Evaluating quality of care for patients with type 2 diabetes using electronic health record information in Mexico

Evaluation of effective coverage for type 2 diabetes in Mexican primary care health information systems: a retrospective registry analysis

BACKGROUND

As the leading cause of disability and the fourth leading cause of premature death in Mexico, type 2 diabetes (T2D) represents a serious public health concern. The incidence of diabetes has increased dramatically in recent years, and data from the Mexican National Health and Nutrition Survey (ENSANUT) indicate that many people remain undiagnosed. Persistent socioeconomic health care barriers exacerbate this situation, as T2D morbidity and mortality are worsened in vulnerable populations, such as those without social security. We evaluated the performance of public primary health centers (PHCs) in T2D medical attention through the measure of effective coverage (EC, a combined measure of health care need, use, and quality) at national, state, health jurisdiction, and municipality levels.

METHODS

This retrospective analysis used blinded data recorded during 2017 in the Non-communicable Diseases National Information System (SIC) and T2D prevalence reported in 2018 ENSANUT to evaluate the EC achieved. We included individuals ≥ 20 years old without social security who did not declare the use of private health care services. Each EC component (need, use, and quality) was estimated based on the Shengelia adapted framework. The Kruskal-Wallis test was applied to evaluate the associations among EC quintiles and demographics.

RESULTS

In 2017, 26.5 million individuals, aged ≥ 20 years, without social security, and without the use of private health care services, were under the care of 12,086 PHCs. The national prevalence of T2D was 10.3%, equivalent to 2.6 million people living with T2D in need of primary health care. Large contrasts were seen among EC components between and within Mexican states. We found that only 37.1% of the above individuals received health services at PHCs and of them, 25.8% improved their metabolic condition. The national EC was 9.3%, and the range (by health jurisdiction) was 0.2%-38.6%, representing a large geographic disparity in EC. We found an evident disconnect among need, utilization, and quality rates across the country.

CONCLUSIONS

Expansion and improvement of EC are urgently needed to address the growing number of people living with T2D in Mexico, particularly in states with vulnerable populations.

The road to recovery: an interrupted time series analysis of policy intervention to restore essential health services in Mexico during the COVID-19 pandemic

Background

Recovery of health services disrupted by the COVID-19 pandemic represents a significant challenge in low- and middle-income countries. In April 2021, the Mexican Institute of Social Security (IMSS), which provides health care to 68.5 million people, launched the National Strategy for Health Services Recovery (Recovery policy). The study objective was to evaluate whether the Recovery policy addressed COVID-related declines in maternal, child health, and non-communicable diseases (NCDs) services.

Methods

We analysed the data of 35 IMSS delegations from January 2019 to November 2021 on contraceptive visits, antenatal care consultations, deliveries, caesarean sections, sick children’s consultations, child vaccination, breast and cervical cancer screening, diabetes and hypertension consultations, and control. We focused on the period before (April 2020 – March 2021) and during (April 2021 – November 2021) the Recovery policy and used an interrupted time series design and Poisson Generalized Estimating Equation models to estimate the association of this policy with service use and outcomes and change in their trends.

Results

Despite the third wave of the pandemic in 2021, service utilization increased in the Recovery period, reaching (at minimum) 49% of pre-pandemic levels for sick children’s consultations and (at maximum) 106% of pre-pandemic levels for breast cancer screenings. Evidence for the Recovery policy role was mixed: the policy was associated with increased facility deliveries (IRR = 1.15, 95%CI = 1.11-1.19) with a growing trend over time (IRR = 1.04, 95%CI = 1.03-1.05); antenatal care and child health services saw strong level effects but decrease over time. Additionally, the Recovery policy was associated with diabetes and hypertension control. Services recovery varied across delegations.

Conclusions

Health service utilization and NCDs control demonstrated important gains in 2021, but evidence suggests the policy had inconsistent effects across services and decreasing impact over time. Further efforts to strengthen essential health services and ensure consistent recovery across delegations are warranted.

Use of an electronic integral monitoring system for patients with diabetes to identify factors associated with an adequate glycemic goal and to measure quality of care

AIMS

To evaluate the use of the electronic integral monitoring system (SMID) to identify factors associated to glycemic control and its impact in the quality of care in patients with type 2 diabetes (T2D).

METHODS

T2D patients registered in SMID were analyzed. Biochemical, clinical and lifestyle variables were recorded. Factors associated to HbA1c ≤7% were explored. Quality of care of the clinic was measured according to the National Committee for Quality Assurance Criteria (NCQA) that requires a score of 75 to achieve a good quality of care.

RESULTS

511 patients were included. Prescription of basal insulin, SGLT-2 inhibitors and barriers to follow nutritional plan were associated with decreased probability of having adequate glycemic control. Patients in the maintenance stage of motivation had higher probability of having HbA1c ≤7%. According to NCQA evaluation 60 points were achieved. Glucose goals were not met; 35.9% had HbA1c ≥9% and 17% HbA1c <7%. While foot evaluation, smoking approach, blood pressure and lipids goals were accomplished; eye and renal evaluations were borderline.

