Alignment of primary care services for people with type 2 diabetes in Saudi Arabia with the Chronic Care Model (CCM): A mixed methods study

Aim: Diabetes mellitus is a major health issue in Saudi Arabia. It is a common, complex, long- term disorder that places a demand on individuals and healthcare providers. To ensure comprehensive and efficient care coordination for people with diabetes, primary care is an important part of the overall care delivery system. This study aimed to determine the extent to which current primary care services in one city in Saudi Arabia are aligned with an evidence- based model of chronic care delivery, the Chronic Care Model (CCM). It also aimed to ascertain the facilitators and barriers to its implementation. Methods: This was an explanatory sequential mixed methods study. The first phase was a narrative review to explore the extent of the use of the CCM as a whole or partially in the MENA region. Then, a cross-sectional survey in Saudi primary care centres was carried out to examine the alignment of diabetes care services with the six elements of the CCM from the perspectives of healthcare providers and people with diabetes. The tools used to examine the alignment were the Assessment of Chronic Illness Care (ACIC) and the Patient Assessment of Chronic Illness Care (PACIC-5A). Following that, a purposive sample of healthcare professionals and diabetes managerial personnel was chosen for the qualitative approach to explain their perceptions about the factors that facilitate and hinder the implementation of the six elements of the CCM. The final phase was to integrate the findings from the quantitative and qualitative approaches to obtain a clearer picture about the suitability to adopt the model in the context of the Saudi Arabian healthcare system. Results: The narrative review showed that the CCM was seldom used in the MENA and had not been systematically evaluated. The participants for the quantitative approach were recruited from 11 primary care centres (PCCs) in the Al Baha region. Responses were collected from 237 out of the 330 surveyed patients, and 27 physicians out of 33, with 71.8% and 81.8% response rates, respectively. From the patients’ perspective using PACIC-5A, primary care services were aligned with the CCM “most of the time”, with a summary score of 3.5/5.0 for PACIC and 3.4/5.0 for a summary score of 5A. The summary scores of the PACIC subscales were in the range of 3.7/5.0 for “delivery design” and “problem-solving/contextual counselling” to 3.2/5.0 for “follow up/coordination”. The subscales of 5A ranged between 3.6/5.0 for “Advise” and 3.0/5.0 for “Arrange”. There was no association between patients’ demographic and social characteristics with the PACI-5A scores. The hierarchical modelling of clustering within PCCs indicated that approximately 14–15% of the variability in the PACIC-5A scores was due to variation between the PCCs. From the healthcare providers’ perspective using ACIC, primary care services were aligned with the CCM and reflected a “reasonably good support for chronic illness care”, with a summary score of 6.3/11. The subscales of ACIC were in the range of “fully developed chronic illness care” for “Organisation of the healthcare delivery system” (7.5/11) to “reasonably good support for illness care” for the “integration of Chronic Care Model components” (5.8/11). Mapping the findings from PACIC-5A and ACIC found that the scores were broadly consistent. However, there was no correlation between the summary scores of PACIC-5A and ACIC, and the identified correlations between the subscales from PACIC-5A and ACIC were not statistically significant. In the interviews, 11 participants were purposively recruited from primary care centres and the region’s General Directorate of Health Affairs. The qualitative analysis for the anticipated facilitators and barriers toward the adoption of the CCM were described. The analysis identified three major themes: top-down system, cultural determinants, and recommendations to improve care. These factors recognised the rigid organisational structure of the healthcare system and cultural determinants to impede the implementation of the different elements in the CCM. The integration of the findings from the quantitative and qualitative approaches concluded that, while the surveys showed apparent high adherence to the CCM, some high scores were for elements that were not actually present, suggesting that the ACIC and PACIC-5A need to be used with caution. In other elements, the adherence reported in the survey was not to the “original” CCM, but to a locally and culturally modified version of it. This creates an important issue for implementation and its measurement between adapting the CCM to a context/culture and enforcing the CCM as originally specified. Conclusion: This study was unique in examining how the CCM was implemented in Saudi Arabia and the MENA region. It was the first study to combine ACIC and PACIC-5A to examine the alignment of PCC services for people with diabetes in Saudi Arabia with the CCM, and to examine the perceptions of healthcare providers, primary care managers, and diabetes coordinators about the factors that support or hinder the model implementation. This mixed methods study indicated that while the CCM is a multifaceted intervention that can be used to improve the quality of service in primary care centres, its assessment tools fall short of addressing a number of critical policy and cultural issues relevant in Saudi Arabia or the Middle East. For future research, the outcomes of this study lay the foundations for assessment studies in which the success of this model’s implementation is evaluated using the necessary analysis that takes specific local contextual aspects into account.