Diabetes Quality Of Care Evaluation In Shanghai Community Healthcare Centers

Background More than 422 million adults are living with Diabetes worldwide,and about one fourth of them are in China.Strengthening the Primary Healthcare(PHC)system capacity for managing Diabetes and other chronic diseases has therefore become a high national priority.In financial terms,this can be seen through the Chinese government increase in subsidies to PHC institutions from 2.8 billion US dollars in 2009 to 20.3 billion in 2015.Also,since the 2009 health-care reform major Chinese cities,including Shanghai,have implemented healthcare delivery models that encourage residents with chronic diseases to be treated by General Practitioners(GPs)working in Community Healthcare Centers(CHCs).However,there is a gap between registering with a GP and receiving effective chronic disease management or high quality of care.Therefore,research is needed for establishing how quality of PHC is measured in the community setting and how Diabetes care can be improved.Objectives(1)To critically analyze policies of quality improvement in China and their manifestation in Shanghai's primary level of care.(2)To appraise the current system of monitoring and improving quality of PHC in Hongkou(HK)district,Shanghai.(3)To explore quality of Diabetes care from the perspectives of stakeholders who provide or receive care for Diabetes in HK district,Shanghai.Methods the study included both quantitative and qualitative methodologies(mixed-methods).For objective(1),policy documents were critically analyzed regarding PHC quality improvement in China and in Shanghai.Data sources included administrative documents,decrees and laws,newspaper articles and policy reports.The document analysis yielded data – excerpts,quotations,or entire passages – which was organized into major themes,categories,and case examples.For objective(2),on the CHC level,official data from Shanghai 2015-6 evaluation of 239 CHCs was analyzed for identifying factors associated with achieving high rates of Diabetes standardized health management on the CHC level.Using multiple linear regression models the association between Diabetes standardized management rates and CHCs' characteristics was assessed.On the patient level,medical examination data of 11,628 diabetic patients from HK district(2017)was analyzed for identifying patterns of variation in controlled Diabetes among patients as well as CHCs.Descriptive statistics were generated for depicting the distribution of age,gender,BMI,CHCs and values of medical examinations in the studied population.Potential quality measures for controlled Diabetes were defined,according to both Chinese and International guidelines,and analyzed according to patient age,gender and CHC using regression.Quantitative analyses were conducted using STATA version 12.Lastly,for objective(3),in-depth interviews were conducted with 16 stakeholders including diabetic patients,GPs,directors of CHCs and policy makers involved in Diabetes quality measurement.Interviews were conducted in Chinese,with the assistance of a native Chinese speaker.Accuracy of translation from Chinese to English was first conducted with automated translation,then quality was assured by a native Chinese speaker according to the original audio recordings.Thematic content analysis was conducted with the support of Atlas TI software version 8.Results In Shanghai,improvements in CHCs' Diabetes standardized management during 2015-2016 were associated with high signing rates in 2015(n=234;b=0.129;p<0.05)and with high Diabetes health management rates in 2015(n=234;b=0.151;p<0.01),after controlling for CHC location and health professionals to residents ratios.Meaning,CHCs who successfully signed more residents and provided healthcare to a higher percentage of diabetic residents in their jurisdiction in 2015 were more likely to improve their Diabetes standardized management during 2015-6 From analyzing data of 11,628 Hongkou district Diabetic residents,it is apparent that most Diabetics who receive care in the district's CHCs in 2017 were elderly(average age: 67.24 ± 8.35 SD)with relatively well controlled Diabetes(median HbA1c: 6.8%;IQR:6.1-7.8%).Furthermore,within the regression analysis there was no significant association between residents age and glycemic control,when using HbA1 c < 7% as threshold.After controlling for gender and CHC,residents who were 20-49 years old(n=209;reference)were as likely to attain glycemic control as residents who were 60-69 years old(n=5680;b=-0.21;p=0.45)and 80-100 years old(n=1001;b=-0.29;p=0.22).According to qualitative findings,factors from both GPs' and patients' perspectives favor the provision of community healthcare services to patients with mild Diabetes while those with more severe conditions are more likely to be treated in tertiary hospitals.CHCs' Diabetes care is currently evaluated based on standardized management rate(i.e.quarterly patient-GP consultations)and control rate(i.e.fasting blood glucose < 7 mmol/L)while periodic testing of Hba1 C is not part of the evaluation conducted by the Health Committee.Discussion In line with national policies as well as international recommendations,Shanghai has prioritized the family doctor model for the treatment of chronic diseases and encourages residents to voluntary sign with a GP for receiving integrated care via the 1+1+1 model.The study's results support further government investment in increasing signing rates and the percentage of Diabetes residents treated in CHC,as they are both statistically associated with better standardized care for Diabetes on the CHC level.There are several possible explanations regarding the lack of significant association between residents age and glycemic control when using HbA1 c < 7% as threshold.The first relies on diagnosis of Diabetes using OGTT and FBG rather than HbA1 c,due to the latter being more expensive and still in the process of standardization in China.Decades of reliance on FBG and OGTT,which have higher sensitivity and lower specificity compared with HbA1 c,may have led to over-diagnosis of Diabetes among elderly in Shanghai.Another possible explanation can be that some patients with type 1 Diabetes may have been included within the reference group(age 20-49;n=209),thus reducing the significance of age and glycemic control within the study.Lastly,incentivized use of several indicators may have promoted the inclusion of elderly residents with mild disease in CHCs Diabetes management cohorts.This possibility is supported by findings from the document analysis as well as in-depth interviews.For example,in 2015 CHCs received a higher score on their evaluation when managing residents who are 70 years old with diagnosed Diabetes,than they would have for 60 years old,as in the former case they would be positively evaluated on both the Diabetes health management and elderly health management indicators for the same resident.Conclusions and policy recommendations the studied CHCs currently cater for the needs of elderly residents with mild Diabetes.Other residents,including adults younger than 60,who seek episodic-acute care in hospitals are at a higher risk of developing complications associated with un-managed Diabetes.Standardization of Diabetes diagnosis pathways for adults younger than 60 and strengthening hospital to CHC referral should receive immediate priority.For the long-term improvement of Diabetes care,HbA1 c testing is recommended to be implemented in all CHCs.Policy makers are recommended to(1)Improve knowledge on HbA1 c testing among residents with Diabetes and GPs,(2)Integrate between district health committee and CDC information platforms and(3)Conduct rigorous analysis of HbA1 c testing stratified by socioeconomic variables.