Does patient education facilitate diabetic patients' possibilities to reach national treatment targets? A national survey in Swedish primary healthcare

Patients' Expectations of Evidence-Based Service at the Pharmacy Regarding Information on Self-Care of the Feet for Persons with Diabetes at Risk of Developing Foot Ulcers - A Cross-Sectional Observational Study in Sweden

Purpose

Self-care of the feet is one of the cornerstones in the prevention of diabetic foot ulcers (DFU). Often, individuals with diabetes seek help at the pharmacy, but it is still unclear whether the service meets their expectations and needs. The aims were to explore patients' expectations of support from the pharmacy regarding self-care of their feet and explore how patients with diabetes felt that they managed the self-care of their feet.

Patients and Methods

The included participants (n = 17), aged 70 ± 9 years, answered surveys regarding their expectations of support from the pharmacy related to self-care of the feet and how they felt that they managed the self-care of their feet. By using software, MyFoot Diabetes, they assessed their risk of developing DFU (ranging from 1 = no risk to 4 = DFU). In addition, a healthcare professional assessed the risk grade.

Results

Sixteen patients had not received any information from the pharmacy regarding how to take care of their feet. Several suggestions for ways the pharmacy could help patients with diabetes to take care of their feet were registered. They included having the necessary skills and competence, giving advice regarding self-care, giving information regarding the products they market and have for sale and giving advice on ointments/creams. The participants gave several examples of how they self-managed their feet: by wearing shoes indoors and outdoors, wearing socks and compression stockings as often as possible, being physically active, inspecting their feet, being aware of the fact that their feet have no problems, washing, moisturising their feet, cutting their nails and finally seeking help to prevent DFU.

Conclusion

The participants thought that they should receive competent information from the personnel at the pharmacy to improve the self-care of their feet, eg, being given information about which ointments/creams to use.

Clinical Trial

NCT05692778.

Variation in the achievement of HbA1c , blood pressure and LDL cholesterol targets in type 2 diabetes in general practice and characteristics associated with risk factor control

AIMS

To identify population, general practitioner, and practice characteristics associated with the achievement of HbA_1c , blood pressure and LDL cholesterol targets, and to describe variation in the achievement of risk factor control.

METHODS

We conducted a cross-sectional survey of 9342 people with type 2 diabetes, 281 general practitioners and 77 general practices in Norway. Missing values (7.4%) were imputed using multiple imputation by chained equations. We used three-level logistic regression with the achievement of HbA_1c , blood pressure and LDL cholesterol targets as dependent variables, and factors related to population, general practitioners, and practices as independent variables.

RESULTS

Treatment targets were achieved for HbA_1c in 64%, blood pressure in 50%, and LDL cholesterol in 52% of people with type 2 diabetes, and 17% met all three targets. There was substantial heterogeneity in target achievement among general practitioners and among practices; the estimated proportion of a GPs diabetes population at target was 55-73% (10-90 percentiles) for HbA_1c , 36-63% for blood pressure, and 47-57% for LDL cholesterol targets. The models explained 11%, 5% and 14%, respectively, of the total variation in the achievement of HbA_1c , blood pressure and LDL cholesterol targets. Use among general practitioners of a structured diabetes form was associated with 23% higher odds of achieving the HbA_1c target (odds ratio 1.23, 95% confidence interval (CI) 1.02-1.47) and 17% higher odds of achieving the LDL cholesterol target (odds ratio 1.17, 95% CI 1.01-1.35).

CONCLUSIONS

Clinical diabetes management is difficult, and few people meet all three risk factor control targets. The proportion of people reaching target varied among general practitioners and practices. Several population, general practitioner and practice characteristics only explained a small part of the total variation. The use of a structured diabetes form is recommended.

Elderly individuals with diabetes and foot ulcer have a probability for healing despite extensive comorbidity and dependency

BACKGROUND

Limited scientific evidence for prevention and treatment of diabetic foot ulcers in elderly with comorbidities.

