Diabetes Health Services in Sri Lanka: Development of a Quality Index

BACKGROUND: Diabetes mellitus is a major public health issue in Sri Lanka and across the globe. Patients with diabetes mellitus (DM) need long term comprehensive care. Quality of care for DM varies in different settings. Service quality assessment leads to identifying service areas that may benefit from appropriate intervention in order to achieve better health outcomes. The aim of this study was to develop and validate an instrument to measure the quality of services provided for patients with DM attending medical and diabetic clinics in state hospitals of Sri Lanka.

METHODS: A ‘Care for DM Quality of services’ (CD QS) instrument comprised of 8 subscales: routine services, glycaemic control, Blood Pressure and lipid control, weight control, annual screening, patient empowerment, recording of information and functional aspects was developed and validated. Trained research assistants collected data from 100 volunteer patients attending four diabetic clinics two each at secondary and tertiary level hospitals. Construct validity was established by multi-trait scaling analysis and known group comparisons. Internal consistency was assessed by item-total correlations and Cronbach’s alpha. Cut off levels to classify the hospital clinic as ‘good’, ‘moderate’ or ‘poor’ performance were determined by the average score in each subscale being above mean + SD (good), between mean + SD (moderate), and below the mean –SD (poor) respectively.

RESULTS: Multi-trait scaling analysis of items showed highest correlation with its own subscale compared to the other subscales. Significantly higher mean scores (p<0.05) for all the subscales were observed in tertiary level clinics compared to the secondary level. Internal consistency of ‘CD QS’ was good with Cronbach’s alpha of 0.9. Intra Class Correlation Coefficients were over 0.9 for all subscales with confidence intervals ranging from 0.8 to 2.9 suggestive of good inter-rater reliability.

CONCLUSIONS: ‘CD QS’ is a valid and reliable tool to assess both functional and technical quality of follow up care provided for patients with DM. This facilitates regular quality assessment of DM care thus identifying the gaps and improving the service quality. Further implementation and testing for clinical usefulness and acceptability will determine the tools application in the healthcare setting.