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Acharya S, Taylor R, Parsons M, Attia J, Leigh L, Oldmeadow C, Wynne K, Rowe C, Joseph M, Luu J, Philcox A, Jackel D, Quach T, Sankoorikal C, Dagg S, Hure A. Spillover effects from a type 2 diabetes integrated model of care in 22,706 Australians: an open cohort stepped wedge trial. BMC Endocr Disord 2024; 24:183. [PMID: 39256722 PMCID: PMC11384678 DOI: 10.1186/s12902-024-01692-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/15/2024] [Indexed: 09/12/2024] Open
Abstract
BACKGROUND Many Australian adults are not receiving timely or effective diabetes management to prevent or delay the onset of diabetes related complications. Integrated care, a worldwide trend in healthcare reform, aims to reduce the fragmented delivery of health services and improve outcomes. This study aimed to test whether a specialist-led integrated model of care provided to a small subset of patients in general practices leads to spillover clinical improvements in all patients of the practice with type 2 diabetes. METHODS Seventy-two general practice sites (clusters) in New South Wales, Australia received the Diabetes Alliance intervention, creating a non-randomised open cohort stepped wedge trial. The intervention comprised of case conferencing, delivered directly to a small proportion of adults with type 2 diabetes (n = 1,072) of the general practice sites; as well as practice feedback, education and training. Spillover clinical improvements were assessed on all adults with type 2 diabetes within the general practice sites (n = 22,706), using practice level data recorded in the MedicineInsight electronic database, compared before and after the intervention. Outcome measures included frequency of diabetes screening tests in line with the Annual Cycle of Care, and clinical results for weight, blood pressure, HbA1c, lipids, and kidney function. RESULTS Compared to before Diabetes Alliance, the odds of all practice patients receiving screening tests at or above the recommended intervals were significantly higher for all recommended tests after Diabetes Alliance (odds ratio range 1.41-4.45, p < 0.0001). Significant improvements in clinical outcomes were observed for weight (absolute mean difference: -1.38 kg), blood pressure (systolic - 1.12 mmHg, diastolic - 1.18 mmHg), HbA1c (-0.03% at the mean), total cholesterol (-0.11 mmol/L), and triglycerides (-0.02 mmol/L) (p < 0.05). There were small but significant declines in kidney function. CONCLUSIONS Integrated care delivered to a small subset of patients with type 2 diabetes across a large geographic region has spillover benefits that improve the process measures and clinical outcomes for all practice patients with type 2 diabetes. TRIAL REGISTRATION ACTRN12622001438741; 10th November 2022, retrospectively registered: https://www.anzctr.org.au/ACTRN12622001438741.aspx .
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Affiliation(s)
- Shamasunder Acharya
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia.
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia.
| | - Rachael Taylor
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Martha Parsons
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
| | - John Attia
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Lucy Leigh
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Clinical Research Design IT and Statistical Support (CReDITSS) Unit, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Christopher Oldmeadow
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
- Clinical Research Design IT and Statistical Support (CReDITSS) Unit, Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Katie Wynne
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Christopher Rowe
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
| | - Morag Joseph
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- Hunter New England Central Coast Primary Health Network, PO Box 2288, Dangar, NSW, 2309, Australia
| | - Judy Luu
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Annalise Philcox
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Damien Jackel
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Tuan Quach
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Christy Sankoorikal
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Simone Dagg
- Hunter New England Health District, John Hunter Hospital, Lookout Road, New Lambton Heights, NSW, 2305, Australia
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
| | - Alexis Hure
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, 2305, Australia
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Ravi S, Meyerowitz-Katz G, Murugesan A, Ayre J, Jayaballa R, Rintoul D, Sarkis M, McCaffery K, Maberly G, Bonner C. Qualitative and Quantitative Evaluation of an Innovative Primary and Secondary Diabetes Clinic in Western Sydney. Int J Integr Care 2024; 24:13. [PMID: 38406628 PMCID: PMC10885848 DOI: 10.5334/ijic.7548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 02/08/2024] [Indexed: 02/27/2024] Open
Abstract
Introduction Western Sydney Diabetes (WSD) established an innovative diabetes service in May 2020, using virtual and in-person care, linking primary care with the diabetes specialist team. This study evaluated the service's feasibility using qualitative and quantitative methods. Method Evaluation included: 1) thematic analysis of interviews and workshops with patients and health professionals (n = 28); 2) quantitative analysis of records of patients admitted July 2020-June 2021 (n = 110). Results Key themes related to 1) benefits: convenient location, access to integrated care, advantages of virtual care; 2) challenges: hard for patients to ask questions, technology issues; 3) confidence: shared care decision making, multidisciplinary team; and 4) future directions: additional multidisciplinary services, expanded insulin stabilisation service, promotion.Improvements between baseline and 3 months included 1.3% reduction in HbA1c (p < 0.05). Sulfonylurea dropped by 25% between initial appointment and follow-up, and GLP1RA/SGLT2i use increasing by 30% (p < 0.05). The clinic covered costs using Medicare billings and Nationally Weighted Activity Units. Discussion The findings suggest this integrated care model was feasible and perceived as beneficial by both patients and providers. The clinic offers a promising model of practice that could be developed further to roll out in other regions for rural delivery of care.
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Affiliation(s)
- Sumathy Ravi
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Gideon Meyerowitz-Katz
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
- School of Health and Society, University of Wollongong, Wollongong, NSW, Australia
| | - Anandhi Murugesan
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Julie Ayre
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Rajini Jayaballa
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
| | | | - Marina Sarkis
- Agency for Clinical Innovation, St Leonards, NSW, Australia
| | - Kirsten McCaffery
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Glen Maberly
- Western Sydney Diabetes, Integrated and Community Health, Western Sydney Local Health District, Blacktown, NSW, Australia
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Carissa Bonner
- Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
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Pallin JA, Buckley-O'Farrell K, Riordan F, McGrath N, O'Neill K, MacLoughlin D, Dinneen SF, Buckley CM, McHugh S, Kearney PM. Implementing an integrated diabetic foot care programme in Ireland: podiatrists' experience. BMC Health Serv Res 2023; 23:1157. [PMID: 37884981 PMCID: PMC10601248 DOI: 10.1186/s12913-023-10144-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/14/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND International evidence suggests that an integrated multidisciplinary approach to diabetic foot management is necessary to prevent ulceration and progression to amputation. Many health systems have introduced policies or models of care supporting the introduction of this evidence into practice, but little is known about the experiences of those involved in implementation. This study addresses this gap by examining the experiences of podiatrists providing integrated diabetic foot care. METHODS Between October 2017 and April 2018, an online survey comprising closed and open-ended questions on podiatrists' demographics, clinical activity, links with other services, continuous professional development activities and experiences of implementing the Model of Care was administered to podiatrists (n = 73) working for Ireland's Health Service Executive in the community and hospital setting. Data were analysed using descriptive statistics and qualitative content analysis. RESULTS The response rate was 68% (n = 50), with 46% (n = 23), 38% (n = 19) and 16% (n = 8) working across hospital, community and both settings, respectively. Most reported treating high-risk patients (66%), those with active foot disease (61%) and educating people about the risk of diabetes to the lower limb (80%). Reported challenges towards integrated diabetic foot care include a perceived lack of awareness of the role of podiatry amongst other healthcare professionals, poor integration between hospital and community podiatry services, especially where new services had been developed, and insufficient number of podiatrists to meet service demands. CONCLUSION Previous evidence has shown that there is often a gap between what is set out by a policy and what it looks like when delivered to service users. Results from the current study support this, highlighting that while most podiatrists work in line with national recommendations, there are specific gaps and challenges that need to be addressed to ensure successful policy implementation.
