1. The quality of care in the integrated chronic disease management model: lessons learned from primary health care facilities in rural South Africa
Soter Ameh, Xavier Gómez-Olivé, Kathleen Kahn, Stephen Tollman and Kerstin Klipstein-Grobusch Presenter: Dr. Soter Ameh Faculty of Health Sciences Research Day 17th September 2014

2. Outline Background Theoretical framework Study aim and objectives
Methods
Results
Conclusions

3. Background South Africa faces a dual burden of chronic diseases
Prevalence of HIV in 2013 was 10%
Prevalence of non-communicable diseases in 2011 was 29%
Fragmented chronic disease care aggravates the dual burden
NDOH initiated the ICDM model as pilot programme in PHC facilities in 2011
“One-stop-shop” for managing chronic diseases
Leverage resources
More efficiently meet patients’ health needs
Evidence shows that integrated care leads to improved health outcomes
There are six priority areas in the ICDM model:
Supply of critical drugs
Prepacking of drugs
Hospital referrals
Defaulter tracing
Patient waiting time
Improve quality of care

4. Theoretical framework
Avedis Donabedian proposed a theory for evaluating the quality of health care
Relationships between structure, process and outcome constructs
Structure: organizational resources needed to provide care e.g. drug supply
Process: things done to and for the patient e.g. defaulter tracing
Outcome: desired result of health care
Technical: disability, disease and death
Interpersonal: patient satisfaction (focus of outcome)
This study utilised Donabedian’s theory to evaluate the quality of care in the ICDM model

5. Theoretical framework (Dimensions of care)

6. Theoretical framework (hypothesised pathways)

7. Study aim and objectives
To evaluate the quality of care in the ICDM model in 2013
Study objectives:
To assess the relationships between structure, process and outcome constructs
To identify priority areas that have been well implemented
To identify priority areas that need further improvement

8. Methods I study area: Agincourt

9. Methods II
Study design: cross-sectional survey , utilising mixed methods
Study settings: seven PHC facilities in the Agincourt HDSS study site
Study population: chronic disease patients and operational managers of facilities
Sample size determination:
Subjects-to-variable ratio (10:1) for studies using confirmatory factor analysis
17 subjects for 22 variables (435 subjects, adjusted for 10% non-response)
Sampling technique:
Proportionate sampling of patients through a three-step process (quantitative)
Health facilities, chronic disease status and patients
Purposive sampling of patients for FGDs (qualitative)
In-depth interviews with all the operational managers (qualitative)
Inclusion criteria:
Patients with markers of chronic diseases (HIV, hypertension and diabetes)
Patients enrolled for treatment since June 2011
Age 18 years and above
Exclusion criteria:
Minors (<18 years) and old people with diminished capacity for comprehension

10. Methods III
Study instrument: patient satisfaction questionnaire (PSQ-18)
Has multiple dimensions of quality of care
Scored on a five-point Likert scale (strongly agree to strongly disagree)
PSQ-18 adapted
To include four of the six priority areas not originally in the PSQ-18
Supply of critical drugs
Prepacking of drugs
Hospital referrals
Defaulter tracing
Thematic content analysis of FGDs and in-depth interviews
Discussions and interviews were conducted until saturation was achieved
Inductive and deductive codes were used to analyse the data

11. Methods IV Operationalization of Donabedian’s theory:
A priori identification of variables intended for SPO constructs
Reliability of adapted PSQ was tested using Cronbach’s alpha coefficient
Confirmatory factor analysis was (factor loadings ≥ 0.30)
Structural equation modelling was used to fit the pathway models.
Model fit indices included:
Root Mean Squared Error of Approximation (RMSEA ≤ good fit);
Comparative Fit Index (CFI) and Tucker-Lewis Index (TLI) (values > good it);
Coefficient of Determination (CD close to 1 - good fit)
χ2 p-value > good fit (not applicable if sample size > 400)
Stata 12 was used for statistical analysis (95% level of significance)

12. Contribution to knowledge
The authors are not aware of any study that has used the PSQ-18 instrument to test Donabedian’s theory
First study to apply Donabedian’s theory in evaluating the quality of care in the ICDM model in South Africa.

13. Results (characteristics)

14. Results - mediation pathway (Quantitative method)

15. Results (qualitative method)
Prepacking of drugs
Most times, the nurses did not prepack drugs before appointment dates
“In this clinic I have seen this a few times” (40 of 51 patients)
“It is waste of time to prepack drugs because patients miss appointments”
(6 of the 7 operational managers)
“There are no prepacking bags” (4 of the 7 operational managers)
Defaulter tracing
Home based volunteers usually visit some homes to do domestic chores
“Do we have them (referring to the defaulter outreach team) in our community?”
Patient waiting time
All patients and operational managers agreed waiting time was long
“I went to the clinic early in the morning like 6h30 and they will help me at 11h00”
“I have to be the last to get the treatment when I miss my appointment……”

16. Conclusions
The relationships between structure, process and outcome are a reasonable representation of the quality of care in the ICDM model
Structure correlated with process and outcome
Given structure, process also correlated with outcome
Two of the six priority areas reflected their intended constructs
Supply of critical drugs and quality of chronic disease care
Four of the six priority areas did not reflect their intended constructs
Defaulter tracing, referrals, prepacking medicines and patient waiting time
We recommend improvement in service delivery in these four priority areas
We recommend country-wide use of the adapted PSQ as a tool in evaluating the quality of care in the ICDM model

17. References
Donabedian A. 1988a. The quality of care. How can it be assessed? JAMA, 260,
Republic of South Africa. Global Health Initiative Strategy ( ). Available from:
HU LT & Bentler PM. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Multidisciplinary Journal 1999; 6:1-55.
Statistics South Africa (2013). Mid year population estimates. Available from
Ware JE, Snyder MK and Wright WR. Development and validation of scales to measure patient satisfaction with health care services: Volume I of a final report part A: review of literature, overview of methods and results regarding construction of scales.
WHO (2011). Non-communicable diseases country profiles . Available from:

18. Acknowledgments
The patients and staff of the PHC health facilities in the study site
The Health Manager of the Bushbuckridge sub-district Department of Health
Funding for this study was provided by the:
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt) South Africa, through the Wellcome Trust, UK
Faculty of Health Sciences, through the MFREF and seed funding research awards
African Doctoral Dissertation Research Fellowship Programme
Fogarty International Center of the National Institutes of Health