CONCLUSION

Glycemic control in patients with long standing T2D and multiple comorbidities is challenging, which directly impacts in the quality of care. Professionals should focus in reinforcing non-pharmacological interventions to optimize glycemic targets.

Evaluation of Medical Care for Diabetic and Hypertensive Patients in Primary Care in Mexico: Observational Retrospective Study

INTRODUCTION

The present study evaluated the quality of medical care for patients diagnosed with diabetes mellitus (DM), hypertension (HBP), and both pathologies (DM+HBP) within a public health system in Mexico.

METHODS

45,498 patients were included from 2012 to 2015. All information was taken from the electronic medical record database. Each patient record was compared against the standard to test the quality of medical care.

RESULTS

Glycemia with hypertension goals reached 29.6% in DM+HBP, 48.6% in DM, and 53.2% in HBP. The goals of serum lipids were reached by 3% in DM+HBP, 5% in DM, and 0.2% in HBP. Glycemia, hypertension, and LDL cholesterol reached 0.04%. 15% of patients had an undiagnosed disease. Clinical follow-up examinations reached 20% for foot examination and clinical eye examination. Specialty referrals reached 1% in angiology or cardiology.

CONCLUSION

Goals for glycemic and hypertension reached 50% in the overall population, while serum lipids, clinical follow-up examinations, and referral to a specialist were deficient. Patients who had both diseases had more consultations, better control for hypertension and lipids, but inferior glycemic control. Overall, quality care for DM and/or HBP has not been met according to the standards.

Efficacy of the treatment with dapagliflozin and metformin compared to metformin monotherapy for weight loss in patients with class III obesity: a randomized controlled trial

Background

Mexico has one of the highest prevalence rates of obesity worldwide. New pharmacological strategies that focus on people with class III obesity are required. Metformin and dapagliflozin are two drugs approved for the treatment of diabetes. Beyond its effects on glucose, metformin has been suggested by some studies to result in weight loss. Therapy with dapagliflozin is associated with a mild but sustained weight loss in patients with diabetes.

The primary outcome of the study is to determine if the combined treatment with dapagliflozin and metformin is more effective than monotherapy with metformin for weight loss in patients with class III obesity and prediabetes or diabetes who are awaiting bariatric surgery (including those patients who do have surgery). We also aimed to assess the effect of this combined treatment on waist circumference, triglycerides, blood pressure, and inflammatory cytokines.

Methods

This randomized phase IV clinical trial will include patients with diabetes or prediabetes who are between the ages of 18 and 60 years and exhibit grade III obesity (defined as body mass index ≥ 40 kg/m²). Patients using insulin will be excluded. Subjects will be randomized to one of two groups as follows: 1) metformin tablets 850 mg PO bid or 2) metformin tablets 850 mg PO bid plus dapagliflozin tablets 10 mg PO qd. The sample size required is 108 patients, which allows for a 20% dropout rate: 54 patients in the metformin group and 54 in the metformin/dapagliflozin group. All participants will receive personalized nutritional advice during the study. A run-in period of one month will be used to assess tolerance and adherence to treatment regimens. Anthropometric and biochemical variables will be recorded at baseline and at 1, 3, 6, and 12 months. A serum sample to determine glucagon, ghrelin, adiponectin, resistin, interleukin 6, and interleukin 10 will be collected at baseline and before surgery, or at 12 months (whatever happens first).

Adherence to treatment and adverse and secondary events will be recorded throughout the study. An intention-to-treat analysis will be used.

Discussion

Forty-six percent of the patients in our Obesity Clinic have been diagnosed with prediabetes (32%) or diabetes (14%). The use of dapagliflozin in this population could improve weight loss and other cardiovascular factors. This effect could be translated into less time before undergoing bariatric surgery and better control of associated comorbidities.

Trial registration

Clinicaltrials.gov, ID: NCT03968224. Retrospectively registered on May 29, 2019.

Assessing health system performance: effective coverage at the Mexican Institute of Social Security

Universal health coverage is a national priority in Mexico, with active efforts to expand public healthcare system access, increase financial protection and improve quality of care. We estimated effective coverage of multiple conditions within the Mexican Institute of Social Security (IMSS), which covers 62 million individuals. We identified routinely collected performance indicators at IMSS from 2016 related to use and quality of care for conditions avertable with high-quality healthcare; where candidate indicators were available, we quantified need for service from a population-representative survey and calculated effective coverage as proportion of individuals in need who experience potential health gains. We assessed subnational inequality across 32 states, and we weighted conditions by relative contribution to national disease burden to estimate composite effective coverage. Conditions accounting for 51% of healthcare-avertable disability-adjusted life years lost in Mexico could be assessed: antenatal care, delivery care, newborn care, childhood diarrhoea, cardiovascular disease and diabetes. Estimated effective coverage ranged from a low of 27% for childhood diarrhoea to a high of 74% for newborn care. Substantial inequality in effective coverage existed between states, particularly for maternal and child conditions. Overall effective coverage of these six conditions in IMSS was 49% in 2016. Gaps in use and quality of care must be addressed to ensure good health for all in Mexico. Despite extensive monitoring of health status and services in Mexico, currently available data are inadequate to the task of fully and routinely assessing health system effective coverage. Leaders at IMSS and similar healthcare institutions must be more purposeful in planning the assessment of population need, utilization of care and quality impacts of care to enable linkage of these data and disaggregation by location or population sub-group. Only then can complex health systems be fairly and fully evaluated.