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Affiliation(s)
| | | | - Fiona Riordan
- School of Public Health, University College Cork, Cork, Ireland
| | - Niamh McGrath
- HRB Evidence Centre, Health Research Board, Grattan House, 67-72 Lower Mount Street, Dublin 2, Ireland
| | - Kate O'Neill
- School of Public Health, University College Cork, Cork, Ireland
| | | | - Sean F Dinneen
- School of Medicine, University of Galway, Galway, Ireland
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland
| | | | - Sheena McHugh
- School of Public Health, University College Cork, Cork, Ireland
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Riordan F, O'Mahony L, Sheehan C, Murphy K, O'Donnell M, Hurley L, Dinneen S, McHugh SM. Implementing a community specialist team to support the delivery of integrated diabetes care: experiences in Ireland during the COVID-19 pandemic. HRB Open Res 2023. [DOI: 10.12688/hrbopenres.13635.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Background: While models of integrated care for people with chronic conditions have demonstrated promising results, there are still knowledge gaps about how these models are implemented in different contexts and which strategies may best support implementation. We aimed to evaluate the implementation of a multidisciplinary diabetes Community Specialist Team (CST) to support delivery of integrated type 2 diabetes care during COVID-19 in two health networks. Methods: A mixed methods approach was used. Quantitative data included administrative data on CST activity and caseload, and questionnaires with GPs, practice nurses (PN) and people with type 2 diabetes. Qualitative data were collected using semi-structured interviews and focus groups about the service from CST members, GPs, PNs and people with type 2 diabetes. We used the Consolidated Framework for Implementation Research framework to explain what influences implementation and to integrate different stakeholder perspectives. Results: Over a 6-month period (Dec 2020-May 2021), 516 patients were seen by podiatrists, 435 by dieticians, and 545 by CNS. Of patients who had their first CST appointment within the previous 6 months (n=29), 69% (n=20) waited less than 4 weeks to see the HCP. During initial implementation, CST members used virtual meetings to build ‘rapport’ with general practice staff, supporting ‘upskilling’ and referrals to the CST. Leadership from the local project team and change manager provided guidance on how to work as a team and ‘iron out’ issues. Where available, shared space enhanced networking between CST members and facilitated joint appointments. Lack of administrative support for the CST impacted on clinical time. Conclusions: This study illustrates how the CST benefited from shared space, enhanced networking, and leadership. When developing strategies to support implementation of integrated care, the need for administrative support, the practicalities of co-location to facilitate joint appointments, and relative advantages of different delivery models should be considered.
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Lyhne CN, Bjerrum M, Riis AH, Jørgensen MJ. Interventions to Prevent Potentially Avoidable Hospitalizations: A Mixed Methods Systematic Review. Front Public Health 2022; 10:898359. [PMID: 35899150 PMCID: PMC9309492 DOI: 10.3389/fpubh.2022.898359] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The demand for healthcare is increasing due to an aging population, more people living with chronic diseases and medical comorbidities. To manage this demand, political institutions call for action to reduce the potentially avoidable hospitalizations. Quantitative and qualitative aspects should be considered to understand how and why interventions work, and for whom. The aim of this mixed methods systematic review was to identify and synthesize evidence on interventions targeting avoidable hospitalizations from the perspectives of the citizens and the healthcare professionals to improve the preventive healthcare services. Methods and Results A mixed methods systematic review was conducted following the JBI methodology using a convergent integrated approach to synthesis. The review protocol was registered in PROSPERO, reg. no. CRD42020134652. A systematic search was undertaken in six databases. In total, 45 articles matched the eligibility criteria, and 25 of these (five qualitative studies and 20 quantitative studies) were found to be of acceptable methodological quality. From the 25 articles, 99 meaning units were extracted. The combined evidence revealed four categories, which were synthesized into two integrated findings: (1) Addressing individual needs through care continuity and coordination prevent avoidable hospitalizations and (2) Recognizing preventive care as an integrated part of the healthcare work to prevent avoidable hospitalizations. Conclusions The syntheses highlight the importance of addressing individual needs through continuous and coordinated care practices to prevent avoidable hospitalizations. Engaging healthcare professionals in preventive care work and considering implications for patient safety may be given higher priority. Healthcare administers and policy-makers could support the delivery of preventive care through targeted educational material aimed at healthcare professionals and simple web-based IT platforms for information-sharing across healthcare settings. The findings are an important resource in the development and implementation of interventions to prevent avoidable hospitalizations, and may serve to improve patient safety and quality in preventive healthcare services. Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=134652, identifier: CRD42020134652.
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Affiliation(s)
- Cecilie Nørby Lyhne
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Research, Horsens Regional Hospital, Horsens, Denmark
- *Correspondence: Cecilie Nørby Lyhne
| | - Merete Bjerrum
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Medicine, Centre for Clinical Guidelines and Danish Centre of Systematic Reviews, A JBI Centre of Excellence, Aalborg University, Aalborg, Denmark
| | - Anders Hammerich Riis
- Department of Research, Horsens Regional Hospital, Horsens, Denmark
- Enversion A/S, Aarhus, Denmark
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Lyhne CN, Bjerrum M, Jørgensen MJ. Person-centred care to prevent hospitalisations - a focus group study addressing the views of healthcare providers. BMC Health Serv Res 2022; 22:801. [PMID: 35725608 PMCID: PMC9210672 DOI: 10.1186/s12913-022-08198-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background The primary healthcare sector comprises various health services, including disease prevention at local level. Research shows that targeted primary healthcare services can prevent the development of acute complications and ultimately reduce the risk of hospitalisations. While interdisciplinary collaboration has been suggested as a means to improve the quality and responsiveness of personal care needs in preventive services, effective implementation remains a challenge. To improve the quality and responsiveness of primary healthcare and to develop initiatives to support the interdisciplinary collaboration in preventive services, there is a need to investigate the views of primary healthcare providers. The aim of this study was to investigate perceptions of preventive care among primary healthcare providers by examining their views on what constitutes a need for hospitalisation, and which strategies are found useful to prevent hospitalisation. Further, to explain how interdisciplinary collaboration can be supported with a view to providing person-centred care. Methods Five focus group interviews were conducted with 27 healthcare providers, including general practitioners, social and healthcare assistants, occupational therapists, physiotherapists, home care nurses, specialist nurses and acute care nurses. Interviews were transcribed, and analysed with qualitative content analysis. Results Three categories emerged from the analysis: 1) Mental and social conditions influence physical functioning and hospitalisation need, 2) Well-established primary healthcare services are important to provide person-centred care through interdisciplinary collaboration and 3) Interdisciplinary collaboration in primary healthcare services is predominantly focussed on handling acute physical conditions. These describe that the healthcare providers are attentive towards the influence of mental, social and physical conditions on the risk of hospitalisation, entailing a focus on person-centred care. Nevertheless, in the preventive services, interdisciplinary collaboration focusses primarily on handling acute physical conditions, which constitutes a barrier for interdisciplinary collaboration. Conclusions By focusing on the whole person, it could be possible to provide more person-centred care through interdisciplinary collaboration and ultimately to prevent some hospitalisations. Stakeholders at all levels should be informed about the relevance of considering mental, social and physical conditions to improve the quality and responsiveness of primary healthcare services and to develop initiatives to support interdisciplinary collaboration. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08198-6.
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Affiliation(s)
- Cecilie Nørby Lyhne
- Research Unit for Nursing and Healthcare, Department of Public Health, Aarhus University, Bartholins Allé 2, 3, 8000, Aarhus C, Denmark. .,Research Unit, Horsens Regional Hospital, Central Denmark Region, Sundvej 30X, 8700, Horsens, Denmark.
| | - Merete Bjerrum
- Research Unit for Nursing and Healthcare, Department of Public Health, Aarhus University, Bartholins Allé 2, 3, 8000, Aarhus C, Denmark.,Center for Clinical Guidelines, Department of Clinical Medicine, Aalborg University, Soendre Skovvej 15, 9000, Aalborg, Denmark
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Dinh NTT, Cox IA, de Graaff B, Campbell JA, Stokes B, Palmer AJ. A Comprehensive Systematic Review of Data Linkage Publications on Diabetes in Australia. Front Public Health 2022; 10:757987. [PMID: 35692316 PMCID: PMC9174992 DOI: 10.3389/fpubh.2022.757987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Aims Our study aimed to identify the common themes, knowledge gaps and to evaluate the quality of data linkage research on diabetes in Australia. Methods This systematic review was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (the PRISMA Statement). Six biomedical databases and the Australian Population Health Research Network (PHRN) website were searched. A narrative synthesis was conducted to comprehensively identify the common themes and knowledge gaps. The guidelines for studies involving data linkage were used to appraise methodological quality of included studies. Results After screening and hand-searching, 118 studies were included in the final analysis. Data linkage publications confirmed negative health outcomes in people with diabetes, reported risk factors for diabetes and its complications, and found an inverse association between primary care use and hospitalization. Linked data were used to validate data sources and diabetes instruments. There were limited publications investigating healthcare expenditure and adverse drug reactions (ADRs) in people with diabetes. Regarding methodological assessment, important information about the linkage performed was under-reported in included studies. Conclusions In the future, more up to date data linkage research addressing costs of diabetes and its complications in a contemporary Australian setting, as well as research assessing ADRs of recently approved antidiabetic medications, are required.
