Quality improvement of the diabetes disease management program at Rx Health, a managed care organisation in South Africa
Background: The prevalence of diabetes mellitus has been on the increase worldwide increasing from 108 million in 1980 to 422 million in 2014. In 2012, diabetes mellitus caused approximately 1.5 million deaths and an additional 2.2 million deaths in related illness worldwide. In South Africa, similar trends have been observed with an estimated 3.85 million people suffering from diabetes mellitus in 2015. Diabetes mellitus, if managed well, may be controlled and the effects of diabetes can be minimised. If not properly managed, diabetes leads to damage to the nervous system, eyes, kidneys, and eventual death. To effectively manage diabetics, there are some monitoring tests that should carried out on all diabetic patients, such as the cholesterol, creatinine, and the glycated hemoglobin tests. Across the medical schemes registered in South Africa there were approximately 490 000 diabetics in 2017. Medical schemes may contract managed care organisations to put in place focused disease management programs. Rx Health, the study site, is a managed care organisation contracted to manage diabetics on-behalf of a registered medical scheme in South Africa.Data reported by the Council for Medical Schemes indicates that the proportion of diabetics receiving these monitoring tests is very low for the industry (28% for total cholesterol, 50% for creatinine and 27% for glycated hemoglobin in 2017) and significantly lower for Rx Health (1% for total cholesterol, 1.7% for creatinine and 1.1% for glycated hemoglobin) in the same year. The quality of care for diabetics at Rx Health is suboptimal and if left in its current state the health impact would be catastrophic for the patients. Objectives: This study had three objectives, exploring the barriers to care at Rx Health, developing change ideas to improve coverage ratios and implementing at least two change ideas and testing for the impact of each change. Methods: This study was an exploratory study that investigated the barriers to care at Rx Health using in-depth interviews. Since the team at Rx Health is small, almost all those involved in care of diabetics were interviewed. The one-on-one interviews were conducted at Rx Health, recorded, and later transcribed. Thematic analysis was used to analyse the interviewresponses and the findings were shared with the quality improvement team. The quality improvement team populated the driver diagram, identifying possible change ideas. The same team then populated the impact effort matrix and selected two change ideas for implementation. After the implementation of the selected change ideas, the coverage ratios of the three monitoring tests were compared pre and post implementation of the change ideas. The run charts were used to establish if the implemented change ideas led to an improvement in the coverage ratios.Results: The study identified several barriers to care such as IT system limitations, fragmentated care and poor benefit design. Some barriers were at Rx Health and others were at the medical scheme, providers and other organisations involved in patient care. The overall design of the care for diabetics at Rx Health had weaknesses, the medical scheme did not provide enough benefits for the diabetics. There is insufficient sharing of vital patient data between the medical scheme, the administrator, the pathology laboratories and Rx Health. The identification of diabetics is reactive rather than proactive. Furthermore, Rx Health is internally focused with minimum interaction with external parties such as other managed care organisations and regulators. The selected change ideas were provider communication through a letter informing the providers to conduct the appropriate monitoring tests and patient reminders through short message service to encourage patients to go for their monitoring tests. The implemented change ideas did not indicate an increase in the coverage ratios. The run charts did not indicate a shift in the coverage ratio for the creatinine and the glycated hemoglobin monitoring tests while total cholesterol test had a decrease in the coverage ratios. Conclusion: The care for diabetics is essential in the management of diabetics to manage the impact of the condition. It is vital that Rx Health follows a systematic way of improving the care it provides to its patients. The other organisations (the medical scheme, providers, and the administrator) involved in the care of diabetics must be brought into the discussion to deal with some of the structural challenges highlighted.
A research report submitted in partial fulfilment for the degree of Master of Science in Epidemiology in the field of Implementation Science to the Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 2020