Box 1. Selected care tasks and key indicators
Care taskKey indicators
QuantitativeQualitative
Screening and diagnosis1. Number of patients with diabetes registered, as percentage of overall outpatient attendance2. Number and percentage of patients examined for baseline clinical and laboratory, and age/anthropometric measurementsPatient’s and provider’s experiences, as well as practice deviations and reasons for:
  • identifying and examining patients who are overweight or symptomatic of diabetes mellitus

  • conducting clinical and laboratory exams, and diagnosis

Prescriptions3. Number and percentage of patients prescribed as per guidelines for diabetes and/or hypertension:
  • without comorbid condition

  • with comorbid condition (renal insufficiency; pregnancy)

4. Number and percentage of uncomplicated patients prescribed drugs without trying a lifestyle change 5. Number and percentage of patients prescribed preventive treatment
Patient’s and provider’s experiences, as well as practice deviations and reasons for:
  • prescribing, as per guide

  • trialling lifestyle changes before drugs

  • prescribing preventive drugs

Lifestyle modification6. Recording of smoking status and staff responsePatient’s and provider’s experiences, as well as practice deviations and reasons for:
  • counselling patient (with pictorial tool) for lifestyle change and smoking cessation

  • estimating and use of 'target weight' for patient counselling

Follow-up and adherence7. Number and percentage of patients adhering to follow-up visits (in first 9 months) 8. Number and percentage of patients examined (clinical/ laboratory) on follow-up visits 9. Number and percentage of patients referred for expert check-up and/or complication and/or severe drug reactionPatient’s and provider’s experiences, as well as practice deviations and reasons for:
  • patient adherence to follow-up visits (include retrieval)

  • staff adherence to care during follow-up visit

  • referrals (for example, side effects)

Material inputsPatient’s and provider’s experiences, as well as practice deviations and reasons for:
  • maintaining uninterrupted inputs

  • coping with input gaps and/or challenges