Actions aimed at the <i>Diabetes Mellitus</i> control in Primary Health Care: a proposal of evaluative model

Borges, Daiani de Bem; Lacerda, Josimari Telino de

doi:10.1590/0103-1104201811613

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ORIGINAL ARTICLE • Saúde debate 42 (116) • Jan-Mar 2018 • https://doi.org/10.1590/0103-1104201811613 copy

Actions aimed at the Diabetes Mellitus control in Primary Health Care: a proposal of evaluative model

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

The article corresponds to the assessment of the feasibility to evaluate the actions directed to the control of Diabetes Mellitus (DM) in Primary Health Care (PHC), and presents a proposal of an evaluation model. Documental analysis, literature review and meetings with experts guided the elaboration of the model. For its validation, the consensus conferencing technique was used. The matrix of analysis and judgment is composed of 19 indicators aggregated in two dimensions. Actions aimed at the control of DM in PHC are susceptible to evaluation. The application of the proposed evaluative model will increase the knowledge of the mechanisms and processes involved in the operationalization of the actions, contributing to its improvement.

KEYWORDS
Health evaluation; Diabetes Mellitus; Primary Health Care

Year	Legislation	Deliberations/Objectives
2001	Ordinance nº 95, of January 26, 2001	Approves the Operational Rule for Health Care -Noas-SUS 01/2001.
2001	Plan for the Reorganization of Attention to Hypertension and Diabetes Mellitus	It technically subsidizes the professionals of the Basic Attention network with the perspective of reorganizing the attention to arterial hypertension and to Diabetes Mellitus.
2002	Ordinance nº 371 / GM, March 4, 2002	Establishes the National Program of Pharmaceutical Assistance for Arterial Hypertension and Diabetes Mellitus, an integral part of the National Plan for Reorganization of Attention to Arterial Hypertension and Diabetes Mellitus.
2006	Law nº 11.347, of September 27, 2006	Provides for the free distribution of drugs and materials necessary for its application and monitoring of capillary glycemia for diabetic patients enrolled in diabetic education programs.
2006	Basic Attention Notebook n ° 16	Protocol based on scientific evidence worldwide aimed at health professionals, especially family health teams, to confront the DM.
2007	Ordinance nº 2,583, of October 10, 2007	Defines the list of drugs and supplies made available by the Unified Health System, pursuant to Law nº 11.347, of 2006, to users with Diabetes Mellitus.
2008	Guidelines and Recommendations for the Comprehensive Care of NTCD (Pact for Life Series, v.8)	It promotes reflection on the assistance model oriented to respond to the needs of people with NTCD.
2010	Ordinance nº 4.279, of December 30, 2010	Establishes guidelines for the organization of the Health Care Network within SUS.
2011	Ordinance nº 2.488, of October 21, 2011	Approves the National Policy of Basic Attention.
2012	Strategic actions plan for the confrontation of NTCD in Brazil 2011-2022	It promotes the development and implementation of effective public policies for the prevention and control of NTCDs and their risk factors and strengthens health services for chronic diseases.
2013	Ordinance nº 1,555, of July 30, 2013	Provides for the rules for financing and execution of the Basic Component of Pharmaceutical Assistance under the SUS.
	Guidelines for care of people with chronic diseases in Health Care Networks and Priority Care Lines	Establishes guidelines for the care of people with chronic diseases in the Network of Care for People with Chronic Diseases.
	Basic Attention Notebook n ° 36	Strategies for coping with NTCDs: Diabetes Mellitus.