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Affiliation(s)
- Ngan T T Dinh
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.,Department of Pharmacology, Thai Nguyen University of Medicine and Pharmacy, Thai Nguyen University, Thai Nguyen, Vietnam
| | - Ingrid A Cox
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Barbara de Graaff
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Julie A Campbell
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Brian Stokes
- Tasmanian Data Linkage Unit, Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Andrew J Palmer
- Health Economics Research Group, Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.,Centre for Health Policy, School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
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Effectiveness of Integrated Diabetes Care Interventions Involving Diabetes Specialists Working in Primary and Community Care Settings: A Systematic Review and Meta-Analysis. Int J Integr Care 2022; 22:11. [PMID: 35634254 PMCID: PMC9104489 DOI: 10.5334/ijic.6025] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 04/19/2022] [Indexed: 11/20/2022] Open
Abstract
Introduction: Evidence that integrated diabetes care interventions can substantially improve clinical outcomes is mixed. However, previous systematic reviews have not focussed on clinical effectiveness where the endocrinologist was actively involved in guiding diabetes management. Methods: We searched EMBASE, COCHRANE, MEDLINE, SCOPUS, CINAHL, Google Scholar databases and grey literature published in English language up to 25 January 2021. Reviewed articles included Randomised Controlled Trials (RCTs) and pre-post studies testing the effectiveness on clinical outcomes after ≥6 months intervention in non-pregnant adults (age ≥ 18 years) with type 1 or type 2 diabetes mellitus. Two reviewers independently extracted data and completed a risk of bias assessment. Appropriate meta-analyses for each outcome from RCTs and pre-post studies were performed. Heterogeneity was assessed using the I2 statistic and Cochran’s Q and publication bias assessed using Doi plots. Studies were not pooled to estimate the cost-effectiveness as the cost outcomes were not comparable across trials/studies. Results: We reviewed 4 RCTs and 12 pre-post studies. The integrated care model of diabetes specialists working with primary care health professionals had a positive impact on HbA1c in both RCTs and pre-post studies and on systolic blood pressure, diastolic blood pressure, total cholesterol and weight in pre-post studies. In the RCTs, interventions reduced HbA1c (–0.10% [–0.15 to –0.05]) (–1.1 mmol/mol [–1.6 to –0.5]), versus control. Pre-post studies demonstrated improvements in HbA1c (–0.77% [–1.12 to –0.42]) (–8.4 mmol/mol [–12.2 to –4.6]), systolic blood pressure (–3.30 mmHg [–5.16 to –1.44]), diastolic blood pressure (–3.61 mmHg [–4.82 to –2.39]), total cholesterol (–0.33 mmol/L [–0.52 to –0.14]) and weight (–2.53 kg [–3.86 to –1.19]). In a pre-post study with no control group only 4% patients experienced hypoglycaemia after one year of intervention compared to baseline. Conclusions: Integrated interventions with an active endocrinologist involvement can result in modest improvements in HbA1c, blood pressure and weight management. Although the improvements per clinical outcome are modest, there is possible net improvements at a holistic level.
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OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:116-128. [DOI: 10.1093/ijpp/riac009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 02/02/2022] [Indexed: 11/12/2022]
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Foluke Bosun-Arije S, Chibuzor Nwakasi C, Ekpenyong M, Serrant L, Esther Sunday-Abel T, Ling J. A nurse-led conceptual model to inform patient-centred, type 2 diabetes mellitus management in public clinical settings. J Res Nurs 2021; 26:763-778. [PMID: 35251284 PMCID: PMC8894752 DOI: 10.1177/17449871211021137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Globally, there is an increased need to provide patient-centred care for people
diagnosed with type 2 diabetes mellitus. In Nigeria, a poorly financed health system has
worsened the difficulties associated with managing type 2 diabetes mellitus in clinical
settings, causing a detrimental effect on patient-centred care. Aims We aimed to develop a conceptual model to promote patient-centred type 2 diabetes
mellitus care in clinical settings. We explored nurses’ contextual perceptions of
clinical practices and operations in light of type 2 diabetes mellitus management across
public hospitals in Lagos, Nigeria. Identifying a nurse-led intervention is critical to
care optimisation for people diagnosed with type 2 diabetes mellitus. Methods We adopted a qualitative approach. Using the constant comparison method and
semi-structured questions and interviewed practice nurses, with over one year’s
experience and who were working in public hospitals across Lagos, Nigeria. The framework
method was used to analyse the data obtained. Results Nurses provided insight into four areas of patient-centred type 2 diabetes mellitus
management in clinical settings: empowering collaboration; empowering flexibility;
empowering approach; and empowering practice. Nurses discussed an empowering pathway
through which health settings could provide patient-centred care to individuals
diagnosed with type 2 diabetes mellitus. The pathway entailed the integration of macro,
meso and micro levels for patient management. Nurses’ accounts have informed the
development of a conceptual model for the optimisation of patient care. Conclusions The model developed from this research sits within the patient-centred care model of
healthcare delivery. The research sits within the patient-centred care model of
healthcare delivery. inform patient-centred care, not only in countries with poorly
financed healthcare systems, but in developed countries with comparatively better
healthcare.
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Affiliation(s)
| | | | - Mandu Ekpenyong
- Research Fellow, Department of Nursing, Manchester Metropolitan University, UK
| | - Laura Serrant
- Professor, Department of Nursing, Manchester Metropolitan University, UK
| | | | - Jonathan Ling
- Professor, Faculty of Health Sciences and Wellbeing, University of Sunderland, UK
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Medea G. Care networks, integrated care models, and primary care. JOURNAL OF GERONTOLOGY AND GERIATRICS 2021. [DOI: 10.36150/2499-6564-n465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Donald M, Jackson CL, Byrnes J, Vaikuntam BP, Russell AW, Hollingworth SA. Community-based integrated care versus hospital outpatient care for managing patients with complex type 2 diabetes: costing analysis. AUST HEALTH REV 2021; 45:42-50. [PMID: 33563370 DOI: 10.1071/ah19226] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/19/2020] [Indexed: 11/23/2022]
Abstract
Objective This study compared the cost of an integrated primary-secondary care general practitioner (GP)-based Beacon model with usual care at hospital outpatient departments (OPDs) for patients with complex type 2 diabetes. Methods A costing analysis was completed alongside a non-inferiority randomised control trial. Costs were calculated using information from accounting data and interviews with clinic managers. Two OPDs and three GP-based Beacon practices participated. In the Beacon practices, GPs with a special interest in advanced diabetes care worked with an endocrinologist and diabetes nurse educator to care for referred patients. The main outcome was incremental cost saving per patient course of treatment from a health system perspective. Uncertainty was characterised with probabilistic sensitivity analysis using Monte Carlo simulation. Results The Beacon model is cost saving: the incremental cost saving per patient was A$365 (95% confidence interval -A$901, A$55) and was cost saving in 93.7% of simulations. The key contributors to the variance in the cost saving per patient course of treatment were the mean number of patients seen per site and the number of additional presentations per course of treatment associated with the Beacon model. Conclusions Beacon clinics were less costly per patient course of treatment than usual care in hospital OPDs for equivalent clinical outcomes. Local contractual arrangements and potential variation in the operational cost structure are of significant consideration in determining the cost-efficiency of Beacon models. What is known about this topic? Despite the growing importance of achieving care quality within constrained budgets, there are few costing studies comparing clinically-equivalent hospital and community-based care models. What does this paper add? Costing analyses comparing hospital-based to GP-based health services require considerable effort and are complex. We show that GP-based Beacon clinics for patients with complex chronic disease can be less costly per patient course of treatment than usual care offered in hospital OPDs. What are the implications for practitioners? In addition to improving access and convenience for patients, transferring care from hospital to the community can reduce health system costs.