Application of machine learning methodology to assess the performance of DIABETIMSS program for patients with type 2 diabetes in family medicine clinics in Mexico

Background

The study aimed to assess the performance of a multidisciplinary-team diabetes care program called DIABETIMSS on glycemic control of type 2 diabetes (T2D) patients, by using available observational patient data and machine-learning-based targeted learning methods.

Methods

We analyzed electronic health records and laboratory databases from the year 2012 to 2016 of T2D patients from six family medicine clinics (FMCs) delivering the DIABETIMSS program, and five FMCs providing routine care. All FMCs belong to the Mexican Institute of Social Security and are in Mexico City and the State of Mexico. The primary outcome was glycemic control. The study covariates included: patient sex, age, anthropometric data, history of glycemic control, diabetic complications and comorbidity. We measured the effects of DIABETIMSS program through 1) simple unadjusted mean differences; 2) adjusted via standard logistic regression and 3) adjusted via targeted machine learning. We treated the data as a serial cross-sectional study, conducted a standard principal components analysis to explore the distribution of covariates among clinics, and performed regression tree on data transformed to use the prediction model to identify patient sub-groups in whom the program was most successful. To explore the robustness of the machine learning approaches, we conducted a set of simulations and the sensitivity analysis with process-of-care indicators as possible confounders.

Results

The study included 78,894 T2D patients, from which 37,767patients received care through DIABETIMSS. The impact of DIABETIMSS ranged, among clinics, from 2 to 8% improvement in glycemic control, with an overall (pooled) estimate of 5% improvement. T2D patients with fewer complications have more significant benefit from DIABETIMSS than those with more complications. At the FMC’s delivering the conventional model the predicted impacts were like what was observed empirically in the DIABETIMSS clinics. The sensitivity analysis did not change the overall estimate average across clinics.

Conclusions

DIABETIMSS program had a small, but significant increase in glycemic control. The use of machine learning methods yields both population-level effects and pinpoints the sub-groups of patients the program benefits the most. These methods exploit the potential of routine observational patient data within complex healthcare systems to inform decision-makers.

Electronic Health Records as Valuable Data Sources in the Health Care Quality Improvement Process

Background

In North Karelia, Finland, the regional electronic health records (EHRs) enable flexible data retrieval and area-level analyses. The aim of this study was to assess the early detection of type 2 diabetes (T2D) in the region and to evaluate the performed activities in order to improve the processes between the years 2012 and 2017.

Methods

Patients with T2D were identified from the EHRs using the ICD-10 codes registered during any visit to either primary or specialized care. The prevalence of T2D was calculated for the years 2012, 2015, and 2017 on the municipality level. The number of people found in the EHRs with diabetes was compared with the number found in the national register of medication reimbursement rights.

Results

In 2012, the age-adjusted prevalence of T2D in North Karelia varied considerably between municipalities (5.5%-8.6%). These differences indicate variation in the processes of early diagnosis. The findings were discussed in the regional network of health professionals treating patients with T2D, resulting in sharing experiences and best practices. In 2017, the differences had notably diminished, and in most municipalities, the prevalence exceeded 8%. The regional differences in the prevalence and their downward trend were observed both in the EHRs and in the medication reimbursement rights register.

Conclusion

Clear differences in the prevalence of T2D were detected between municipalities. After visualizing these differences and providing information for the professionals, the early detection of T2D improved and the regional differences decreased. The EHRs are a valuable data source for knowledge-based management and quality improvement.

Adequate health literacy is associated with better health outcomes in people with type 2 diabetes in Mexico

This study evaluates the health literacy of people with type 2 diabetes and its association with health outcomes. We conducted a cross-sectional survey in two family medicine clinics of the Mexican Institute of Social Security that included 778 diabetic patients >19 years of age. The Spanish version of the European Health Literacy questionnaire served to measure health literacy. Multiple logistic regressions were performed to determine the association between the independent variable (health literacy) and dependent variables (good self-rated health, glycemic control, and diabetes-related hospitalizations) after controlling for conceptually relevant patient's characteristics. Only 17.6% of patients had adequate health literacy; while, the remaining percentage showed inadequate (23%), or problematic (59.4%) health literacy. After adjusting for the patients' characteristics, those with adequate health literacy had 4.66 (95%CI: 2.26-9.61) times the odds of good self-rated health compared to those with inadequate literacy. Patients with adequate health literacy had 0.65 (95%CI: 0.49-0.86) times the odds of hospitalization due to diabetes compared to those with inadequate literacy. Compared to inadequate health literacy, problematic literacy was associated with increased odds of glycemic control. In conclusion, healthcare providers should actively address the health literacy needs of patients to increase good self-rated health, glucose control and reduce hospitalizations.