AIM

To explore patient-related factors and outcomes in patients ≥75 years with diabetes and a foot ulcer.

METHOD

Sub-analysis of consecutively presenting patients ≥75 years (N = 1008) from a previous study on 2,480 patients with diabetic foot ulcer treated in a multidisciplinary system until healing. Patient characteristics: age - 81(75-96); diabetes type 2-98.7%; male/female - 49/51%; living with a spouse - 47%; nursing home 16%; or with home nursing 64%.

RESULT

Primary healing was achieved in 54%, minor amputation 8%, major amputation 9%, auto-amputation 2%, and 26% of the patients died unhealed. Among the oldest (88-96 years), 31% healed without any amputation. Extensive comorbidities were frequent: neuropathy 93%, visual impairment 73%, cardiovascular disease 60%, cerebrovascular disease 34%, and severe peripheral disease in 29% of the patients. Out of patients (80%) living in institutions or dependent on home nursing, 56% healed without amputation, compared to 44% of patients living in their own home without any support from social services or home nursing.

CONCLUSION

Healing without major amputation was achieved in 84% of surviving patients ≥75 years, despite extensive comorbidity and dependency.

Nurse-led patient-centered self-management support improves HbA1c in patients with type 2 diabetes-A randomized study

OBJECTIVES

The aim of this study was to evaluate the effect of a patient-centered self-management support, in type 2 diabetes (T2D) with regard to metabolic changes.

METHODS

182 patients were randomized into group intervention (GI), individual intervention (II) or internal controls (IC). An external control (EC) group was recruited from another county council. The intervention consisted of six sessions that featured themes, which regarded different views of their illness experiences. Data were collected in 2010 and 2011.

RESULTS

HbA1c was significantly decreased at 12-month follow-up with 5mmol/mol in the GI and 4mmol/mol in the II. In the IC group, the HbA1c was close to baseline. The EC group had increased HbA1c, though not significantly. When the HbA1c difference at baseline was adjusted, there was a significant difference between intervention groups and the EC-group.

CONCLUSION

Patient-centered self-management support, led by nurses, can lower HbA1c among patients with type 2 diabetes.

PRACTICE IMPLICATIONS

It is possible to train diabetes specialist nurses in clinical patient-centered care, and simultaneously influence patients' metabolic balance positively.

Patients' experiences of support for learning to live with diabetes to promote health and well-being: A lifeworld phenomenological study

Learning to live with diabetes in such a way that the new conditions will be a normal and natural part of life imposes requirements on the person living with diabetes. Previous studies have shown that there is no clear picture of what and how the learning that would allow persons to incorporate the illness into their everyday life will be supported. The aim of this study is to describe the phenomenon of support for learning to live with diabetes to promote health and well-being, from the patient’s perspective. Data were collected by interviews with patients living with type 1 or type 2 diabetes. The interviews were analysed using a reflective lifeworld approach. The results show that reflection plays a central role for patients with diabetes in achieving a new understanding of the health process, and awareness of their own responsibility was found to be the key factor for such a reflection. The constituents are responsibility creating curiosity and willpower, openness enabling support, technology verifying bodily feelings, a permissive climate providing for participation and exchanging experiences with others. The study concludes that the challenge for caregivers is to create interactions in an open learning climate that initiates and supports reflection to promote health and well-being.

Low attendance at structured education for people with newly diagnosed type 2 diabetes: General practice characteristics and individual patient factors predict uptake

OBJECTIVE

The aims were to determine the association between individual and neighbourhood factors and attendance at structured education amongst people with newly diagnosed type 2 diabetes (T2DM).

METHODS

Multi-level analysis of questionnaire data from a prospective cohort of adults newly diagnosed T2DM. Setting was primary care, London, UK. Main outcome was attendance at structured education within 2 years.