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Affiliation(s)
- Maria Donald
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston Road, Herston, Qld 4029, Australia; and Corresponding authors. ;
| | - Claire L Jackson
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston Road, Herston, Qld 4029, Australia; and Corresponding authors. ;
| | - Joshua Byrnes
- Centre for Applied Health Economics, Sir Samuel Griffith Centre, Griffith University, Nathan, Qld 4111, Australia.
| | - Bharat Phani Vaikuntam
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Herston Road, Herston, Qld 4029, Australia; and Present address: John Walsh Centre for Rehabilitation Research, Sydney Medical School - Northern, The University of Sydney, St Leonards, NSW 2065, Australia.
| | - Anthony W Russell
- Faculty of Medicine, The University of Queensland, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Qld 4102, Australia. ; and Department of Diabetes and Endocrinology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Qld 4102, Australia
| | - Samantha A Hollingworth
- School of Pharmacy, The University of Queensland, 20 Cornwall Street, Woolloongabba, Qld 4102, Australia.
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Murtagh S, McCombe G, Broughan J, Carroll Á, Casey M, Harrold Á, Dennehy T, Fawsitt R, Cullen W. Integrating Primary and Secondary Care to Enhance Chronic Disease Management: A Scoping Review. Int J Integr Care 2021; 21:4. [PMID: 33613136 PMCID: PMC7880002 DOI: 10.5334/ijic.5508] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 10/28/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In Ireland, as in many healthcare systems, health policy has committed to delivering an integrated model of care to address the increasing burden of chronic disease. Integrated care is an approach to healthcare systems delivery that aims to minimise fragmentation of patient services and improve care continuity. To this end, how best to integrate primary and secondary care is a challenge. This paper aims to undertake a scoping review of empirical work on the integration of primary and secondary care in relation to chronic disease management. METHODS A search was conducted of 'PubMed', 'Cochrane Library' and 'Google Scholar' for papers published between 2009-2019 using Arksey and O'Malley's framework for conducing scoping reviews. RESULTS Twenty-two studies were included. These reported research from a wide range of healthcare systems (most commonly UK, Australia, the Netherlands), adopted a range of methodologies (most commonly randomised/non-randomised controlled trials, case studies, qualitative studies) and among patients with a range of chronic conditions (most commonly diabetes, COPD, Parkinson's disease). No studies reported on interventions to address the needs of whole populations. Interventions to enhance integration included multidisciplinary teams, education of healthcare professionals, and e-health interventions. Among the effectiveness measures reported were improved disease specific outcomes, and cost effectiveness. CONCLUSION With healthcare systems increasingly recognising that integrated approaches to patient care can enhance chronic disease management, considerable literature now informs how this can be done. However, most of the research published has focussed on specific diseases and their clinical outcomes. Future research should focus on how such approaches may improve health outcomes for populations as a whole.
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Affiliation(s)
- Sara Murtagh
- School of Medicine, University College Dublin, Ireland
| | - Geoff McCombe
- School of Medicine, University College Dublin, Ireland
| | - John Broughan
- School of Medicine, University College Dublin, Ireland
| | - Áine Carroll
- School of Medicine, University College Dublin, Ireland
| | - Mary Casey
- School of Nursing Midwifery and Health Systems, University College Dublin, Ireland
| | - Áine Harrold
- School of Medicine, University College Dublin, Ireland
| | | | - Ronan Fawsitt
- School of Medicine, University College Dublin, Ireland
- Ireland East Hospital Group, Dublin, Ireland
| | - Walter Cullen
- School of Medicine, University College Dublin, Ireland
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14
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Davis TME, Drinkwater JJ, Fegan PG, Chikkaveerappa K, Sillars B, Davis WA. Community-based management of complex type 2 diabetes: adaptation of an integrated model of care in a general practice setting. Intern Med J 2019; 51:62-68. [PMID: 31661182 DOI: 10.1111/imj.14669] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2019] [Revised: 09/09/2019] [Accepted: 10/15/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Overburdened hospital clinics can have adverse outcomes. AIMS To evaluate the effectiveness and patient acceptability of an integrated model of complex type 2 diabetes care delivered in a community-based general practice by upskilled general practitioners (GP) co-located with an endocrinologist and diabetes nurse educator. METHODS Patients transferred from hospital clinic lists or referred by local GP were assessed in two southern Perth practices. An upskilled GP and endocrinologist developed a management plan which was communicated to the participant's usual GP. Up to two follow-up visits over 6 months ensured that management was acceptable and effective. RESULTS A total of 464 people with type 2 diabetes (mean ± standard deviation age = 59.3 ± 13.7 years, 52.2% males) was enrolled. Their mean glycated haemoglobin (HbA1c ) was 9.3% (78 mmol/mol) and their mean body mass index 33.7 kg/m2 . Use of injectable blood glucose-lowering therapies increased between the initial and final visit in association with a median HbA1c reduction of 1.2% (13 mmol/mol) which was sustained to 12 months in assessable participants. There were also reductions in blood pressure, and serum low-density lipoprotein cholesterol and triglyceride concentrations. Patient satisfaction with current treatment, time for self-management, time spent in diabetes-related appointments and diabetes knowledge increased significantly. Non-attendance for scheduled appointments was <10%. Local hospital referrals and waiting lists reduced over the study period. CONCLUSIONS This study confirms the value of integrated community-based care of complex type 2 diabetes which could represent a sustainable solution to overburdened hospital diabetes outpatient clinics.
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Affiliation(s)
- Timothy M E Davis
- Medical School, Fremantle Hospital, University of Western Australia, Fremantle, Western Australia, Australia
| | - Jocelyn J Drinkwater
- Medical School, Fremantle Hospital, University of Western Australia, Fremantle, Western Australia, Australia
| | - P Gerry Fegan
- Department of Endocrinology and Diabetes, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | | | - Brett Sillars
- Department of Endocrinology, Nambour General Hospital, Nambour, Queensland, Australia
| | - Wendy A Davis
- Medical School, Fremantle Hospital, University of Western Australia, Fremantle, Western Australia, Australia
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15
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Jackson CL, Donald M, Russell AW, McIntyre HD. Establishing a new model of integrated primary and secondary care based around general practice: a case study of lessons learned and challenges. AUST HEALTH REV 2019; 42:299-302. [PMID: 28483036 DOI: 10.1071/ah16147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 03/14/2017] [Indexed: 11/23/2022]
Abstract
This case study describes the development and implementation of an innovative integrated primary-secondary model of care for people with complex diabetes. The aim of the paper is to present the experiences of clinicians and researchers involved in implementing the 'Beacon' model by providing a discussion of the contextual factors, including lessons learned, challenges and solutions. Beacon-type models of community care for people with chronic disease are well placed to deliver on Australia's health care reform agenda, and this commentary provides rich contextual information relevant to the translation of such models into policy and practice.
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Affiliation(s)
- Claire L Jackson
- Primary Care Clinical Unit, Faculty of Medicine, Level 8 Health Sciences Building, Royal Brisbane and Women's Hospital, The University of Queensland, Herston, Qld 4006, Australia. Email
| | - Maria Donald
- Primary Care Clinical Unit, Faculty of Medicine, Level 8 Health Sciences Building, Royal Brisbane and Women's Hospital, The University of Queensland, Herston, Qld 4006, Australia. Email
| | - Anthony W Russell
- Department of Diabetes and Endocrinology, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Qld 4102, Australia. Email
| | - H David McIntyre
- Mater-Southside Clinical Unit, Faculty of Medicine, Mayne Medical Building, The University of Queensland, 288 Herston Road, Herston, Qld 4006, Australia. Email
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16
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Gómez-Huelgas R, Lara-Rojas CM, López-Carmona MD, Jansen-Chaparro S, Barba R, Zapatero A, Guijarro-Merino R, Tinahones FJ, Pérez-Belmonte LM, Bernal-López MR. Trends in Diabetes-Related Potentially Preventable Hospitalizations in Adult Population in Spain, 1997⁻2015: A Nation-Wide Population-Based Study. J Clin Med 2019; 8:jcm8040492. [PMID: 30978979 PMCID: PMC6526470 DOI: 10.3390/jcm8040492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/05/2019] [Accepted: 04/08/2019] [Indexed: 11/16/2022] Open
Abstract
We aimed to assess national trends in the rates of diabetes-related potentially preventable hospitalizations (overall and by preventable condition) in the total adult population of Spain. We performed a population-based study of all adult patients with diabetes who were hospitalized from 1997 to 2015. Overall potentially preventable hospitalizations and hospitalizations by diabetes-related preventable conditions (short-term complications, long-term complications, uncontrolled diabetes, and lower-extremity amputations) were examined. Annual rates adjusted for age and sex were analyzed and trends were calculated. Over 19-years-period, 424,874 diabetes-related potentially preventable hospitalizations were recorded. Overall diabetes-related potentially preventable hospitalizations decreased significantly, with an average annual percentage change of 5.1 (95%CI: −5.6–(−4.7%); ptrend < 0.001). Among preventable conditions, the greatest decrease was observed in uncontrolled diabetes (−5.6%; 95%CI: −6.7–(−4.7%); ptrend < 0.001), followed by short-term complications (−5.4%; 95%CI: −6.1–(−4.9%); ptrend < 0.001), long-term complications (−4.6%; 95%CI: −5.1–(−3.9%); ptrend < 0.001), and lower-extremity amputations (−1.9%; 95%CI: −3.0–(−1.3%); ptrend < 0.001). These reductions were observed in all age strata for overall DM-related PPH and by preventable condition but lower-extremity amputations for those <65 years old. There was a greater reduction in overall DM-related PPH, uncontrolled DM, long-term-complications, and lower extremity amputations in females than in males (all p < 0.01). No significant difference was shown for short-term complications (p = 0.101). Our study shows a significant reduction in national trends for diabetes-related potentially preventable hospitalizations in Spain. These findings could suggest a sustained improvement in diabetes care in Spain, despite the burden of these diabetes-related complications and the increase in the diabetes mellitus prevalence.