Diabetes and the direct secondary use of electronic health records: Using routinely collected and stored data to drive research and understanding

Introduction

Electronic health records provide an unparalleled opportunity for the use of patient data that is routinely collected and stored, in order to drive research and develop an epidemiological understanding of disease. Diabetes, in particular, stands to benefit, being a data-rich, chronic-disease state. This article aims to provide an understanding of the extent to which the healthcare sector is using routinely collected and stored data to inform research and epidemiological understanding of diabetes mellitus.

Methods

Narrative literature review of articles, published in both the medical- and engineering-based informatics literature.

Results

There has been a significant increase in the number of papers published, which utilise electronic health records as a direct data source for diabetes research. These articles consider a diverse range of research questions. Internationally, the secondary use of electronic health records, as a research tool, is most prominent in the USA. The barriers most commonly described in research studies include missing values and misclassification, alongside challenges of establishing the generalisability of results.

Discussion

Electronic health record research is an important and expanding area of healthcare research. Much of the research output remains in the form of conference abstracts and proceedings, rather than journal articles. There is enormous opportunity within the United Kingdom to develop these research methodologies, due to national patient identifiers. Such a healthcare context may enable UK researchers to overcome many of the barriers encountered elsewhere and thus to truly unlock the potential of electronic health records.

Loss of job-related right to healthcare is associated with reduced quality and clinical outcomes of diabetic patients in Mexico

Objectives

The Mexican Institute of Social Security (IMSS) provides a package of health, economic and social benefits to workers employed in private firms within the formal labour market and to their economic dependants. Affiliates have a right to these benefits only while they remain contracted, thus posing a risk for the continuity of healthcare. This study evaluates the association between the time (in days) without the right to healthcare due to job loss in the formal labour market and the quality of healthcare and clinical outcomes among IMSS affiliates with Type 2 diabetes mellitus (T2DM).

Design

Retrospective cohort study 2013-2015.

Setting

Six IMSS family medicine clinics (FMC) in Mexico City.

Participants

T2DM patients (n = 27 217) affiliated with job-related health insurance and at least one consultation with a family doctor during 2013.

Source of Information

IMSS affiliation department database and electronic health records and clinical laboratory databases.

Main Outcome Measure(s)

Quality of the processes (eight indicators) and outcomes (three indicators) of healthcare.

Results

The results indicated that losing IMSS right to healthcare is frequent, occurring to one-third of T2DM patients during the follow-up period. The time without the right to healthcare in the observed period was of 120 days on average and was associated with a 43.2% loss of quality of care and a 19.2% reduction in clinical outcomes of T2DM.

Conclusion

Policies aimed at ensuring access and continuity of care, regardless of job status, are critical for improving the quality of processes and outcomes of healthcare for diabetic patients.

Quality indicators for responsible use of medicines: a systematic review

OBJECTIVE

All healthcare systems require valid ways to evaluate service delivery. The objective of this study was to identify existing content validated quality indicators (QIs) for responsible use of medicines (RUM) and classify them using multiple frameworks to identify gaps in current quality measurements.

DESIGN

Systematic review without meta-analysis.

SETTING

All care settings.

SEARCH STRATEGY

CINAHL, Embase, Global Health, International Pharmaceutical Abstract, MEDLINE, PubMed and Web of Science databases were searched up to April 2018. An internet search was also conducted. Articles were included if they described medication-related QIs developed using consensus methods. Government agency websites listing QIs for RUM were also included.

ANALYSIS

Several multidimensional frameworks were selected to assess the scope of QI coverage. These included Donabedian's framework (structure, process and outcome), the Anatomical Therapeutic Chemical (ATC) classification system and a validated classification for causes of drug-related problems (c-DRPs; drug selection, drug form, dose selection, treatment duration, drug use process, logistics, monitoring, adverse drug reactions and others).

RESULTS

2431 content validated QIs were identified from 131 articles and 5 websites. Using Donabedian's framework, the majority of QIs were process indicators. Based on the ATC code, the largest number of QIs pertained to medicines for nervous system (ATC code: N), followed by anti-infectives for systemic use (J) and cardiovascular system (C). The most common c-DRPs pertained to 'drug selection', followed by 'monitoring' and 'drug use process'.

CONCLUSIONS

This study was the first systematic review classifying QIs for RUM using multiple frameworks. The list of the identified QIs can be used as a database for evaluating the achievement of RUM. Although many QIs were identified, this approach allowed for the identification of gaps in quality measurement of RUM. In order to more effectively evaluate the extent to which RUM has been achieved, further development of QIs may be required.