RESULTS

Of 1790 people recruited, attendance data were available for 1626 (91%). Only 22.4% (n=365/1626) attended education. Attendance was independently associated with female gender (OR 1.28, 95% CI 1.05-1.46), lower HbA1c (OR 0.98 mmol/mol 95% CI 0.97-0.99) and non-smoker status (OR 1.36, 95% CI 1.07-1.55). General practice covariates, achievement of primary care targets for glycaemic control (OR 1.05, 95% C.I. 1.01-1.08) and recording of retinal screening (OR 0.96, 95% C.I. 0.93-0.99) were independently associated with attendance but unexplained general practice clustering accounted for 17% of the variance.

CONCLUSION

Education uptake is low amongst people with new onset T2DM. Attenders are more likely to be female, non-smokers with better HbA1c. General practices achieving glycaemic targets are more likely to have patients who attend education.

PRACTICE IMPLICATIONS

Strategies are needed to improve attendance at structured diabetes education particularly amongst hard to reach groups.

Manoeuvring between anxiety and control: patients' experience of learning to live with diabetes: a lifeworld phenomenological study

Research shows that people with diabetes want their lives to proceed as normally as possible, but some patients experience difficulty in reaching their desired goals with treatment. The learning process is a complex phenomenon interwoven into every facet of life. Patients and healthcare providers often have different perspectives in care which gives different expectations on what the patients need to learn and cope with. The aim of this study, therefore, is to describe the experience of learning to live with diabetes. Interviews were conducted with 12 patients afflicted with type 1 or type 2 diabetes. The interviews were then analysed with reference to the reflective lifeworld research approach. The analysis shows that when the afflicted realize that their bodies undergo changes and that blood sugar levels are not always balanced as earlier in life, they can adjust to their new conditions early. The afflicted must take responsibility for balancing their blood sugar levels and incorporating the illness into their lives. Achieving such goals necessitates knowledge. The search for knowledge and sensitivity to changes are constant requirements for people with diabetes. Learning is driven by the tension caused by the need for and dependence on safe blood sugar control, the fear of losing such control, and the fear of future complications. The most important responsibilities for these patients are aspiring to understand their bodies as lived bodies, ensuring safety and security, and acquiring the knowledge essential to making conscious choices.

Organizational determinants of high-quality routine diabetes care

OBJECTIVE

Randomized trials showed that changes in healthcare organization improved diabetes care. This study aimed to identify which organizational determinants were associated with patient outcomes in routine diabetes care.

DESIGN

Observational study, in which multilevel regression analyses were applied to examine the impact of 12 organizational determinants on diabetes care as separate measures and as a composite score.

SETTING

Primary care practices in the Netherlands.

SUBJECTS

11,751 patients with diabetes in 354 practices.

MAIN OUTCOME MEASURES

Patients' recorded glycated hemoglobin (HbA1c), systolic blood pressure, and serum cholesterol levels.

RESULTS

A higher score on the composite measure of organizational determinants was associated with better control of systolic blood pressure (p = 0.017). No effects on HbA1C or cholesterol levels were found. Exploration of specific organizational factors found significant impact of use of an electronic patient registry on HbA1c (OR = 1.80, 95% CI 1.12-2.88), availability of patient leaflets on systolic blood pressure control (OR = 2.59, 95% CI 1.06-6.35), and number of hours' nurse education on cholesterol control (OR = 2.51, 95% CI 1.02-6.15).

CONCLUSION

In routine primary care, it was found that favorable healthcare organization was associated with a number of intermediate outcomes in diabetes care. This finding lends support to the findings of trials on organizational changes in diabetes care. Notably, the composite measure of organizational determinants had most impact.

Severe hypoglycaemia in drug-treated diabetic patients needs attention: a population-based study

OBJECTIVE

To study one-year incidence and risk factors of severe hypoglycaemias (SH) in adult drug-treated diabetic patients living in two Finnish communities.

DESIGN

The episodes of SH and their risk factors were identified from local ambulance registers, from the databases of local health care units, and from patient questionnaires.