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Affiliation(s)
- Ricardo Gómez-Huelgas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain.
| | - Carmen M Lara-Rojas
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - María D López-Carmona
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Sergio Jansen-Chaparro
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Raquel Barba
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, 28933 Móstoles, Madrid, Spain.
| | - Antonio Zapatero
- Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Universidad Rey Juan Carlos, 28942 Fuenlabrada, Madrid, Spain.
| | - Ricardo Guijarro-Merino
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Francisco J Tinahones
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain.
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
| | - Luis M Pérez-Belmonte
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
- Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, 28029 Madrid, Spain.
| | - M Rosa Bernal-López
- Servicio de Medicina Interna, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga (IBIMA), Universidad de Málaga (UMA), 29010 Málaga, Spain.
- Centro de Investigación Biomédica en Red Fisiopatología de la Obesidad y Nutrición (CIBERobn), Instituto de Salud Carlos III, 28029 Madrid, Spain.
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17
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Riordan F, McGrath N, Dinneen SF, Kearney PM, McHugh SM. 'Sink or Swim': A Qualitative Study to Understand How and Why Nurses Adapt to Support the Implementation of Integrated Diabetes Care. Int J Integr Care 2019; 19:2. [PMID: 30971868 PMCID: PMC6450245 DOI: 10.5334/ijic.4215] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 03/12/2019] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Integrated care, organising care delivery within and between services, is an approach to improve the quality of care. Existing specialist roles have evolved to work across settings and services to integrate care. However, there is limited insight into how these expanded roles are implemented, including how they may be shaped by context. This paper examines how new diabetes nurse specialists working across care boundaries, together with hospital-based diabetes nurse specialists, adapt to support the implementation of integrated care. METHODS We conducted semi-structured focus groups and interviews with diabetes nurse specialists purposively sampled by work setting and health service region (n = 30). Analysis was data-driven, coding actions or processes to stay closer to the data and using In Vivo codes to preserve meaning. FINDINGS Community nurse specialists described facing a choice of "sink or swim" when appointed with limited guidance on their role. To 'swim' and implement their role, required them to use their initiative and adapt to the local context. When first appointed, both community and hospital nurse specialists actively managed misconceptions of their role by other staff. To establish clinics in general practices, community nurse specialists capitalised on professional contacts to access GPs who might utilise their role. They built GP trust by adopting practice norms and responding to individual needs. They adapted to the lack of a multidisciplinary team "safety net" in the community, by "practicing at a higher level", working more autonomously. Developing professional links and pursuing on-going education was a way to create an alternative 'safety net' so as to feel confident in their clinical decision-making when working in the community. Workarounds facilitated information flow (i.e. patient blood results, treatment, and appointments) between settings in the absence of an electronic record shared between general practices and hospital settings. CONCLUSIONS Flexibility and innovation facilitates a new way of working across boundaries. Successful implementation of nurse specialist-led integrated care requires strategies to address elements in the inner (differences in practice organisation, role acceptance) and outer (information systems) context.
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Affiliation(s)
- Fiona Riordan
- School of Public Health, Western Gateway Building, University College Cork, IE
| | - Niamh McGrath
- School of Public Health, Western Gateway Building, University College Cork, IE
| | - Sean F. Dinneen
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, School of Medicine, National University of Ireland, Galway, IE
| | - Patricia M. Kearney
- School of Public Health, Western Gateway Building, University College Cork, IE
| | - Sheena M. McHugh
- School of Public Health, Western Gateway Building, University College Cork, IE
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18
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O'Neill KN, McHugh SM, Kearney PM. Cycle of Care for people with diabetes: an equitable initiative? HRB Open Res 2019. [DOI: 10.12688/hrbopenres.12890.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Structured management of uncomplicated diabetes in primary care constitutes good quality diabetes care. The cycle of care is a national initiative that financially remunerates general practitioners to provide structured diabetes care for people with type 2 diabetes. However, eligibility for the cycle of care is limited to those with means-tested public health insurance. We investigate the national coverage of the cycle of care and describe the socio-demographic and clinical profile of those eligible and non-eligible for the initiative. Methods: A cross-sectional analysis of The Irish LongituDinal study on Ageing (TILDA) Wave 1 was conducted. Type 2 diabetes was defined using self-reported doctor-diagnosis of diabetes, age at diagnosis and use of insulin/oral hypoglycaemic agents. Findings were applied to the 2016 Irish census figures to estimate the absolute population eligible and non-eligible for the cycle of care. Pearson’s chi-square test was used to compare the profiles of those eligible and non-eligible for the initiative. Results: Of the 8,107 TILDA participants, 609 had type 2 diabetes (7.9% [95%CI: 7.3%, 8.5%]) and 31.6% (95%CI: 27.8, 35.6) of these were not eligible for the cycle of care. Applying these estimates to census data, an estimated 36,567 (95%CI: 32,170, 41,196) individuals aged ≥50 years with type 2 diabetes in Ireland are not eligible for the initiative. Those not eligible were less likely to be on insulin and more likely to be managing their diabetes without medication. Conclusions: Nearly one-third of people with type 2 diabetes aged ≥50 years are not eligible for the cycle of care and appear to fit the outlined criteria for uncomplicated diabetes which can be appropriately managed in primary care. Financial barriers to managing uncomplicated diabetes in primary care exist. It is essential that the cycle of care is extended to all those likely to benefit from regular structured diabetes management.
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19
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Huang IS, Wren J, Brannigan RE. Clinically integrated health care: optimizing our approach to reproductive medicine. Fertil Steril 2018; 110:362-363. [PMID: 30098683 DOI: 10.1016/j.fertnstert.2018.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 06/21/2018] [Indexed: 11/18/2022]
Affiliation(s)
- I-Shen Huang
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Department of Urology, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Urology, School of Medicine, Shu-Tien Urological Research Center, Taipei, Taiwan
| | - James Wren
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert E Brannigan
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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20
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Sabione I, Cavalot F, Paccotti P, Massucco P, Vigna-Taglianti FD. Outcomes of integrated management versus specialized care for patients with type 2 diabetes: An observational study. Diabetes Res Clin Pract 2018; 140:208-215. [PMID: 29626586 DOI: 10.1016/j.diabres.2018.03.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 03/16/2018] [Accepted: 03/29/2018] [Indexed: 11/21/2022]
Abstract
AIMS To compare type 2 diabetes (T2D) patients included in a Diabetes Integrated Management (DIM) program with those followed in Diabetes Specialized Care (DSC), investigating differences in general characteristics, changes in clinical outcomes, and factors related with the inclusion in the DIM program. METHODS T2D patients living in the ASLTO3 district and included into the DIM program, a shared disease management between general practitioners and diabetes specialists, from 2008 to 2014 were compared with T2D patients living in the same district and in charge of the local DSC. Demographic, anthropometric and clinical data for both groups of patients were obtained from the electronic records of DSC. RESULTS 1326 DIM patients were compared with 3494 DSC patients. A higher proportion of females was observed among DIM patients than among DSC patients. DIM patients were older, more frequently in therapy with diet only or with oral hypoglycemic, and had HbA1c and creatinine lower than DSC patients. The analyses of changes in clinical parameters during the study period showed a good and statistically significant improvement of most parameters, independently of the inclusion in DIM or DSC, with the exception of creatinine level. CONCLUSIONS Integrated Management is an efficient and effective way to achieve good long-term clinical outcomes for patients with diabetes.