Implementation and Outcomes of a Comprehensive Type 2 Diabetes Program in Rural Guatemala

Background

The burden of chronic, non-communicable diseases such as diabetes is growing rapidly in low- and middle-income countries. Implementing management programs for diabetes and other chronic diseases for underserved populations is thus a critical global health priority. However, there is a notable dearth of shared programmatic and outcomes data from diabetes treatment programs in these settings.

Program Description

We describe our experiences as a non-governmental organization designing and implementing a type 2 diabetes program serving Maya indigenous people in rural Guatemala. We detail the practical challenges and solutions we have developed to build and sustain diabetes programming in this setting.

Methods

We conduct a retrospective chart review from our electronic medical record to evaluate our program’s performance. We generate a cohort profile, assess cross-sectional indicators using a framework adapted from the literature, and report on clinical longitudinal outcomes.

Results

A total of 142 patients were identified for the chart review. The cohort showed a decrease in hemoglobin A1C from a mean of 9.2% to 8.1% over an average of 2.1 years of follow-up (p <0.001). The proportions of patients meeting glycemic targets were 53% for hemoglobin A1C < 8% and 32% for the stricter target of hemoglobin A1C < 7%.

Conclusion

We first offer programmatic experiences to address a gap in resources relating to the practical issues of designing and implementing global diabetes management interventions. We then present clinical data suggesting that favorable diabetes outcomes can be attained in poor areas of rural Guatemala.

Feasibility of extracting data from electronic medical records for research: an international comparative study

BACKGROUND

Electronic medical records (EMR) offer a major potential for secondary use of data for research which can improve the safety, quality and efficiency of healthcare. They also enable the measurement of disease burden at the population level. However, the extent to which this is feasible in different countries is not well known. This study aimed to: 1) assess information governance procedures for extracting data from EMR in 16 countries; and 2) explore the extent of EMR adoption and the quality and consistency of EMR data in 7 countries, using management of diabetes type 2 patients as an exemplar.

METHODS

We included 16 countries from Australia, Asia, the Middle East, and Europe to the Americas. We undertook a multi-method approach including both an online literature review and structured interviews with 59 stakeholders, including 25 physicians, 23 academics, 7 EMR providers, and 4 information commissioners. Data were analysed and synthesised thematically considering the most relevant issues.

RESULTS

We found that procedures for information governance, levels of adoption and data quality varied across the countries studied. The required time and ease of obtaining approval also varies widely. While some countries seem ready for secondary uses of data from EMR, in other countries several barriers were found, including limited experience with using EMR data for research, lack of standard policies and procedures, bureaucracy, confidentiality, data security concerns, technical issues and costs.

CONCLUSIONS

This is the first international comparative study to shed light on the feasibility of extracting EMR data across a number of countries. The study will inform future discussions and development of policies that aim to accelerate the adoption of EMR systems in high and middle income countries and seize the rich potential for secondary use of data arising from the use of EMR solutions.

Adaptation and validation of the Distress Scale for Mexican patients with type 2 diabetes and hypertension: a cross-sectional survey

OBJECTIVES

The aim of this study was to adapt and validate the Distress Scale for Mexican patients with type 2 diabetes and hypertension (DSDH17M).

SETTING

Two family medicine clinics affiliated with the Mexican Institute of Social Security.

PARTICIPANTS

722 patients with type 2 diabetes and/or hypertension (235 patients with diabetes, 233 patients with hypertension and 254 patients with both diseases).

DESIGN

A cross-sectional survey.

METHODS

The validation procedures included: (1) content validity using a group of experts, (2) construct validity from exploratory factor analysis, (3) internal consistency using Cronbach's α, (4) convergent validity between DSDH17M and anxiety and depression using the Spearman correlation coefficient, (5) discriminative validity through the Wilcoxon rank-sum test and (6) test-retest reliability using intraclass correlation coefficient.

RESULTS

The DSDH17M has 17 items and three factors explaining 67% of the total variance. Cronbach α ranged from 0.83 to 0.91 among factors. The first factor of 'Regime-related Distress and Emotional Burden' moderately correlated with anxiety and depression scores. Discriminative validity revealed that patients with obesity, those with stressful events and those who did not adhere to pharmacological treatment had significantly higher distress scores in all DSDH17M domains. Test-retest intraclass correlation coefficient for DSDH17M ranged from 0.92 to 0.97 among factors.

CONCLUSIONS

DSDH17M is a valid and reliable tool to identify distress of patients with type 2 diabetes and hypertension.

Gender differences in the association between hyperuricemia and diabetic kidney disease in community elderly patients

AIMS

To investigate gender differences of the associations between hyperuricemia and diabetic kidney disease (DKD) in elderly patients with type 2 diabetes mellitus (T2DM) based on electronic health records (EHR).

