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




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BMC Health Services Research

, 17:229

Quality, performance, safety and outcomes

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.

KeywordsIntegrated Chronic Disease Management ICDM Model Avedis donabedian Constructs Quality of care Satisfaction Chronic communicable diseases Non-communicable chronic diseases Structural equation model Primary Health Care PHC Mpumalanga province South Africa AbbreviationsARSAcquiescent response set

ARTAntiretroviral treatment

CDCoefficient of determination

CFAConfirmatory factor analysis

CFIComparative fit index

CHWsCommunity health workers

HDSSHealth and demographic surveillance system

HIV-AIDSHuman immunodeficiency virus-acquired immune deficiency syndrome

ICDMIntegrated chronic disease management

LMICsLow- and middle-income countries

MLMVThe maximum likelihood for missing values

NCDsNon-communicable diseases

NDoHNational Department of Health

PHCPrimary health care

PSQPatient satisfaction questionnaire

RMSEARoot mean squared error of approximation

SEMStructural equation modelling

SPOStructure, process, and outcome

SSASub-Saharan Africa

TLITucker-Lewis Index

UNAIDSJoint United Nations Programme on HIV-AIDS

WHOWorld Health Organization.

Electronic supplementary materialThe online version of this article doi:10.1186-s12913-017-2177-4 contains supplementary material, which is available to authorized users.

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Autor: Soter Ameh - Francesc Xavier Gómez-Olivé - Kathleen Kahn - Stephen M. Tollman - Kerstin Klipstein-Grobusch

Fuente: https://link.springer.com/







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