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.
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.
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DOI：
10.1186/s12913-017-2177-4
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发表时间：
2017-03-23
影响因子：
2.8
通讯作者：
Klipstein-Grobusch K
中科院分区：
文献类型：
--
作者：
Ameh S;Gómez-Olivé FX;Kahn K;Tollman SM;Klipstein-Grobusch K
南非面临着慢性传染性疾病和非传染性疾病的复杂双重负担。作为回应，2011年在初级保健设施中启动了综合慢性病管理模式，以利用艾滋病毒/抗逆转录病毒疗法方案扩大非传染性疾病服务，实现最佳患者健康结果，并提高医疗质量。然而，对ICDM模式中的护理质量知之甚少。本研究的目的是：i）评估患者和运营经理对ICDM服务维度的满意度; ii）使用Avedis Donabedian的结构（资源）、过程（临床活动）和结果（医疗保健的预期结果）之间关系理论作为护理质量的衡量标准，评估ICDM模型中的护理质量。2013年在南非东北部姆普马兰加省布什巴克里奇市的七个初级保健设施进行了一项横断面研究-该地区有一个强大的健康和人口监测系统（HDSS）。患者满意度问卷（PSQ-18），与措施反映结构/过程/结果（SPO）的结构，进行了调整和管理的435名慢性病患者和所有7个PHC设施的业务经理。经调整的调查问卷包含17个护理方面，其中包括被确定为ICDM模式优先领域的8个方面-关键药物、设备、转诊、违约者追踪、药物预包装、诊所预约、等待时间和一致性。一个结构方程模型适合操作多纳贝迪安的理论，使用单向，调解和互惠途径。中介路径表明，结构，过程和结果之间的关系代表质量体系的ICDM模型。结构与过程（0.40）和结果（0.75）相关。给定结构，过程与结果相关（0.88）。在ICDM模型的17个护理维度中，三个结构（设备、关键药物、可及性）、三个过程（专业性、友好性和对患者的照顾）和三个结果（能力、信心和一致性）维度反映了其预期的结构。在优先事项方面，转诊、违约者追踪、药品预包装、预约和患者等待时间并没有反映其预期结构。Donabedian的理论框架可用于为ICDM模型中的质量体系提供证据。本文的在线版本（doi：10.1186/s12913-017-2177-4）包含补充材料，可供授权用户使用。
South 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. A 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. The 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. Of 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. The online version of this article (doi:10.1186/s12913-017-2177-4) contains supplementary material, which is available to authorized users.