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Affiliation(s)
- I Sabione
- School of Medicine, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - F Cavalot
- Metabolic Diseases and Diabetes Unit, San Luigi Gonzaga Hospital, Orbassano, Torino, Italy
| | - P Paccotti
- School of Medicine, Department of Clinical and Biological Sciences, University of Torino, Italy; Internal Medicine Unit, San Luigi Gonzaga Hospital, Orbassano, Torino, Italy
| | - P Massucco
- Metabolic Diseases and Diabetes Unit, San Luigi Gonzaga Hospital, Orbassano, Torino, Italy
| | - F D Vigna-Taglianti
- School of Medicine, Department of Clinical and Biological Sciences, University of Torino, Italy.
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21
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Bonora E, Monami M, Bruno G, Zoppini G, Mannucci E. Attending Diabetes Clinics is associated with a lower all-cause mortality. A meta-analysis of observational studies performed in Italy. Nutr Metab Cardiovasc Dis 2018; 28:431-435. [PMID: 29627120 DOI: 10.1016/j.numecd.2018.02.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 01/28/2018] [Accepted: 02/19/2018] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The epidemiological explosion of diabetes is a challenge for Health Systems and the identification of the most appropriate models of care are warranted. The inclusion of primary care physicians in the models is unquestioned whereas the role played by secondary and tertiary care (Diabetes Clinic) is often debated. However, studies focusing on hard endpoints and comparing Diabetes Clinic attendance vs. no attendance are scant. RESEARCH DESIGN AND METHODS A meta-analysis was performed including all observational cohort studies performed in Italy, reporting crude and/or adjusted estimates of all-cause mortality in patients with diabetes attending or not attending Diabetes Clinics. Attendance was defined by prescriptions and reimbursement of specialist visits by the National Health System. RESULTS Three studies enrolling 191,847 subjects with diabetes were included in the analysis, and about half of them had at least one visit in the Diabetes Clinic per year. During the follow-up, ranging 1-11 years, 9653 subjects died. Mortality was remarkably lower in subjects attending Diabetes Clinic (MH-OR 0.70, 95% CI 0.55-0.88, p = 0.002). Results were confirmed after adjusting for confounders (MH-OR 0.81, 95% CI 0.69-0.95, p = 0.009). CONCLUSIONS The results of the present study suggest that attending Diabetes Clinics is associated with a lower all-cause mortality. This finding might be instrumental to implement the best models of care for persons with diabetes.
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Affiliation(s)
- E Bonora
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy.
| | - M Monami
- Diabetology, Azienda Ospedaliera Careggi and University of Florence, Italy
| | - G Bruno
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - G Zoppini
- Division of Endocrinology, Diabetes and Metabolism, University and Hospital Trust of Verona, Verona, Italy
| | - E Mannucci
- Diabetology, Azienda Ospedaliera Careggi and University of Florence, Italy
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22
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Effectiveness of joint specialist case conferences for building general practice capacity to enhance diabetes care. JOURNAL OF INTEGRATED CARE 2018. [DOI: 10.1108/jica-09-2017-0029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Type 2 diabetes mellitus has become a major concern of Australian healthcare providers. From rates of barely more than 1 percent in the mid-90s, diabetes is now the leading cause of morbidity in the country. To combat the growing diabetes epidemic, Western Sydney Local Health District created the Western Sydney Diabetes (WSD) initiative. One of the key components of the WSD initiative since 2014 has been joint specialist case conferencing (JSCC). The purpose of this paper is to evaluate the JSCC service including both individual- and practice-based changes.
Design/methodology/approach
The authors evaluated the JSCC program by conducting an analysis of patient-level data in addition to a discrete practice-level study. The study aim was to examine both the effect on individual patients and the practice, as well as acceptability of the program for both doctors and their patients. The evaluation included data collection and analysis of primary patient outcomes, as well as a survey of GPs and patients. Patient data on primary outcomes were obtained by accessing and downloading them through GP practice management software by GP practice staff.
Findings
The authors found significant improvements at both the patient levels, with reductions in BMI, HbA1c and blood pressure sustained at three years, and at the practice level with improvements in markers of patient management. The authors also found high acceptability of the program from both patients and GPs.
Originality/value
This paper provides good evidence for the use of a JSCC program to improve diabetes management in primary care through capacity building with GPs.
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McGrath RT, Dryden JC, Newlyn N, Pamplona E, O'Dea J, Hocking SL, Glastras SJ, Fulcher GR. Utility of the Hospital Admission Risk Programme diabetes risk calculator in identifying patients with type 2 diabetes at risk of unplanned hospital presentations. Intern Med J 2018; 48:1198-1205. [PMID: 29604162 DOI: 10.1111/imj.13824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/23/2018] [Accepted: 03/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Prevention of hospitalisation is an important aspect of type 2 diabetes (T2D) management. AIMS We retrospectively determined the utility of the Hospital Admission Risk Programme (HARP) diabetes risk calculator (HARP tool) in identifying patients with T2D more likely to have unplanned hospital presentations. METHODS The HARP tool includes a clinical assessment score (Part A) and a psychosocial and self-management impact score (Part B), and categorises patients into low, medium, high or urgent risk of acute hospitalisation. It was completed for T2D patients attending Royal North Shore Hospital, Sydney, in 2013. RESULTS Within the cohort of 278 patients (age 65.3 ± 10.5 years; 62.9% male; diabetes duration 10.7 ± 6.6 years), 67.3% were classified as low risk, 32.7% as medium risk and none as high or urgent risk. Following adjustment for confounders, a medium HARP score was associated with a 3.1-fold increased risk of unplanned hospital presentations in the subsequent 12 months (95% confidence interval: 1.35-7.31; P = 0.008). Part A scores were significantly higher for patients that presented to hospital compared to those that did not (14.2 ± 6.8 vs 11.4 ± 5.5; P = 0.034), whereas there was no difference in Part B scores (P = 0.860). CONCLUSIONS In patients with low and medium HARP scores, clinical features were more predictive of hospital presentations than certain psychosocial or self-management factors in the present cohort. Further studies are required to characterise unplanned hospitalisation in patients with higher HARP scores, or whether additional psychosocial assessments could improve the tool's predictability.
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Affiliation(s)
- Rachel T McGrath
- Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Kolling Institute of Medical Research, Sydney, New South Wales, Australia
| | - Justin C Dryden
- Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neroli Newlyn
- Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Elline Pamplona
- Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Judy O'Dea
- Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Samantha L Hocking
- Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Sarah J Glastras
- Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Kolling Institute of Medical Research, Sydney, New South Wales, Australia
| | - Gregory R Fulcher
- Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia.,Northern Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Seidu S, Than T, Kar D, Lamba A, Brown P, Zafar A, Hussain R, Amjad A, Capehorn M, Martin E, Fernando K, McMoran J, Millar-Jones D, Kahn S, Campbell N, Brice R, Mohan R, Mistry M, Kanumilli N, St John J, Quigley R, Kenny C, Khunti K. Therapeutic inertia amongst general practitioners with interest in diabetes. Prim Care Diabetes 2018; 12:87-91. [PMID: 28993141 DOI: 10.1016/j.pcd.2017.09.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/29/2017] [Accepted: 09/06/2017] [Indexed: 11/21/2022]
Abstract
INTRODUCTION As the therapeutic options in the management of type 2 diabetes increase, there is an increase confusion among health care professionals, thus leading to the phenomenon of therapeutic inertia. This is the failure to escalate or de-escalate treatment when the clinical need for this is required. It has been studied extensively in various settings, however, it has never been reported in any studies focusing solely on primary care physicians with an interest in diabetes. This group is increasingly becoming the focus of managing complex diabetes care in the community, albeit with the support from specialists. METHODS In this retrospective audit, we assessed the prevalence of the phenomenon of therapeutic inertia amongst primary care physicians with an interest in diabetes in UK. We also assessed the predictive abilities of various patient level characteristics on therapeutic inertia amongst this group of clinicians. RESULTS Out of the 240 patients reported on, therapeutic inertia was judged to have occurred in 53 (22.1%) of patients. The full model containing all the selected variables was not statistically significant, p=0.59. So the model was not able to distinguish between situations in which therapeutic inertia occurred and when it did not occur. None of the patient level characteristics on its own was predictive of therapeutic inertia. CONCLUSION Therapeutic inertia was present only in about a fifth of patient patients with diabetes being managed by primary care physicians with an interest in diabetes.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom.