METHODS

A total of 20,207 older diabetic patients (mean age 71±7years) were investigated based on the EHR from 2012 to 2013 in the Minhang District of Shanghai-China. The status of hyperuricemia, albuminuric DKD and the odds ratios of DKD relative to hyperuricemia were analyzed among 8541 men and 11,666 women.

RESULTS

The overall rate of hyperuricemia was 20.5% (males: 17.2%, females: 23.0%) and that of albuminuric DKD was 36.2% (males: 32.2%, female: 39.1%) in these diabetic patients. Hyperuricemia was independently associated with increased risk of reduced renal function and albuminuria (p<0.001) in both genders. After adjustment of traditional DKD risk factors, hyperuricemia had a stronger association with albuminuric DKD in males (OR 1.67, 95% CI: 1.48-1.88) than in females (OR 1.23, 95% CI: 1.12-1.35).

CONCLUSIONS

This study showed an independent association of hyperuricemia with albuminuric DKD that was stronger in elderly males for the first time in China based on EHR. The level of uric acid should be monitored and managed in older diabetic patients.

Quality of Diabetes Care: The Challenges of an Increasing Epidemic in Mexico. Results from Two National Health Surveys (2006 and 2012)

Background

The quality of diabetes care remains suboptimal according to numerous studies assessing the achievement of quality indicators for diabetes care in various healthcare settings. We report about global and specific quality indicators for diabetes care and their association to glycemic control at the population level in two national health surveys in Mexico.

Methods

We conducted a cross-sectional analysis of the 2006 and 2012 National Health Surveys in Mexico. We examined quality of care for 2,965 and 4,483 adults (≥ 20 years) with diagnosed type 2 diabetes using fourteen simple and two composite indicators derived from self-reported information. In a subsample for both surveys, glycated hemoglobin (HbA1c) was measured at the time of the interview. We obtained survey weight-adjusted estimators using multiple regression models (logistic and linear) with combined data files, including survey year as covariate to assess change.

Results

Global quality of care in 2012 was 40.8%, with a relative improvement of 11.7% between 2006 and 2012. Detections of cardiovascular disease risk factors (dyslipidemia and hypertension) were the indicators with the highest improvement, while non-pharmaceutical treatment and diabetic foot exams showed minor changes. We found a significant association between the quality of the process of diabetes care and glycemic control (OR 2.53, 95% CI 1.63-3.94). Age more than 65 years old, the type of health subsystem, gender (males), and high socio-economic status were also significantly associated to glycemic control.

Conclusions

Quality diabetes care and glycemic control improved and are significantly associated. However, according to international standards, the current situation remains suboptimal. A more holistic approach is needed, with an emphasis on improving quality in outpatient care.

Quality of diabetes care at outpatient clinic, sultan qaboos university hospital

OBJECTIVE

To assess the clinical care of type 2 diabetes mellitus (T2D) patients at Sultan Qaboos University Hospital (SQUH), a countrywide tertiary referral center in Muscat, Oman. .

METHODS

We performed a retrospective, observational, cross-sectional study using a total of 673 Omani T2D patients from the Diabetes and Family Medicine Clinics at SQUH. We collected patient data from June 2010 to February 2012 from the Hospital Information System (HIS). Patients had to be Omani, aged more than 18 years old, and have T2D with active follow-up and at least three visits within one year to be included in the study. Ninety-three percent of the patients (n=622) were on oral hypoglycemic drugs and/or insulin, and 70% were on statins. Patients' anthropometric data, biochemical investigations, blood pressure, and duration of diabetes were recorded from the HIS. .

RESULTS

Using the recommended standards and guidelines of medical care in diabetes (American Diabetes Association and the American National Cholesterol Education Program III NCDP NIII standards), we observed that 22% of the patients achieved a HbA1C goal of <7%, 47% achieved blood pressure goal of <140/80mm Hg, 48% achieved serum low density lipoprotein cholesterol goal of <2.6mmol/L, 67% achieved serum triglycerides goal of <1.7 mmol/L, 59% of males and 43% of females achieved high density lipoprotein cholesterol goals (males>1.0; females >1.3mmol/L). Almost 60% of the patients had urinary microalbumin/creatinine ratio within the normal range. .

CONCLUSIONS

The clinical outcomes of the care that T2D patients get at SQUH were lower than those reported in Europe and North America. However, it is similar to those reported in other countries in the Arabian Gulf.

Quality of care for hip and knee osteoarthritis at family medicine clinics: lessons from Mexico

OBJECTIVE

(i) To develop quality-of-care indicators suitable for evaluation of care for knee and hip osteoarthritis (KHOA) at the primary care level using data from the electronic health records (EHRs) and (ii) to evaluate the quality of care that patients with KHOA receive at family medicine clinics (FMCs).

DESIGN

(i) Development of indicators following the RAND-UCLA method. (ii) A cross-sectional analysis of quality-of-care provided for patients with osteoarthritis.

