Improved care of type 2 diabetes patients as a result of the introduction of a practice nurse: 2003-2007

Complex primary care for multimorbid patients in the Netherlands: Interprofessional perspectives within and beyond general practice

Many consultations in general practice concern patients with multimorbidity, pressuring our healthcare systems with complex care needs. The number of people affected from multimorbidity is still increasing, as is the average number of co-occurring diseases per patient. The resulting complexity of care needs cannot be managed by health professionals from a single discipline, but requires interprofessional collaborative practice. This paper describes best practices from the Netherlands to facilitate interprofessional caretaking of patients with multimorbidity in primary care. The focus here is on collaborations within general practice and at community level.

Nurses' adoption of diabetes clinical practice guidelines in primary care and the impacts on patient outcomes and safety: An integrative review

BACKGROUND

Complications related to diabetes mellitus impose substantial health and economic burdens to individuals and society. While clinical practice guidelines improve diabetes management in primary care settings, the variability in adherence to these guidelines persist. Hence, there is a need to comprehensively review existing evidence regarding factors influencing nurses' adherence to implementation of clinical practice guidelines to improve clinical care and patient safety.

OBJECTIVE

This integrative review seeks to investigate nurses' adherence to clinical guidelines for diabetes management in primary healthcare settings and to explore factors influencing effective implementation, focusing on the role of nurses and impacts on patient outcomes.

METHODS

A comprehensive search was conducted in March 2023 across six electronic databases. The search targeted studies that examined the use of Type 2 diabetes mellitus guidelines by nurses in primary healthcare settings with a focus on clinical management outcomes related to diabetes care or patient safety. Included studies were classified using the Effective Practice and Organisation of Care taxonomy, synthesised narratively and presented thematically. Reporting of the review adhered to PRISMA guidelines. (PROSPERO ID CRD42023394311).

RESULTS

The review included ten studies conducted between 2000 and 2020, and the results were categorised into three themes. These were: (i) Implementation strategies to promote clinical practice guidelines adherence, including health professional development, reminders for clinicians, patient-mediated interventions, health information systems, role expansion, and comprehensive package-of-care. A multifaceted educational approach emerged as the most effective strategy. (ii) Impact of guidelines adherence: These strategies consistently improved clinical management, lowering HbA1c levels, improving blood pressure and lipid profiles, and enhancing patient self-care engagement, along with increased nurses' adherence to diabetes clinical guidelines. (iii) The role of nurses in guideline implementation, enabling independent practice within multidisciplinary teams. Their roles encompassed patient education, collaborative practice with fellow healthcare professionals, program planning and execution, and comprehensive documentation review. Nurse-led interventions were effective in improving patient outcomes, underscoring the necessity of empowering nurses with greater autonomy in providing primary diabetes care.

CONCLUSION

Implementing a diverse range of strategies, focusing on comprehensive education for healthcare providers, is paramount for enhancing guideline adherence in diabetes care, to improve clinical management towards optimal patient health outcomes. Tailoring these strategies to meet local needs adds relevance to the guidelines. Empowering nurses to take a leading role in primary care not only enhances patient safety but also promotes quality of care, resulting in improved overall outcomes.

TWEETABLE ABSTRACT

In primary care, empowering nurses with diabetes guideline education and tailoring strategies to local needs enhance guideline adherence and improve patient outcomes.

Primary Care Variation in Rates of Unplanned Hospitalizations, Functional Ability, and Quality of Life of Older People

PURPOSE

To investigate variability in older people's outcomes according to general practitioner (GP) and practice characteristics in New Zealand and the Netherlands.

METHODS

We used data from 2 primary care-based, cluster-randomized, controlled trials to separately fit mixed models of unplanned admission rates, functional ability, and quality of life (QOL) and examine variation according to GP- and practice-level characteristics after adjusting for participant-level characteristics. For the New Zealand sample (n = 3,755 aged 75+ years in 60 practices), we modeled 36-month unplanned admission rates, Nottingham Extended Activities of Daily Living (NEADL) scale, and QOL domain ratings from the brief version of the World Health Organization Quality of Life assessment tool. For the Netherlands sample (n = 3,141 aged 75+ years in 59 practices), we modeled 12-month unplanned admission rates, Groningen Activity Restriction Scale scores, and EuroQOL 5 dimensions (EQ-5D) summary index.

