV/ART programme to scale-up services for NCDs, achieve optimal patient health outcomes and improve the quality of medical care. However, little is known about the quality of care in the ICDM model. The objectives of this study were to: i) assess patients’ and operational managers’ satisfaction with the dimensions of ICDM services; and ii) evaluate the quality of care in the ICDM model using Avedis Donabedian’s theory of relationships between structure (resources), process (clinical activities) and outcome (desired result of healthcare) constructs as a measure of quality of care.MethodsA cross-sectional study was conducted in 2013 in seven PHC facilities in the Bushbuckridge municipality of Mpumalanga Province, north-east South Africa - an area underpinned by a robust Health and Demographic Surveillance System (HDSS). The patient satisfaction questionnaire (PSQ-18), with measures reflecting structure/process/outcome (SPO) constructs, was adapted and administered to 435 chronic disease patients and the operational managers of all seven PHC facilities. The adapted questionnaire contained 17 dimensions of care, including eight dimensions identified as priority areas in the ICDM model - critical drugs, equipment, referral, defaulter tracing, prepacking of medicines, clinic appointments, waiting time, and coherence. A structural equation model was fit to operationalise Donabedian’s theory, using unidirectional, mediation, and reciprocal pathways.ResultsThe mediation pathway showed that the relationships between structure, process and outcome represented quality systems in the ICDM model. Structure correlated with process (0.40) and outcome (0.75). Given structure, process correlated with outcome (0.88). Of the 17 dimensions of care in the ICDM model, three structure (equipment, critical drugs, accessibility), three process (professionalism, friendliness and attendance to patients) and three outcome (competence, confidence and coherence) dimensions reflected their intended constructs.ConclusionOf the priority dimensions, referrals, defaulter tracing, prepacking of medicines, appointments, and patient waiting time did not reflect their intended constructs. Donabedian’s theoretical framework can be used to provide evidence of quality systems in the ICDM model.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2177-4) contains supplementary material, which is available to authorized users.

Medication adherence interventions and outcomes: an overview of systematic reviews

“…The structure represents the conditions under which care is provided, the process represents the activities that constitute healthcare and the outcome represents the changes in the health status 18. It is suggested that good outcome is a result of a structure that promotes a good process,19 and that any efforts to improve the approaches in the triad must be seen in the light of care and needs of the patients 20. In the ECHO model, the outcomes of medical care are classified along three general dimensions: clinical, economic and humanistic 21.…”

Paradox of HIV stigma in an integrated chronic disease care in rural South Africa: viewpoints of users and providers

“…This qualitative research is a case study of implementation of an ICDM model in PHC facilities and their catchment communities, and a part of a broader mixed methods research project which evaluated the quality of care in the ICDM model (15) in the study setting. The study population consisted of clients 18 years and above being managed for HIV, hypertension and diabetes in the seven PHCs in the sub-district.…”

“…Patients diagnosed with and being managed in the health facilities for HIV, hypertension, and diabetes were eligible to participate in the study. Inclusion criteria were being on treatment six months before the ICDM model was implemented, participating in health facility exit quantitative interviews on quality of the ICDM model of care commenced in June 2013 (15) and willingness to participate in the current Focus Group Discussions (FGDs). The managers of the seven health facilities in the district were purposively selected for the In-depth Interviews (IDIs) based on their depth of experience.…”

“…The exit interviews provided a large sampling frame from which purposive selection of prospective participants for the FGDs was done to explore patients' in-depth perspectives on the quality of care in the ICDM model. During the exit interview of 435 randomly selected patients in the quantitative study on quality of care in the ICDM model (15), 80 patients who volunteered to participate in the FGDs were invited to do so based on the inclusion criteria described above. Of the 80 purposively selected prospective participants, 61 participated in the eight FGDs (one FGD per health facility and one FGD for defaulters, defined as those who missed three or more consecutive clinic appointments as was observed through the review of clinic records) giving a response rate of 76%.…”

Can Integrated Care Improve the Efficiency of Hospitals? - Research based on 200 Hospitals in China

“…Most studies have focused on measuring health outcomes among the elderly that may be attributed to the implementation of IC. [14][15][16][17][18][19][20][21][22][23][24] Furthermore, it remains unclear from that literature the direction of effect, if any, of IC on hospital e ciency. Some studies demonstrated that integrated partnerships and a coordinated continuum of services dedicated to the treatment of specialized diseases or a de ned population may improve hospital e ciency.…”