SETTING

The target population consisted of all drug-treated diabetic patients from the two middle-sized communities in southern Finland, altogether 1776 patients. The study was retrospective.

SUBJECTS

A total of 1469 patients (82.7% of the target population) gave informed consent for the use of their medical records and 1325 patients (74.6% of the target population) returned the detailed 36-item questionnaire.

RESULTS

Of type 1 and type 2 insulin-treated diabetic patients, 14.6% and 1.0%, respectively, needed ambulance or emergency room care (incidence of 30.5 and 3.0 per 100 patient years). However, 31.0% of type 1 and 12.3% of type 2 diabetic patients reported at least one episode of SH (incidence of 72.0 and 27.0 per 100 patient years). Of all insulin-treated patients, 53 (7.8%) reported three or more episodes of SH. Significant independent risk factors for SH were depression, daily exercise, and nephropathy but not glycaemic control.

CONCLUSION

The incidence of SH was high in both types of insulin-treated diabetic patients. However, the recurrent episodes of SH were clustered in a small minority of insulin-treated patients with diabetes. The risk of SH should be considered when assessing the treatment target for an individual diabetic patient.

The relationship between HbA1c level, symptoms and self-rated health in type 2 diabetic patients

OBJECTIVE

Improving glycaemic control is generally supposed to reduce symptoms experienced by type 2 diabetic patients, but the relationships between glycated haemoglobin (HbA(1c)), diabetes-related symptoms, and self-rated health (SRH) are unclarified. This study explored the relationships between these aspects of diabetes control.

DESIGN

A cross-sectional study one year after diagnosis of type 2 diabetes.

SUBJECTS

A population-based sample of 606 type 2 diabetic patients, median age 65.6 years at diagnosis, regularly reviewed in primary care.

MAIN OUTCOME MEASURES

The relationships between HbA(1c), diabetes-related symptoms, and SRH.

RESULTS

The patients' median HbA(1c) was 7.8 (reference interval: 5.4-7.4 % at the time of the study). 270 (45.2%) reported diabetes-related symptoms within the past 14 days. SRH was associated with symptom score (γ = 0.30, p < 0.001) and HbA(1c) (γ = 0.17, p = 0.038) after correction for covariates. The relation between HbA(1c) and symptom score was explained by SRH together with other confounders, e.g. hypertension (γ = 0.02, p = 0.40). The relation between the symptom fatigue and SRH was not explained by symptom score and significantly modified the direct association between symptom score and SRH.

CONCLUSIONS

Symptom relief may not occur even when HbA(1c) level is at its lowest average level in the natural history of diabetes, and symptoms and SRH are closely linked. Monitoring symptoms in the clinical encounter to extend information on disease severity, as measured e.g. by HbA(1c), may help general practitioners and patients to understand the possible impact of treatments and of disease manifestations in order to obtain optimum disease control.

Experiences of the encounter with the diabetes team-a comparison between obese and normal-weight type 2 diabetic patients

OBJECTIVE

the aim of this study was to highlight and compare obese and normal-weight type 2 diabetic patients' perceptions and reported behaviors in terms of their care encounter with the diabetes team.

METHODS

interviews were conducted with 28 diabetic patients. Qualitative content analysis was used as analysis method.

RESULTS

the experiences revealed that when the care encounters took place from a health care perspective, there were no opportunities for individual support. For the obese diabetic patients, especially women, this gave rise to feelings of being stuck, defiance and shame, for those of normal weight, it created a sense of being left, despair and confusion. When encounters took place from the perspective of the individual, the diabetic patients need for support was fulfilled. For the obese diabetic patients this meant that the health care professionals recognised their needs and for those of normal weight, a feeling of security was created.

CONCLUSIONS

the results demonstrate differences in the experiences of obese and normal-weight diabetic patients' men and women in terms of their encounters with the diabetes team.

PRACTICE IMPLICATION

diabetic patients, especially the obese diabetic women, require tailor-made support provided by the health professionals in the diabetes team.

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.