RESULTS

None of the GP or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample, but we found greater rates of admission in larger practices (incidence rate ratio [IRR], 1.45; 95% CI, 1.15-1.81) and practices staffed with a practice nurse (IRR, 1.74; 95% CI, 1.20-2.52) in the Netherlands sample. In both samples, differences were consistently small where there were significant associations with function (range, -0.26 to 0.19 NEADL points in the New Zealand sample; no associations in the Netherlands sample) and QOL (range, -1.64 to 0.97 QOL points in New Zealand; -0.01 EQ-5D points in the Netherlands).

CONCLUSIONS

In the absence of substantial differences in older people's function and QOL, it remains unclear whether intriguing GP- or practice-related variations in admission rates represent low- or high-quality practice.

Association between GP participation in a primary care group and monitoring of biomedical and lifestyle target indicators in people with type 2 diabetes: a cohort study (ELZHA cohort-1)

OBJECTIVE

Whether care group participation by general practitioners improves delivery of diabetes care is unknown. Using 'monitoring of biomedical and lifestyle target indicators as recommended by professional guidelines' as an operationalisation for quality of care, we explored whether (1) in new practices monitoring as recommended improved a year after initial care group participation (aim 1); (2) new practices and experienced practices differed regarding monitoring (aim 2).

DESIGN

Observational, real-life cohort study.

SETTING

Primary care registry data from Eerstelijns Zorggroep Haaglanden (ELZHA) care group.

PARTICIPANTS

Aim 1: From six new practices (n=538 people with diabetes) that joined care group ELZHA in January 2014, two practices (n=211 people) were excluded because of missing baseline data; four practices (n=182 people) were included. Aim 2: From all six new practices (n=538 people), 295 individuals were included. From 145 experienced practices (n=21 465 people), 13 744 individuals were included.

EXPOSURE

Care group participation includes support by staff nurses on protocolised diabetes care implementation and availability of a system providing individual monitoring information. 'Monitoring as recommended' represented minimally one annual registration of each biomedical (HbA1c, systolic blood pressure, low-density lipoprotein) and lifestyle-related target indicator (body mass index, smoking behaviour, physical exercise).

PRIMARY OUTCOME MEASURES

Aim 1: In new practices, odds of people being monitored as recommended in 2014 were compared with baseline (2013). Aim 2: Odds of monitoring as recommended in new and experienced practices in 2014 were compared.

RESULTS

Aim 1: After 1-year care group participation, odds of being monitored as recommended increased threefold (OR 3.00, 95% CI 1.84 to 4.88, p<0.001). Aim 2: Compared with new practices, no significant differences in the odds of monitoring as recommended were found in experienced practices (OR 1.21, 95% CI 0.18 to 8.37, p=0.844).

CONCLUSIONS

We observed a sharp increase concerning biomedical and lifestyle monitoring as recommended after 1-year care group participation, and subsequently no significant difference between new and experienced practices-indicating that providing diabetes care within a collective approach rapidly improves registration of care.

The roles of healthcare professionals in diabetes care: a qualitative study in Norwegian general practice

