Developing and testing an Evaluation Strategy for Integrated care for Type II Diabetes in three health system contexts (Belgium, Cambodia and Slovenia)

Introduction: Primary health care (PHC) systems across the globe are struggling to produce an effective response to the rising burden of disease related to Type 2 Diabetes (T2D). However, effective T2D care at the PHC level – the ‘Integrated Care Package (ICP)’– exists and is cost-effective. Further, there is evidence that this integrated care package ((1) structure) leads to improved care processes (2), to health care responsive to people’s needs and eventually to better health outcomes (3). There is however a clear need for an assessment framework to enable countries to evaluate their progress towards integrated care for T2D.

We aim to test an assessment framework incorporating these 3 elements: (1) a tool to assess the degree to which the T2D care provided corresponds to the ICP for T2D (structure); (2) cascades-of-care to visualize and detect the ‘leakages’ at each separate step of the care continuum (process and outcomes of T2D care); and (3) a contextualization of (1) and (2) in order to explain why the implementation of specific ICP elements has or has not led to the expected outcomes. This framework will be tested in 3 countries with different PHC approaches, namely Slovenia, Belgium and Cambodia.

Methods:  A mixed methods design is used. First, information about the level of ICP implementation is collected using the ICP Grid at the health care facility level. Secondly, patient level data is used to build de T2D cascades-of-care: we rely on representative survey data (5000 individuals) in Cambodia, on health insurance (+ laboratory) data in Belgium and routine data in Slovenia. Where feasible, we used ICP scores as explanatory variables explaining the drops in the cascade. Thirdly, expert consultations and stakeholder interviews were used to contextualize the findings.

Results: The ICP grid scores showed considerable variations in the implementation of the ICP for patients with T2D between Belgium, Slovenia, and Cambodia – with Slovenia consistently reporting the highest scores. However, important in-country variations were observed for Belgium and Cambodia indicating that specific initiatives have resulted in higher levels of integrated care. In terms of T2D care process and outcomes, the country cascades-of-care display similar profiles with the biggest drops at the ‘diagnosis’ and ‘under control’-bars. The qualitative data on the health system clearly demonstrate that the context can hamper (1) the construction of the cascades (i.e. in Belgium and Cambodia due an absence of a routine monitoring system) and (2) the linking of the ICP grid data with the cascade-of-care data (i.e. in Cambodia where the private sector takes up a large proportion of T2D care).

Conclusions: The developed framework offers a promising strategy to assess (1) the progress made in ICP implementation in PHC for T2D as well as (2) its impact on the T2D care process and outcomes. As such, the framework offers policy makers and stakeholders a tool to monitor T2D care and adapt specific elements where required. The study, however, also indicated severe challenges in collecting the required data which also limited the cross-country comparability of the produced outcomes.