Health Surveillance and Disease Management / Noncommunicable Diseases / Diabetes
Implementation Manual for Collaborative Projects to Improve the Quality of Care for People with Chronic Diseases
Introduction | About This Manual
In Latin America, the estimated number of people with diabetes in the year 2000 was 13.3 million, and for 2030 the projected figure is 32.9 million, or double the number of cases. The estimates indicate that the diabetes epidemic will continue, even if the prevalence of obesity was maintained as it is now until the year 2030. The twofold increase in the number of people with diabetes will only occur as a consequence of population aging and urbanization. However, due to the increase that has been observed in the prevalence of obesity in many countries of the world and the importance of this as a risk factor for diabetes, the number of diabetes cases in 2030 could be much higher.
The increase in the prevalence of diabetes in the United States has been explained by a similar increase in the proportion of obese people, and not from an absolute in the risk of diabetes presenting itself. In accordance with the CAMDI survey carried out in Central America in people aged 20 years and over, the prevalence was higher in Belize (12.4%), Nicaragua (9.01%), and Guatemala (8.23); middling in Costa Rica (7.9%) and El Salvador (7.4%); and less in Honduras (6.1%).
Diabetes is often diagnosed very late. In accordance with various research projects, 50% of all patients with type 2 diabetes present some cardiovascular complication at the time of their diagnosis. Of all the complications (micro- or macrovascular), retinopathy stands out with percentages from 10% to 30%, neuropathy from 8% to 33%, and impotence from 5% to 66%, while hypertension ranges between 32% and 65%. Diabetes is the most frequent cause of polyneuropathy, and around 50% of the people with diabetes mellitus present neuropathic alterations in the 25 years following their diagnosis. Diabetes is responsible for some 90% of all non-traumatic amputations and is the leading cause of terminal renal failure.
The QUALIDIAB study carried out in clinics in the Central American capitals demonstrated that the people with diabetes treated in the centers did not have adequate glycemic control. The proportion of patients with good glycemic control was variable, with higher proportions in Nicaragua and Costa Rica and lower proportions in Guatemala and Honduras. Numerous incomplete files were found among clinicians that impeded the adequate evaluation of their care. Preventive practices, such as nutritional education and physical activity, were deficient. Improving care for diabetes and other chronic diseases should be a priority in medical practice in Central America since between 6% and 9% of all adults suffer from this disease; and the prognoses indicate a marked increase in the near future.
One strategy to improve the quality of care for people with diabetes was to carry out and implement a collaborative project destined for those countries or health services that are interested in develop continuous improvement projects for the quality of care, based on the Breakthrough Series (BTS) model proposed by the Institute for Healthcare Improvement in Boston, which has proved to be effective in hundreds of initiatives in the US, Canada, and many other countries throughout the world.
The objective of the collaborative project is to improve the quality of the care for people with chronic diseases on an ongoing basis through a joint effort on the part of professionals and health managers for excellent practice in the health units or services. During the approximate term of one year, the managers, health professionals, and people with chronic diseases should meet in Learning Sessions (3 in all) with the objective of participating in training, planning, and evaluation activities. During these Learning Sessions, the participants from the health units/services will work on evaluating their services, preparing an intervention plan based on a proposed change package package, and making a statement of what activities they will be carrying out. The involvement of each team in producing the proposed plans is important in order to bring about the results.
The methodology has already been used in different countries and has permitted lasting change once it generates a change in mentality change and a joint effort on the part of each and every one of the health teams, with the involvement of each professional.
PAHO had a positive experience in the implementation of this type of project in Mexico. Through this manual, it now hopes to get other countries enthusiastically involved with similar proposals.
The purpose of this manual is to provide interested parties with information on references for collaborative projects. The manual is also aimed at helping with the successful initial preparation for the year of work done on this project that promotes the improvement of the quality of life of people with chronic diseases.
The first part, Theoretical Framework of Collaborative Projects, contains a general view of the Collaborative and its theoretical framework, with a proposal for a timetable of te events and the most important activities.
In the section on Activities in the Preparatory Stage of the Collaborative, step-by-step instructions are provided on designing the project and organizing the participants, as well as tools to establish the baseline that will be used to measure the project's impact.
In the section on Operational Stage of the Collaborative, the main activities and their objectives are detailed step by step for the Learning Sessions of and the time during which activities will be carried out.
Finally the Annexes provide the VICEN evaluation and ACIC instruments, examples of indicators, agendas, and model for change packages.