		Indicator	Measures	Parameter	Source
Political-Organizational Dimension	People management	Coverage of professionals	Number of people residing in the area covered by the EqAB	Between 2500 and 3500 people without areas of social interest (10 pts);Between 2500 and 3500 people with an area of social interest (5 pts); More than 3500 peoples (0 pts)	DA Interview DO
			Perception of EqAB regarding the number of people residing in the area of coverage	Appropriate and convergent (10 pts); Partially convergent (5pts); Inadequate or divergent (0 pts)
			Support from physical educator, nutritionist, pharmacist to EqAB	Of the 3 professionals (10 pts);OF 2 professionals (5 pts); Of 1 or none (0 pts)
			Perception about the workload of support professionals available to EqAB.	Appropriate and convergent (10 pts); Partially convergent (5pts); Inadequate or divergent (0 pts)
		Permanence of professionals	Length of stay of the doctor in the EqAB	Good: 2 years or more (20 pts); Regular: from 1 to 2 years (10 pts);Bad: <1 year (5 pts)	Interview
		Permanence of professionals	Perception of EqAB regarding its professional valuation	Appropriate and convergent (20 pts); Partially convergent (5pts); Inadequate or divergent (0 pts)	Interview
		Qualification of professionals	Training on the organization/operation of the municipal network	Yes (10 pts); No (0 pts)	Interview DO
		Qualification of professionals	Update on NTCD or DM	Yes (10 pts); No (0 pts)	Interview DO
	Infrastructure at BHU	Physical structure of BHU	% of items included in checklist 'BHU with accessibility to users'	Transformation in score following the ratio (maximum 10 pts).	Interview DO
			Perception about user accessibility to BHU	Appropriate and convergent (10 pts); Partially convergent (5 pts); Inadequate or divergent (0 pts)
			% of items included in the checklist 'BHU with adequate physical structure'	Transformation in score following the ratio (maximum 10 pts).
			Perception about the adequacy of the physical structure of the BHU	Appropriate and convergent (10 pts); Partially convergent (5 pts); Inadequate or divergent (0 pts)
		Materials and equipment	% of items included in the checklist 'Materials and equipment for actions aimed at DM control'	Transformation in score following the ratio (maximum 10 pts)	Interview DO
			Perception of the EqAB regarding the materials and equipment available for the actions directed to the control of DM in BHU	Appropriate and convergent (10 pts); Partially convergent (5 pts); Inadequate or divergent (0 pts)
			Periodic maintenance of materials and equipment at BHU	Yes (10 pts); Partial (5 pts); No (0 pts)
		Medications and supplies	% of items included in the checklist 'Provision of medicines for the treatment of DM in BHU'	Transformation in score following the ratio (maximum 7,5 pts)	Interview DO
			% of items included in the checklist 'Supply of inputs for the application of insulin and AMGC in BHU'	Transformation in score following the ratio (maximum 7,5 pts)
			Perception regarding the supply of all medicines and supplies provided for the treatment of DM	Appropriate and convergent (7.5 pts); Partially convergent (3 pts); Inadequate or divergent (0 pts)
			Strategies adopted to guarantee the supply of medications and supplies in case of absences	Yes (7,5 pts); Partial (3 pts); No (0 pts)
Political-Organizational Dimension	Integration of the network of attention	Normatization of Attention	Use of protocol and guidelines aimed at the attention to the people with DM (doctor and nurse)	Yes (10 pts); Partial (5pts); No (0pts)	Interview DO
		Normatization of Attention	Use of protocol with access flows between the different points of the care network (doctor and nurse)	Yes (10 pts); Partial (5pts); No (0pts)	Interview DO
		Regulation of access to specialized services	Mechanisms for regulating access to specialized services	Yes (10 pts); No (0pts)	Interview DO
		Regulation of access to specialized services	Strategies to optimize the supply of specialized services	Yes (10 pts); Partial (5pts); No (0pts)	Interview DO
		Adequacy of supply to specialized services	Perception of waiting time for laboratory tests	Appropriate (10 pts); Partially appropriate (5 pts);Inadequate (0 pts)	Interview DO
			Perception of waiting time for consultation with endocrinologist	Appropriate (10 pts); Partially appropriate (5 pts);Inadequate (0 pts)
			Perception about waiting time for consultation with ophthalmology in the care network	Appropriate (10 pts); Partially appropriate (5 pts);Inadequate (0 pts)
