Abstract

The Costa Rican Social Security (CRSS) operates under the principles of solidarity and universal coverage in the country, without discrimination, regardless of origin, race or nationality. However, internal factors, such as failure in the fund raising system, increased spending and structural problems, have created a tendency to under-funding and non-sustainability of the institution, since the early nineties.^1,2

Because of this, the international agencies began to question the investment projects of the CRSS, therefore, it was determined to establish a process of modernization in terms of the structure and institutional functions and resource allocation based on efficiency, which stimulate user satisfaction and improve the quality of care.^1,2

As a regulatory tool, “management commitment” (MC) was created, which sets the standards, rules, incentives, penalties and assessments and adjustments in the implementation period, according to the planning and management control to detect deviations in meeting the goals and targets, and the redirection of resources, seeking to fit the needs of a given population. From underfunding, international financial organizations have recommended the public sector to work more efficiently and effectively in organizational management.

In the early nineties, the state begins to speak of social sector reform, and within this, the health sector, with a new direction: strengthening primary care. In turn, the Ministry of Health becomes a nationwide health vigilante governing body. The CRSS assumes the role of primary care, the preventative part; three levels of health care are established, according to the level of complexity; the reference and counter reference system between levels are promoted, to reduce service duplications and the vision of reducing the high hospital cost, by continuing the specialty services at various levels, is reinforced.³

A new institutional expense control mechanism is implemented, by introducing the new MC instrument, which marks the quality of service standards to users by age group, type of disease, and by the group according to the clinical characteristics– what becomes a model of health spending control-, and the CCSS quality of care (information obtained from Cerdas Angulo, Manuel, “Effects caused by management commitment assessment in the first six months, in the Monsignor Sanabria Hospital”, Puntarenas; MBA thesis on Sustainable Health Administration, SEP, UNED, Costa Rica, 1997).

One way to determine compliance with the quality of care at the primary level, is to study directly the compliance of the quality of care in an age group or a group of the same disease. In this case a cross-sectional study of diabetic patients in a health area was developed, as their high national prevalence and the high cost of care is an important issue.

This work aimed to study the compliance of the quality of care for diabetic users of the Alajuelita Health Area (AHA), and the determining factors in the failure to propose suggestions to improve it. It tried to show how the physical structure, the lack of training and health staff equipment contribute to flout the rules established in the MC, for the care of diabetic patients in the Alajuelita Health Area, from January to July 2007.

Materials and methods

A cross-sectional observational analytic descriptive study was conducted, based on data from the records of diabetic patients of the AHA,4 in the Alajuelita community, located south of San Jose, which is a marginal urban area.

The universe of analysis is the population of diabetics who have their medical checkups in the AHA. The target population consisted of diabetic patients with medical records in the AHA, a total of: 3088. Using a consecutive sample of the Area, 500 diabetic patient clinical files were analyzed to examine level compliance of the quality of their care, between January and July 2007. The sample included diabetic patients with associated diagnosis of hypertension and ischemic heart disease. Data collection was performed using a precoded sheet design based on that used for the control of diabetic patients, as part of MC nationwide.

To complement this, 40 Health Area workers directly related to the compliance of MC standards were interviewed. 40 employees were distributed (technicians, doctors, nurses and primary care technicians), the questionnaire about the physical plant, ventilation and lighting, space and distribution services in the Alajuelita Health Area.

The variables that were included on diabetic patient were age, sex, co morbidities, BMI, fasting glucose control, HbA1c, cholesterol and triglyceride levels, diabetic foot, -which was evaluated with PATONA- and education. Information was collected from medical consultations during the period of January to July 2007.

Results

The sample distribution of the diabetics evaluated by age and sex are shown in Figure 1. 29,6% of diabetics are men and 79,4% women. Diabetic women are most prevalent in the age group between 61-70 years old (21%), while in men prevails the group of >70 years old, which is 9,2%.