| | - Tun Than
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom
| | - Deb Kar
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom
| | - Amrit Lamba
- Colindale Medical Centre, 61 Colindeep Lane, Colindale, London, NW9 6DJ, United Kingdom
| | - Pam Brown
- Kings Road Surgery, Mumbles, Swansea, United Kingdom
| | - Azhar Zafar
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom
| | | | - Ahmed Amjad
- Cheetham Hill Primary Care Centre, 244 Cheetham Hill Road, Manchester, Greater Manchester, M8 8UP, United Kingdom
| | | | - Elizabeth Martin
- Diabetes Department, St. James Teaching Hospital, United Kingdom
| | - Kevin Fernando
- North Berwick Health Centre, North Berwick Group Practice, 54 St. Baldred's Road, North Berwick, EH39 4PU, United Kingdom
| | - Jim McMoran
- The Community Diabetes and Cardiovascular Risk Clinic service is based on the first floor Spires Suite of City of Coventry Health Centre, 2 Stoney Stanton Road, Coventry CV1 4FS, United Kingdom
| | | | - Shahzada Kahn
- Vicarage Lane Health Centre, 10 Vicarage Lane, Stratford, London, Greater London, E15 4ES, United Kingdom
| | - Nigel Campbell
- Lisburn Health Centre, Linenhall Street, Lisburn, BT28 1LU, United Kingdom
| | - Richard Brice
- Estuary View Medical Centre, Boorman Way, Whitstable, CT5 3SE, United Kingdom
| | - Rahul Mohan
- Church House Surgery, Shaw Street, NG11 6HF Ruddington, United Kingdom
| | - Mukesh Mistry
- The Community Diabetes and Cardiovascular Risk Clinic service is based on the first floor Spires Suite of City of Coventry Health Centre, 2 Stoney Stanton Road, Coventry CV1 4FS, United Kingdom
| | | | - Joan St John
- Law Medical Group Practice, Wembley and Willesden, United Kingdom
| | - Richard Quigley
- Thornliebank Health Centre, 20 Kennishead Road, Glasgow, G46 8NY, United Kingdom
| | | | - Kamlesh Khunti
- Diabetes Research Centre, Gwendolen Road, Leicester General Hospital, Leicester LE5 4WP, United Kingdom
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Doshi R, Aseltine RH, Sabina AB, Graham GN. Interventions to Improve Management of Chronic Conditions Among Racial and Ethnic Minorities. J Racial Ethn Health Disparities 2017; 4:1033-1041. [PMID: 29067651 DOI: 10.1007/s40615-017-0431-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 09/05/2017] [Accepted: 09/07/2017] [Indexed: 11/25/2022]
Abstract
Digital and mhealth interventions can be effective in improving health outcomes among minority patients with diabetes, congestive heart failure, and chronic respiratory diseases. A number of electronic and digital approaches to individual and population-level interventions involving telephones, internet and web-based resources, and mobile platforms have been deployed to improve chronic disease outcomes. This paper summarizes the evidence supporting the efficacy of various behavioral and digital interventions targeting intermediate outcomes and hospitalizations with particular emphasis on studies examining the effects of these interventions on racial and ethnic minority population.
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Affiliation(s)
- Riddhi Doshi
- Department of Community Medicine and Healthcare, University of Connecticut Health Center, Farmington, CT, USA
| | - Robert H Aseltine
- Division of Behavioral Science and Community Health, University of Connecticut Health Center, 263 Farmington avenue MC 6030, Farmington, CT, 06030, USA.
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Riordan F, McHugh SM, Murphy K, Barrett J, Kearney PM. The role of nurse specialists in the delivery of integrated diabetes care: a cross-sectional survey of diabetes nurse specialist services. BMJ Open 2017; 7:e015049. [PMID: 28801394 PMCID: PMC5724109 DOI: 10.1136/bmjopen-2016-015049] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES International evidence suggests the diabetes nurse specialist (DNS) has a key role in supporting integrated management of diabetes. We examine whether hospital and community DNS currently support the integration of care, examine regional variation in aspects of the service relevant to the delivery of integrated care and identify barriers to service delivery and areas for improvement. DESIGN A cross-sectional survey of hospital and community-based DNS in Ireland. METHODS Between September 2015 and April 2016, a 67-item online survey, comprising closed and open questions on their clinical role, diabetes clinics, multidisciplinary working, and barriers and facilitators to service delivery, was administered to all eligible DNS (n=152) in Ireland. DNS were excluded if they were retired or on maternity leave or extended leave. RESULTS The response rate was 66.4% (n=101): 60.6% (n=74) and 89.3% (n=25) among hospital and community DNS, respectively. Most DNS had patients with stable (81.8%) and complicated type 2 diabetes mellitus (89.9%) attending their service. The majority were delivering nurse-led clinics (81.1%). Almost all DNS had a role liaising with (91%), and providing support and education to (95%), other professionals. However, only a third reported that there was local agreement on how their service should operate between the hospital and primary care. Barriers to service delivery that were experienced by DNS included deficits in the availability of specialist staff (allied health professionals, endocrinologists and DNS), insufficient space for clinics, structured education and issues with integration. CONCLUSIONS Delivering integrated diabetes care through a nurse specialist-led approach requires that wider service issues, including regional disparities in access to specialist resources and formalising agreements and protocols on multidisciplinary working between settings, be explicitly addressed.
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Affiliation(s)
- Fiona Riordan
- Department of Epidemiology and Public Health, University College Cork National University of Ireland, Cork, Ireland
| | - Sheena M McHugh
- Department of Epidemiology and Public Health, University College Cork National University of Ireland, Cork, Ireland
| | - Katie Murphy
- Department of General Practice, University College Cork, Cork, Ireland
| | - Julie Barrett
- Department of Epidemiology and Public Health, University College Cork National University of Ireland, Cork, Ireland
| | - Patricia M Kearney
- Department of Epidemiology and Public Health, University College Cork National University of Ireland, Cork, Ireland
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Hollingworth SA, Donald M, Zhang J, Vaikuntam BP, Russell A, Jackson C. Impact of a general practitioner-led integrated model of care on the cost of potentially preventable diabetes-related hospitalisations. Prim Care Diabetes 2017; 11:344-347. [PMID: 28442341 DOI: 10.1016/j.pcd.2017.03.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 02/27/2017] [Accepted: 03/29/2017] [Indexed: 11/25/2022]
Abstract
AIM To estimate potential savings for Australia's health care system through the implementation of an innovative Beacon model of care for patients with complex diabetes. METHODS A prospective controlled trial was conducted comparing a multidisciplinary, community-based, integrated primary-secondary care diabetes service with usual care at a hospital diabetes outpatient clinic. We extracted patient hospitalisation data from the Queensland Hospital Admitted Patient Data Collection and used Australian Refined Diagnosis Related Groups to assign costs to potentially preventable hospitalisations for diabetes. RESULTS 327 patients with complex diabetes referred by their general practitioner for specialist outpatient care were included in the analysis. The integrated model of care had potential for national cost savings of $132.5 million per year. CONCLUSIONS The differences in hospitalisations attributable to better integrated primary/secondary care can yield large cost savings. Models such as the Beacon are highly relevant to current national health care reform initiatives to improve the continuity and efficiency of care for those with complex chronic disease in primary care.