Objective: To explore the experiences of general practitioners (GPs), nurses and medical secretaries in providing multi-professional diabetes care and their perceptions of professional roles.Design, setting and subjects: Semi-structured interviews were conducted with six GPs, three nurses and two medical secretaries from five purposively sampled diabetes teams. Interviews were analysed thematically.Main outcome measures: Healthcare professionals' (HCPs') experiences of multi-professional diabetes care in general practice.Results: The involvement of nurses and medical secretaries (collaborating health care professionals) was mainly motivated by GPs' time pressure and their perception of diabetes care as easy to standardize. GPs reported that diabetes care had become more structured and continuous after the involvement of collaborating health care professionals (cHCPs). cHCPs defined their role differently from GPs, emphasizing that their approach included acknowledging patients' need for diabetes education, listening to their stories and meeting their need for emotional support. GPs appeared less involved in patients' emotional concerns and more focused on the biomedical aspects of illness. There was little emphasis on teamwork among GPs and cHCPs, and none of the practices used care plans to involve patients in decisions or unify treatment among professionals. Participants stated that institutional structures including a discriminatory remuneration system, lack of role descriptions and missing procedures for collaborative approaches were an obstacle to MPC.Conclusions: cHCPs worked independently under delegated leadership of the GPs. Although cHCPs had a complementary role, HCPs in general practice may not take full advantage of the potential of sharing patient responsibility and learning with, from and about each other. Contextual barriers for team-based care approaches should be addressed in future research.KEY POINTSIt has been suggested that multi-professional approaches improve quality of care in people with long-term conditions.In this study, nurses and medical secretaries perceived to have a complementary role to general practitioners (GPs) in diabetes care, focusing on patient education, building trusting relationships and providing patients with emotional support.As multi-professional collaboration was minimal, GPs, nurses and medical secretaries in the included practices may not take full advantage of the potential of sharing care responsibility and learning with, from and about each other.

Real-world comparison of HbA1c reduction at 6-, 12- and 24-months by primary care provider type

AIMS

To assess differences in hemoglobin A_1c (HbA_1c) over time in diabetics treated by internal medicine physicians using the chronic care model (IMP-ancillary) or an advanced practice nurse (APN-IMP).

METHODS

Retrospective, 2-group comparative design using administrative databases and matching of IMP-ancillary and APN-IMP subjects 2:1 based on patient age (±3years), gender and race. Subjects were diabetics treated ≥2 times during 2007-2010, had ≥1 follow-up visit 6-months from baseline and ≥2 HbA_1c levels. HbA_1c levels were assessed longitudinally using linear mixed effect models. Pearson chi-square and two-sample t-tests compared groups on patient characteristics.

RESULTS

A total of 774 patients were identified. After matching 93 APN-IMP patients with 176 IMP-ancillary patients (N=269), there were no differences between groups in demographics; however, baseline mean (SD) HbA_1c was higher in APN-IMP group, p<0.001. Compared to baseline, at follow-up there were no between-group differences in HbA_1c levels at 6 and 12 months; at 24month follow-up, APN-IMP tended to have a large decrease in HbA_1c compared to the IMP-ancillary group; mean difference (95% CI), -0.26 (-0.56, 0.05) p=0.097.

CONCLUSION

Compared to baseline HbA_1c, patients treated by APN-IMP and IMP-ancillary provider groups had equivalent reductions in HbA_1c.

Implementation of selective prevention for cardiometabolic diseases; are Dutch general practices adequately prepared?

OBJECTIVE

Current guidelines acknowledge the need for cardiometabolic disease (CMD) prevention and recommend five-yearly screening of a targeted population. In recent years programs for selective CMD-prevention have been developed, but implementation is challenging. The question arises if general practices are adequately prepared. Therefore, the aim of this study is to assess the organizational preparedness of Dutch general practices and the facilitators and barriers for performing CMD-prevention in practices currently implementing selective CMD-prevention.

DESIGN

Observational study.

SETTING

Dutch primary care.

SUBJECTS

General practices.

MAIN OUTCOME MEASURES

Organizational characteristics.

RESULTS

General practices implementing selective CMD-prevention are more often organized as a group practice (49% vs. 19%, p = .000) and are better organized regarding chronic disease management compared to reference practices. They are motivated for performing CMD-prevention and can be considered as 'frontrunners' of Dutch general practices with respect to their practice organization. The most important reported barriers are a limited availability of staff (59%) and inadequate funding (41%).

CONCLUSIONS

The organizational infrastructure of Dutch general practices is considered adequate for performing most steps of selective CMD-prevention. Implementation of prevention programs including easily accessible lifestyle interventions needs attention. All stakeholders involved share the responsibility to realize structural funding for programmed CMD-prevention. Aforementioned conditions should be taken into account with respect to future implementation of selective CMD-prevention. Key Points   There is need for adequate CMD prevention. Little is known about the organization of selective CMD prevention in general practices.   • The organizational infrastructure of Dutch general practices is adequate for performing most steps of selective CMD prevention.   • Implementation of selective CMD prevention programs including easily accessible services for lifestyle support should be the focus of attention.   • Policy makers, health insurance companies and healthcare professionals share the responsibility to realize structural funding for selective CMD prevention.