Regarding the behavior of the blood sugar levels in diabetics in the AHA, it was revealed that 2,8% of the sample were not given the test; 14,4% were given, but the result was not found in the file; 39,4% had blood glucose level between 101-150mg/dl; only 50 patients had blood glucose < de 100, which is 10%. In addition, 14 patients (2,8%) had a fasting blood glucose level between 201-300 mg/dl. Of these 500 patients, 63 had a fasting blood glucose >300, which is 12,6% of people poorly controlled (Table 1).

The distribution of total cholesterol levels in diabetics that were studied shows that 29,8% of patients were not at all given the test (Table 2). 47,6% of theses diabetics maintain the level of total cholesterol between 151-300mg/dl. Only 123 patients maintain a cholesterol <150 mg/dl, which is 24,6%. The study found that 60 diabetics (12%) did not have the total triglyceride levels indicated.

166 patients were not at all given the HDL cholesterol test, which is 33,2%. Similarly, 188 were not noted in the study of the LDL levels (37,6%). Only 165 diabetic patients (33%) have an adequate level of HDL, which is > 40 mg/dl; 169 maintain the level of HDL cholesterol <40 mg/ dl (Table 3).

In table 4, the BMI behavior of the sample of diabetic patients from the Area can be seen; 3,8% of the data cannot be obtained, corresponding to patients for whom their BMI did not appear in the file. The BMI was calculated and interpreted for 96,25%. Of the total sample analyzed, 183 patients (36,6%) had a BMI between 26-30. For 119 a BMI between 31-35 (23,8%) was registered.

Measurement of glycosylated hemoglobin was not indicated at all for 110 patients (22%). It was noted that many times the AHA clinical laboratory did not meet the medical indication for an unknown reason. The glycosylated hemoglobin level was obtained for 43,6% of the sample; of these, 125 patients (25% of the total) maintain an adequate level of HbA1c. 54 patients (10,8%) had a HbA1c level between 7,^1-8. And 39 diabetic patients maintain a level > 8 in this indicator, which is 7,8% (Table 5).

By interviewing technical personnel, it was discovered that 32,5% of the staff felt that the physical plant of the AHA is good; 22,5% said it was very good, and 20% said it was normal. 30% of the staff felt that the ventilation of the doctors and nurses offices is normal; 25% said it was good, and 17,5%, that is very good (Table 6).

Discussion

In Costa Rica, DM is one of the non-transmittable diseases whose prevalence is increasing and represents high costs for social security.^5,6 The lifestyle changes of the population, specifically in dietary habits and physical activity, have conditioned an increased incidence of chronic metabolic diseases and their complications. These changes affect the young population, which is experiencing an impact on some specific morbities, such as DM.^7-9

The two techniques available for assessing management effectiveness of glycemic control are the measurement of glucose and the HbA1c. The latter reflects blood glucose levels in ten weeks before, and has a strong predictive value for diabetic complications. Furthermore, it allows to corroborate the accuracy of the results reported by patient self-monitoring.

Glycosylated hemoglobin (HbA1c) is useful for evaluating long-term control of DM; it is a complementary test to the fasting and postprandial glycemia.¹⁰ Its assessment can make the necessary adjustments of the treatment in order to achieve the international goal proposals for adequate control of diabetic patients and preventing complications.¹¹

Clinical indicators for monitoring diabetes mellitus found in the cases studied in the AHA, provide an overview of the level of compliance with quality standards. It was found that the indication of the fasting glucose for patients is almost 100%, since the employees are aware of their importance for proper control in diabetic patients. Despite this, the indication for lipid profile percentage is relatively low (30%). It also emerged that the percentage of non-indication for HbA1c and other parameters required by MC by the AHA medical staff is low (22%).

It is known by many that medical personnel in health areas are very limited in time (15 minutes/ patient), and the MC evaluates more the filling of records than direct care and quality. An adjustment is necessary to relieve the medical staff of pressure from factors outside the MC.

This is the first AHA study in its 10 years of performance in the field of MC and care quality. The contribution made in staff perception of the Area, about the level of compliance with the quality of care provided to users, is important to verify treatment adherence, user satisfaction and promotion of healthy lifestyles through the prevention education program.