SETTING

Four FMCs in Mexico City.

PARTICIPANTS

Knee and hip osteoarthritis patients, older than 19 years.

SOURCE OF THE INFORMATION

2009 EHR data.

MAIN OUTCOME MEASURES

Quality of care was evaluated using six indicators developed in the first stage of this study.

RESULTS

The quality of care evaluation identified that 26.1% of patients were advised in regard to physical exercise, and weight loss was encouraged in 19.7%. Only 5% of patients received acetaminophen as an initial oral analgesic; 54% of patients at risk for gastrointestinal complications received gastroprotective medicines. On average, the percentage of recommended care received was lower for patients who attended only one visit with family physician (17.6%) and higher for those with >3 visits (41.9%).

CONCLUSION

The quality of osteoarthritis care at FMCs in Mexico is suboptimal relative to the standards of care and requires continuous evaluation and implementation of improvement strategies.

Quality of care for children with upper respiratory infections at Mexican family medicine clinics

BACKGROUND

Upper respiratory infections are the principal cause of morbidity in children <5 years of age. The objectives of this study were (i) to develop quality-of-care indicators for evaluation of care for children with upper respiratory infections (URI) at the primary care level using data from the electronic health records and (ii) to evaluate the quality of URI care offered to children <5 years of age at family medicine clinics (FMCs).

METHODS

Development of indicators following the RAND-UCLA method was used. A cross-sectional analysis of quality of care provided for children with URI in four FMCs in Mexico City where 10,677 children <5 years of age with URI participated. The source of information was data from 2009 electronic health records. Quality of care was evaluated using six indicators developed in the first stage of this study.

RESULTS

The quality of care evaluation identified that only 15% of children had registries of intentional search of respiratory distress signs and 27% received information on warning signs. More than 61% of children diagnosed with uncomplicated and nonstreptococcal URI received antibiotic prescription during the first visit. In the case of children diagnosed with streptococcal pharyngitis or tonsillitis, 57.5% received the appropriate antibiotic. On average, the percentage of recommended care received was 47.2%.

CONCLUSIONS

It is reasonable to promote the use of electronic health records to routinely evaluate the quality of URI care. It is necessary to consider quality flaws that were found in order to endorse strategies aimed at strengthening the technical capacity of health personnel to exercise evidence-based clinical practice.

Quality improvement of metabolic control for patients with type 2 diabetes treated at a general hospital: a quantitative open cohort study

RATIONALE, AIMS AND OBJECTIVES

Most patients with type 2 diabetes have metabolic risk factors above recommend goals. The present intervention aimed to escalate medical treatment to improve metabolic control. The study was carried out at a Norwegian general hospital as a quantitative open cohort study.

METHODS

The audit evaluated 191 patients treated from 2007 to 2012. To improve metabolic control, a medical intervention used stepped care and goals for the metabolic risk factors. A database was used to overview the intervention. Multiple regression analyses assessed whether baseline characteristics and components of the intervention were associated with change of metabolic risk factors.

RESULTS

The intervention increased number of antihypertensive drugs and dose of metformin and insulin. The intensification lowered mean systolic blood pressure from 142 to 132 mmHg, low-density lipoprotein cholesterol from 2.6 to 2.1 mmol L(-1) and glycated haemoglobin, HbA1c, from 8.5 to 7.6% (64-57 mmol mol(-1) , P < 0.001, t-tests). At end of the study, 25 (13%) patients fulfilled targets for the three metabolic risk factors. Multiple linear regression analyses showed that changes of the three metabolic risk factors were significantly associated with levels at start of the study and number of visits or length of follow-up.

CONCLUSIONS

Stepped care was an effective treatment for type 2 diabetes at a general hospital. The database supported the intervention. It improved metabolic control over 4 years.

Opportunity cost for early treatment of Chagas disease in Mexico

Background

Given current neglect for Chagas disease in public health programs in Mexico, future healthcare and economic development policies will need a more robust model to analyze costs and impacts of timely clinical attention of infected populations.

Methodology/Principal Findings

A Markov decision model was constructed to simulate the natural history of a Chagas disease cohort in Mexico and to project the associated short and long-term clinical outcomes and corresponding costs. The lifetime cost for a timely diagnosed and treated Chagas disease patient is US$ 10,160, while the cost for an undiagnosed individual is US$ 11,877. The cost of a diagnosed and treated case increases 24-fold from early acute to indeterminate stage. The major cost component for lifetime cost was working days lost, between 44% and 75%, depending on the program scenario for timely diagnosis and treatment.

Conclusions/Significance

In the long term, it is cheaper to diagnose and treat chagasic patients early, instead of doing nothing. This finding by itself argues for the need to shift current policy, in order to prioritize and attend this neglected disease for the benefit of social and economic development, which implies including treatment drugs in the national formularies. Present results are even more relevant, if one considers that timely diagnosis and treatment can arrest clinical progression and enhance a chronic patient's quality of life.