Strategies to promote practice nurse capacity to deliver evidence-based care

Purpose

– Evidence-based practice is pivotal to effective patient care. However, its translation into practice remains limited. Given the central role of primary care in many healthcare systems, it is important to identify strategies that bolster clinician-capacity to promote evidence-based care. The purpose of this paper is to identify strategies to increase Practice Nurse capacity to promote evidence-based sexual healthcare within general practice.

Design/methodology/approach

– A survey of 217 Practice Nurses in an Australian state and ten respondent-interviews regarding two resources to promote evidence-based sexual healthcare – namely, a clinical aide and online training.

Findings

– The perceived impact of both resources was determined by views on relevance and design – particularly for the clinical aide. Resource-use was influenced by role and responsibilities within the workplace, accessibility, and support from patients and colleagues.

Research limitations/implications

– This is the first Australian study to reveal strategies to promote evidence-based sexual healthcare among Practice Nurses. The findings provide a platform for future research on knowledge translation processes, particularly among clinicians who might be disengaged from sexual healthcare.

Practical implications

– Given the benefits of evidence-based practices, it is important that managers recognize their role, and the role of their services, in promoting these. Without explicit support for evidence-based care and recognition of the Practice Nurse role in such care, knowledge translation is likely to be limited.

Originality/value

– Knowledge translation among Practice Nurses can be facilitated by: resources-deemed informative, relevant, and user-friendly, as well as support from patients, colleagues, and their workplace.

Association between quality management and performance indicators in Dutch diabetes care groups: a cross-sectional study

OBJECTIVES

To enhance the quality of diabetes care in the Netherlands, so-called care groups with three to 250 general practitioners emerged to organise and coordinate diabetes care. This introduced a new quality management level in addition to the quality management of separate general practices. We hypothesised that this new level of quality management might be associated with the aggregate performance indicators on the patient level. Therefore, we aimed to explore the association between quality management at the care group level and its aggregate performance indicators.

DESIGN

A cross-sectional study.

SETTING

All Dutch care groups (n=97).

PARTICIPANTS

23 care groups provided aggregate register-based performance indicators of all their practices as well as data on quality management measured with a questionnaire filled out by 1 or 2 of their quality managers.

PRIMARY OUTCOMES

The association between quality management, overall and in 6 domains ('organisation of care', 'multidisciplinary teamwork', 'patient centredness', 'performance management', 'quality improvement policy' and 'management strategies') on the one hand and 3 process indicators (the percentages of patients with at least 1 measurement of glycated haemoglobin, lipid profile and systolic blood pressure), and 3 intermediate outcome indicators (the percentages of patients with glycated haemoglobin below 53 mmol/mol (7%); low-density lipoprotein cholesterol below 2.5 mmol/L; and systolic blood pressure below 140 mm Hg) by weighted univariable linear regression.

RESULTS

The domain 'management strategies' was significantly associated with the percentage of patients with a glycated haemoglobin <53 mmol/mol (β 0.28 (0.09; 0.46) p=0.01) after correction for multiple testing. The other domains as well as overall quality management were not associated with aggregate process or outcome indicators.

CONCLUSIONS

This first exploratory study on quality management showed weak or no associations between quality management of diabetes care groups and their performance. It remains uncertain whether this second layer on quality management adds to better quality of care.

Quality assessment of practice nurse communication with type 2 diabetes patients

OBJECTIVE

Nurse self-management support for type 2 diabetes patients may benefit from applying theory-based behavior change counseling. The 5As model was used to assess if, and how, nurses applied the five key elements of self-management support in standard care.

METHODS

Seven practice nurses audio-recorded consultations with 66 patients. An existing instrument for assessing counseling quality was used to determine if the 5As were applied. Applied As were compared with quality criteria, to provide an in-depth assessment.

