Background: Integrated and comprehensive models of care for chronic disease management have been proven effective. Considering that South Asia has the highest worldwide burden of diabetes, the need to implement and sustain these types of care models is critical. Little is known about what factors enhance or inhibit the sustainability of integrated diabetes care in South Asia or what factors impact scalability. 

Aims: To identify and describe barriers and facilitators to the sustainability and scalability of an intensive and comprehensive diabetes care improvement strategy to reduce cardiovascular risk in South Asia. 

Method: As a part of a longitudinal evaluation of the Cardiovascular Disease Risk Reduction Strategies in South Asia (CARRS) Translational Trial, a multi-site, controlled translation trial of integrated and comprehensive care strategies to reduce CVD risk among type 2 diabetes mellitus patients, in-depth interviews with physicians were conducted at three points in time throughout study implementation. 18 Physicians representing the ten participating study sites were interviewed about their perceptions of the CARRS Trial (i.e., utilizing a non-physician care coordinator and decision-supported electronic health records [DS-EHR]) prior to implementation (baseline), one year after implementation (interim), and two years after implementation (end line). Because the interim evaluation only included a subset of sites, a total of 35 interviews were collected and included in analysis. Verbatim transcriptions of all interviews were prepared. Two study team members developed a codebook upon reviewing a subset of interviews across the different time points, which, once finalized, was used to code all of the interview data using qualitative data analysis software (MAXQDA).  A thematic analysis approach was used to identify potential physician and clinic-level barriers to sustaining and scaling this model of care.  

Results: Prior to implementation, physicians perceived the intervention to be tested in the CARRS Trial as a potentially effective approach for providing responsive diabetes care. In addition, all clinics were already using evidence-based diabetes care guidelines so acceptability of the decision support software [DSS] was high. Positive feedback from patients and continued evidence of improvements in patient health outcomes sustained providers’ motivation to participate in the trial.  While acceptance of DSS prompts varied during implementation, the perception of this system as an aid in making treatment decisions supported physicians’ view that the DSS plays an important role in diabetes management. Physicians highly valued the role of care coordinators. Though physicians expressed concern over the sustainability of hiring care coordinators, most felt the benefits in terms of improved patient care and management, as well as costs saved at the clinic level over time, made this component a worthwhile investment. 

Physicians were less certain about the feasibility of the intervention at lower levels of care, but felt it may be more effective at the primary care level. When asked whether they would recommend this system be implemented at the primary care level, physicians stated it would provide a standardized approach to treating diabetes patients. Unlike physicians participating in this trial, those at the primary care level lack specialty training in diabetes care and would benefit from care prompts specific to cardiovascular risk factors. Clinics that have a higher patient burden were also identified as settings that would benefit from DSS system and a care coordinator. 

Discussion: These findings demonstrate acceptability of the CARRS Trial intervention among physicians with experience treating diabetes and advocate for further research into the feasibility of implementing this model of care at the primary care level in India. Efforts to sustain the CARRS Trial intervention in care settings where it has already been implemented should focus on maximizing the role of the care coordinator, enhancing the functionality of the DSS, and using the DSS to provide clinic-level data on patient health outcomes.

Factors impacting the sustainability and scalability of a multicomponent quality improvement strategy: the CARRS Trial