Chagas disease is caused by the flagellated protozoan parasite Trypanosoma cruzi, vectored in Mexico in both rural and urban areas via one of 18 triatomine bug species. Despite ample morbidity and mortality evidence, however, health policy managers in Mexico have continued to neglect prevention, control and clinical attention for the disease. A computer simulation Markov model was programmed and fed with information from published evidence and an expert panel. The lifetime cost for a timely diagnosed and treated Chagas disease patient is US$ 10,160, while the cost for an undiagnosed individual is US$ 11,877. The cost of a diagnosed and treated case increases 24-fold from early acute to indeterminate stage. The major cost component for lifetime cost was working days lost, between 44% and 75%, depending on the program scenario for timely diagnosis and treatment. Timely medical attention for infected individuals is cheaper than doing nothing, especially if life and labor costs are included. The evidence provided, essential for decision-making, should be used to develop disease-specific prevention, control and patient clinical diagnosis and treatment policies for Chagas disease in Mexico.

Use of electronic health records to evaluate the quality of care for hypertensive patients in Mexican family medicine clinics

OBJECTIVES

Patients with hypertension require life-long care and should be monitored to identify whether they are receiving the appropriate healthcare and reach their expected health outcomes. Our objectives were to develop quality of healthcare indicators (QCI) and evaluate the quality of care that hypertensive patients receive in family medicine clinics at the Mexican Institute of Social Security.

METHOD

We used a two-stage mixed methods approach: development of QCIs following the RAND-UCLA method; quality of care evaluation using electronic health record (EHR) data from 47 150 hypertensive patients who received care in 2009. We developed 15 QCIs, which were possible to construct using EHR data. The QCIs evaluated the process of care and health outcomes.

RESULTS

Most hypertensive patients were women (64%) more than 60 years old; 79% were overweight/obese and 31% had diabetes. On average, these patients attended regularly to the family doctor (≥7 visits a year); however, they received only 27% of recommended care. Among the hypertensive patients without comorbidity, 62% had achieved blood pressure (BP) control, whereas in the group of hypertensive patients with diabetes or chronic kidney disease, only 7% had achieved BP control.

CONCLUSION

EHR can become a source of information to evaluate routinely quality of care in developing countries that are beginning to modernize their health information systems.

Diabetes in North America and the Caribbean: an update

The North America and Caribbean (NAC) Region faces a high burden of diabetes. In 2013, the number of children (aged 0-14 years) with type 1 diabetes was 108,600, with 16.7 new cases diagnosed per 100,000 children. Furthermore, there were 36,755,500 individuals with diabetes (mostly type 2 diabetes) in adults (20-79 years), and an additional 44,277,700 individuals had impaired glucose tolerance. The age-adjusted prevalence of diabetes in adults was 9.6%; the second highest among the seven Regions of the International Diabetes Federation. This estimate is expected to grow to 9.9% by 2035. There was some heterogeneity in the estimates within the Region with the age-adjusted prevalence for the USA estimated at 9.2%, 7.9% for Canada, 12.6% for Mexico, and 9.6% for the Caribbean islands. Mortality due to diabetes in the NAC Region is not limited to older age groups, with 37.6% of deaths occurring in people under the age of 60. The economic impact was also enormous, with healthcare expenditure due to diabetes estimated at 263.2 billion USD for 2013 - the highest of all IDF Regions. Diabetes threatens the public health and economies of countries in the NAC Region, and efforts in prevention and management must be intensified in order to surmount this growing problem.

Linking quality of healthcare and health-related quality of life of patients with type 2 diabetes: an evaluative study in Mexican family practice

Objective

To assess the association between quality of care and health-related quality of life among type 2 diabetes patients.

Design

A cross-sectional study assessing the association between quality of care and quality of life using multiple linear regression analysis.

Setting

Family medicine clinics (FMC) (n = 39) of the Mexican Institute of Social Security (IMSS) in Mexico City.

Participants

Type 2 diabetes patients (n = 312), older than 19 years.

Main Outcome Measure(s)

Health-related quality of life was measured using the MOS Short-Form-12 (SF-12); quality of healthcare was measured as the percentage of recommended care received under each of four domains: early detection of diabetes complications, non-pharmacological treatment, pharmacological treatment and health outcomes.

Results

The average quality of life score was 41.4 points on the physical component and 47.9 points on the mental component. Assessment of the quality of care revealed deficiencies. The average percentages of recommended care received were 21.9 for health outcomes and 56.6 for early detection of diabetes complications and pharmacological treatment; for every 10 percent additional points on the pharmacological treatment component, quality of life improved by 0.4 points on the physical component (coefficient 0.04, 95% confidence intervals 0.01–0.07).

Conclusions

There was a positive association between the quality of pharmacological care and the physical component of quality of life. The quality of healthcare for type 2 diabetes patients in FMC of the IMSS in Mexico City is not optimal.