RESULTS

In almost every consultation, nurses assessed health behaviors, and arranged a follow-up meeting. However, nurses advised behavior change in less than half of the consultations, while setting goals and assisting patients to overcome barriers were used even less. Comparing applied As with quality criteria revealed several issues that could be improved.

CONCLUSION

Nurses consistently discussed health behaviors with patients, but important elements of self-management support were not applied.

PRACTICE IMPLICATIONS

Self-management support may benefit from training nurses in performing assessments that form the base for specific advice, setting goals, and addressing barriers to behavior change. Nurses also have to learn how to combine being medical expert and behavioral counselor. Clarifying both roles to patients may facilitate communication and establishing a collaborative relationship.

Effective Nurse Communication With Type 2 Diabetes Patients

Many type 2 diabetes mellitus patients have difficulties reaching optimal blood glucose control. With patients treated in primary care by nurses, nurse communication plays a pivotal role in supporting patient health. The twofold aim of the present review is to categorize common barriers to nurse–patient communication and to review potentially effective communication methods. Important communication barriers are lack of skills and self-efficacy, possibly because nurses work in a context where they have to perform biomedical examinations and then perform patient-centered counseling from a biopsychosocial approach. Training in patient-centered counseling does not seem helpful in overcoming this paradox. Rather, patient-centeredness should be regarded as a basic condition for counseling, whereby nurses and patients seek to cooperate and share responsibility based on trust. Nurses may be more successful when incorporating behavior change counseling based on psychological principles of self-regulation, for example, goal setting, incremental performance accomplishments, and action planning.

Quality of type 2 diabetes management in general practice is associated with involvement of general practice nurses

AIMS

To assess whether involvement of general practice nurses in type 2 diabetes care in Danish general practice is associated with improved adherence to national guidelines on regular type 2 diabetes monitoring, and with lower HbA1c and cholesterol levels in the type 2 diabetes population.

METHODS

The study was an observational study soliciting questionnaire data from 193 Danish general practices and register data on 12,960 patients with type 2 diabetes (age range 40-80 years) from a diabetes database and a laboratory database. Clustering was addressed in the analyses.

RESULT

Practices with well-implemented nurse-led type 2 diabetes consultations and practices with no nurse(s) employed differed according to the mean proportions of patients whose HbA1c was measured (6.4%-points: 95% CI: 1.5 to 11.4), and the mean proportions of patients whose HbA1c was ≥ 8% (-3.7%-points: 95% CI: -6.7 to -0.6). Small non-significant differences were found in the cholesterol analyses.

CONCLUSION

Compared with practices with no nurse(s) employed, the quality of diabetes management was generally higher in terms of that HbA1c was measured according to the guidelines in a larger proportion of the diabetes population and the proportion of patients with an HbA1c level ≥ 8% was lower in practices with well-implemented nurse-led type 2 diabetes consultations.

The Swedish National Survey of the Quality and Organization of Diabetes Care in Primary Healthcare--Swed-QOP

AIM

To describe the quality and organization of diabetes care in primary healthcare in Sweden regarding resources and ways of working.

METHOD

A questionnaire was used to collect data from all 921 primary healthcare centres (PHCCs) in Sweden. Of these, 74.3% (n=684) responded to the questionnaire covering list size of the PHCCs, number of diabetic patients, personnel resources and ways of working.

RESULTS

The median list size reported from the PHCCs was 9,000 patients, 294 of whom were diabetic patients. The majority (72%) of PHCCs had diabetes-responsible general practitioners (GPs) and almost all (97%) had diabetes specialist nurses (DSNs) with some degree of postgraduate education in diabetes. The PHCCs reported that they used regional/local diabetes guidelines (93%), were engaged in call-recall diabetic reviews by GP(s) (66%) and DSN(s) (89%), checked that patients had participated in the reviews by GP(s) (69%) and DSN(s) (78%), arranged group education programmes (23%) and reported data to a National Diabetes Register (82%).

CONCLUSIONS

The presence of diabetes-responsible GP(s) and DSN(s) who use guidelines may contribute to good and equal quality of care. It is, however, necessary to improve the call-recall system and there is an urgent need for all diabetic patients to receive patient education.