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Affiliation(s)
- Samantha A Hollingworth
- School of Pharmacy, The University of Queensland, 20 Cornwall St., Woolloongabba, QLD 4102, Australia.
| | - Maria Donald
- School of Medicine, The University of Queensland, Herston, QLD 4006, Australia.
| | - Jianzhen Zhang
- School of Medicine, The University of Queensland, Herston, QLD 4006, Australia.
| | | | - Anthony Russell
- School of Medicine, The University of Queensland, Herston, QLD 4006, Australia; Princess Alexandra Hospital, Woolloongabba, QLD 4102, Australia.
| | - Claire Jackson
- School of Medicine, The University of Queensland, Herston, QLD 4006, Australia.
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Greenhalgh T, Jackson C, Shaw S, Janamian T. Achieving Research Impact Through Co-creation in Community-Based Health Services: Literature Review and Case Study. Milbank Q 2017; 94:392-429. [PMID: 27265562 PMCID: PMC4911728 DOI: 10.1111/1468-0009.12197] [Citation(s) in RCA: 462] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Policy Points: Co‐creation—collaborative knowledge generation by academics working
alongside other stakeholders—is an increasingly popular approach to
aligning research and service development. It has potential for “moving beyond the ivory towers” to deliver
significant societal impact via dynamic, locally adaptive
community‐academic partnerships. Principles of successful co‐creation include a systems perspective,
a creative approach to research focused on improving human
experience, and careful attention to governance and process. If these principles are not followed, co‐creation efforts may
fail.
Context Co‐creation—collaborative knowledge generation by academics working
alongside other stakeholders—reflects a “Mode 2” relationship (knowledge
production rather than knowledge translation) between universities and society.
Co‐creation is widely believed to increase research impact. Methods We undertook a narrative review of different models of co‐creation
relevant to community‐based health services. We contrasted their diverse
disciplinary roots and highlighted their common philosophical assumptions,
principles of success, and explanations for failures. We applied these to an
empirical case study of a community‐based research‐service partnership led by the
Centre of Research Excellence in Quality and Safety in Integrated
Primary‐Secondary Care at the University of Queensland, Australia. Findings Co‐creation emerged independently in several fields, including
business studies (“value co‐creation”), design science (“experience‐based
co‐design”), computer science (“technology co‐design”), and community development
(“participatory research”). These diverse models share some common features, which
were also evident in the case study. Key success principles included (1) a systems
perspective (assuming emergence, local adaptation, and nonlinearity); (2) the
framing of research as a creative enterprise with human experience at its core;
and (3) an emphasis on process (the framing of the program, the nature of
relationships, and governance and facilitation arrangements, especially the style
of leadership and how conflict is managed). In both the literature review and the
case study, co‐creation “failures” could often be tracked back to abandoning (or
never adopting) these principles. All co‐creation models made strong claims for
significant and sustainable societal impacts as a result of the adaptive and
developmental research process; these were illustrated in the case study. Conclusions Co‐creation models have high potential for societal impact but
depend critically on key success principles. To capture the nonlinear chains of
causation in the co‐creation pathway, impact metrics must reflect the dynamic
nature and complex interdependencies of health research systems and address
processes as well as outcomes.
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Affiliation(s)
- Trisha Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Claire Jackson
- Discipline of General Practice, School of Medicine, University of Queensland
| | - Sara Shaw
- Nuffield Department of Primary Care Health Sciences, University of Oxford
| | - Tina Janamian
- Discipline of General Practice, School of Medicine, University of Queensland
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29
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Seidu S, Bodicoat DH, Davies MJ, Daly H, Stribling B, Farooqi A, Brady EM, Khunti K. Evaluating the impact of an enhanced primary care diabetes service on diabetes outcomes: A before-after study. Prim Care Diabetes 2017; 11:171-177. [PMID: 27745857 DOI: 10.1016/j.pcd.2016.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/20/2016] [Accepted: 09/25/2016] [Indexed: 11/30/2022]
Abstract
UNLABELLED Diabetes is an ambulatory care-sensitive condition and a high quality primary care or risk factor control can lead to a decrease in the risk of non-elective hospitalisations while ensuring continuity of care with usual primary care teams. AIMS AND METHODS In this before and after study, eight primary care practices providing a newer enhanced diabetes model of care in Leicester UK, were compared with matched neighbouring practices with comparable demographic features providing a more expensive integrated specialist-community care diabetes service. The primary outcome at twelve months was to demonstrate equivalence in non-elective bed days. The enhanced practices had primary care physicians and nurses with an interest in diabetes who attended monthly diabetes education meetings and provided care plans and audits. The control practices provided an integrated primary-specialist care service. RESULTS The difference between the mean change in the non-elective bed days from baseline and at follow up in core and enhanced practices was not statistically significant (mean=2.20 per 100 patients, 95% CI=-0.92 to 5.31 per 100 patients, p=0.14). The analogous change for first outpatients' attendance were 0.23 per 100 patients (95% CI=-0.47 to 0.52 per 100 patients p=0.92) and for diabetes related complications admissions was 0.30 per 100 patients (95% CI=-0.85 to 1.45 per 100 patients p=0.55). CONCLUSION A model of enhanced primary care based diabetes care appears unlikely to increase hospitalisations, outpatients' attendance or admissions for diabetes related complications.
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Affiliation(s)
- S Seidu
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK.
| | - D H Bodicoat
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - M J Davies
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - H Daly
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - B Stribling
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - A Farooqi
- NHS Leicester City Clinical Commissioning Group, St. Johns House, 30 East Street Leicester Leicestershire LE1 6NB, UK
| | - E M Brady
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
| | - K Khunti
- Leicester Diabetes Centre, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK; Diabetes Research Centre, University of Leicester, Leicester General Hospital, Gwendolen Road, Leicester LE5 4WP, UK
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Falster MO, Jorm LR, Leyland AH. Visualising linked health data to explore health events around preventable hospitalisations in NSW Australia. BMJ Open 2016; 6:e012031. [PMID: 27604087 PMCID: PMC5020859 DOI: 10.1136/bmjopen-2016-012031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE To explore patterns of health service use in the lead-up to, and following, admission for a 'preventable' hospitalisation. SETTING 266 950 participants in the 45 and Up Study, New South Wales (NSW) Australia METHODS Linked data on hospital admissions, general practitioner (GP) visits and other health events were used to create visual representations of health service use. For each participant, health events were plotted against time, with different events juxtaposed using different markers and panels of data. Various visualisations were explored by patient characteristics, and compared with a cohort of non-admitted participants matched on sociodemographic and health characteristics. Health events were displayed over calendar year and in the 90 days surrounding first preventable hospitalisation. RESULTS The visualisations revealed patterns of clustering of GP consultations in the lead-up to, and following, preventable hospitalisation, with 14% of patients having a consultation on the day of admission and 27% in the prior week. There was a clustering of deaths and other hospitalisations following discharge, particularly for patients with a long length of stay, suggesting patients may have been in a state of health deterioration. Specialist consultations were primarily clustered during the period of hospitalisation. Rates of all health events were higher in patients admitted for a preventable hospitalisation than the matched non-admitted cohort. CONCLUSIONS We did not find evidence of limited use of primary care services in the lead-up to a preventable hospitalisation, rather people with preventable hospitalisations tended to have high levels of engagement with multiple elements of the healthcare system. As such, preventable hospitalisations might be better used as a tool for identifying sicker patients for managed care programmes. Visualising longitudinal health data was found to be a powerful strategy for uncovering patterns of health service use, and such visualisations have potential to be more widely adopted in health services research.
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Affiliation(s)
- Michael O Falster
- Centre for Big Data Research in Health, University of New South Wales Australia, Sydney, Australia
| | - Louisa R Jorm
- Centre for Big Data Research in Health, University of New South Wales Australia, Sydney, Australia
| | - Alastair H Leyland
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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Jackson CL, Janamian T, Booth M, Watson D. Creating health care value together: a means to an important end. Med J Aust 2016; 204:S3-4. [PMID: 27078790 DOI: 10.5694/mja16.00122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/15/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Claire L Jackson
- Discipline of General Practice, Centre of Research Excellence – Building Primary Care Quality, Performance and Sustainability via Research Co-Creation, University of Queensland, Brisbane, QLD
| | - Tina Janamian
- Discipline of General Practice, Centre of Research Excellence – Building Primary Care Quality, Performance and Sustainability via Research Co-Creation, University of Queensland, Brisbane, QLD
| | - Mark Booth
- Health Systems Policy Division, Department of Health, Canberra, ACT
| | - Diane Watson
- National Health Performance Authority, Sydney, NSW
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