	Monitoring and Evaluation	Availability of information	Systematic updating of the IS to register users/families	Yes (30 pts);Partial (15 pts);No (0 pts)	Interview DO
		Monitoring of actions aimed at DM control	Indicators of monitoring of the actions directed to the control of DM in the municipal network	Yes (15 pts);Partial (7 pts);No (0 pts)	Interview DO Prom
		Monitoring of actions aimed at DM control	Planning and organization of actions aimed at DM control based on the evaluation of selected indicators	Yes (15 pts);Partial (7 pts);No (0 pts)	Interview DO Prom
Technical-Assistance Dimension	Organization of care	Appropriation of territory	% of micro areas covered by CHAs	Transformation into score following the ratio (maximum 20 pts)	Interview DO Prom
			Perception of the actions of CHAs in the appropriation of the territory	Adequate and convergent (20 pts); Partially convergent (10 pts); Inadequate or divergent (0 pts)
			Updated mapping of PHC markers, including people with DM	Yes (20 pts); No (0 pts)
		Organization of the Agenda	Prioritizing care for people with DM	Yes (20 pts); Partial (10 pts);No (0 pts)	Interview DO Prom
			Guarantee of follow-up visits for people with DM	Yes (20 pts); No (0 pts)
			Emergency care for people with DM in the event of an accident	Yes (20 pts); Partial (10 pts);No (0 pts)
		Interdisciplinary action	Participation of CHAs in team meetings	Always (20 pts); Sometimes (10 pts); Never (0 pts)	Interview DO Prom
			Discussion of cases between EqAB and support professionals.	Always (20 pts); Sometimes (10 pts); Never (0 pts)
			Interlocution of different professionals in the organization of educational activities.	Always (20 pts); Sometimes (10 pts); Never (0 pts)
	Diagnosis, Treatment/ Follow-up	Early diagnosis of DM	Search of risk factors for the development of DM in medical and nursing care	Always (20 pts); Sometimes (10 pts); Never (0 pts)	Interview DO Prom
		Early diagnosis of DM	Request for exams for early diagnosis of MD in people aged 45 years or older and/or with BMI> 25, associated with at least one more risk factor	Always (20 pts); Sometimes (10 pts); Never (0 pts)	Interview DO Prom
		Early diagnosis of DM	Request for exams for early diagnosis of DM in pregnant women	Always (20 pts); Sometimes (10 pts); Never (0 pts)	Interview DO Prom
		Appropriate treatment	Orientations about the Lifestyle Modification (LM) in writing	Always (20 pts); Sometimes (10 pts); Never (0 pts)	Interview DO Prom
			Dispensing with guidance for the appropriate use of drugs for DM treatment	Adequada (20 pts: com orientação na maioria dos casos); Parcialmente adequada (10 pts: orientação em parte dos casos);Inadequada (0 pts: sem orientação)
			Prescriptions of R Insulin with guidance for dose adjustment according to HGT	Adequado (20 pts: na maioria dos casos); Parcialmente adequado (10 pts: em parte dos casos); Inadequado (0 pts: dose fixa na grande maioria dos casos)
			Frequency of requesting laboratory tests (FG and/or Hb1Ac) for people with DM	Adequada (20 pts: a cada 6 meses, se compensado);Parcialmente adequada (10 pts: uma vez por ano, independentemente de se está compensado ou não);Inadequada (sem uma periodicidade definida)
		Systematic follow-up	Use of a specific instrument to follow up people with DM	Yes (20 pts); Parcialmente (10 pts);No (0 pts)	Interview DO Prom
			Active Search for missing persons with DM	Yes (20 pts); Parcialmente (10 pts);No (0 pts)
			AMGC among people who use insulin	Adequada (20 pts: maioria sabe interpretar os resultados do HGT);Inadequada (0 pts: maioria não sabe interpretar os resultados do HGT)
	Prevention of DM and its complications	Health education activities	Periodic activities aimed at the primary prevention of DM	Yes (20 pts); No (0 pts)	Interview Prom
		Health education activities	Periodic activities aimed at DM control	Yes (20 pts); No (0 pts)	Interview Prom
		Prevention of complications associated with DM	Systematic assessment of diabetic foot in people with DM	Yes (20 pts); Parcialmente (10 pts);No (0 pts)	Interview Prom
			Systematic evaluation of the oral cavity in people with DM	Yes (20 pts); Parcialmente (10 pts);No (0 pts)	Interview Prom
			Periodic referral of people with DM for eye fundus evaluation	Yes (20 pts); Parcialmente (10 pts);No (0 pts)

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[1] Conflict of interests: non-existent