The impact of intensive multifactorial treatment on perceptions of chronic care among individuals with screen-detected diabetes: results from the ADDITION-Denmark trial

Patient perspectives of diabetes care in primary care networks in Singapore: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) remains an important chronic condition worldwide requiring integrated patient-centred care as advocated by the Chronic Care Model (CCM). The Primary Care Networks (PCNs) in Singapore organise general practitioners (GPs) with nurses and care coordinators to deliver team-based care for patients with chronic conditions. This study examined the quality of care in the PCNs as defined by the CCM from the patients' perspective.

METHODS

This study followed a cross-sectional convergent mixed-method design with T2D patients across three PCN types (GP-led, Group, and Cluster). The Patient Assessment of Chronic Illness Care (PACIC, range 1-5) was completed by a convenience sample of 343 patients. Multivariate linear regression was performed to estimate the associations between patient and service characteristics and PACIC summary score. Twenty-four participants were purposively recruited for interviews on the experienced care until thematic saturation was reached. Quantitative and qualitative data were collected concurrently and independently. Integration occurred during study design and data analysis using the CCM as guidance. Quantitative and qualitative results were compared side-by-side in a joint comparison table to develop key concepts supported by themes, subthemes, and patients' quotes.

RESULTS

The PACIC mean summary score of 3.21 for 343 patients evidenced that some have received CCM consistent care in the PCNs. Being younger and spending more time with the GP were associated with higher PACIC summary scores. PACIC summary scores did not differ across PCN types. The 24 patients interviewed in the qualitative study reported receiving team-based care, nurse services, good continuity of care, as well as patient-centred care, convenient access, and affordable care. Key concepts showed that integrated care consistent with the CCM was sometimes received by patients in the PCNs. Patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling were sometimes received by patients, while follow-up/coordination was generally not received.

CONCLUSIONS

Patients with T2D from the Singapore Primary Care Networks received integrated care consistent with the Chronic Care Model, particularly in patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling. Follow-up/coordination needed improvement to ensure higher quality of diabetes care.

Patients' Assessment of Chronic Illness Care (PACIC): Validation and Evaluation of PACIC Scale among Patients with Type 2 Diabetes in Hungary

Introduction:

The aims of this study were to evaluate the psychometric properties of the Hungarian translation of the PACIC in a sample of patients with type 2 diabetes and to reveal the associations between the mean PACIC scores and the number of chronic diseases, or visits to GPs, and specialist. An exploratory factor analysis (EFA) has also been performed to test the structural validity of the PACIC scale.

Methods:

The Hungarian version of PACIC was validated using randomly selected patients with type 2 diabetes (N = 684) from licensed GP practices.

Results:

Floor (1.6%–30.2%) and ceiling effects (11.3–33.6%) were similar of the PACIC scale. The internal consistency of the total scale (Cronbach’s alpha 0.93) was excellent and subscales were good (between 0.73–0.9). The mean scores of each PACIC subscale group were between 2.99–3.53. There was a weak significant correlation between the mean PACIC scores of subscales and the number of GP visits (p < 0.001), and specialist visits (p < 0.001). The EFA identified four factors on the sample (KMO = 0.931). Gender and education showed correlation with some new factors.

Conclusion:

The psychometric properties of the Hungarian version of PACIC questionnaire showed a reasonable level of validity among patients with type 2 diabetes. Now, this instrument is ready to assess the chronic care of diabetic patients in Hungary.

Patients' assessment of care for type 2 diabetes: Results of the Patient Assessment of Chronic Illness Care scale in a Danish population

Background

The Patient Assessment of Chronic Illness Care (PACIC) scale is the most appropriate for assessing self-reported experience in chronic care. We aimed to validate the PACIC questionnaire by (1) assess patients’ perception of the quality of care for Danish patients with type 2 diabetes, (2) identify which factors are most important to the quality of care designated by the five subscales in PACIC, and (3) the validity of the questionnaire.

Methods

A survey of 7,745 individuals randomly selected from the National Diabetes Registry. Descriptive statistics inter-item and item-rest correlations and factor analysis assessed the PACIC properties. Quality of care was analysed with descriptive statistics; linear and multiple regression assessed the effect of forty-nine covariates on total and subscale scores.

Results

In total, 2,696 individuals with type 2 diabetes completed ≥ 50 % of items. The floor effect for individual items was 8.5–74.5 %; the ceiling effect was 4.1–47.8 %. Cronbach’s alpha was 0.73–0.86 for the five subscales. The comparative fit index (CFI) and the Tucker–Lewis index (TLI) were 0,87, and 0,84, respectively. Mean PACIC score was 2.44 (± 0.04). Respondents, who receive diabetes care primarily at general practice and outpatient clinics had higher scores compared to those receiving care at a private specialist. Receiving rehabilitation was followed by higher scores in all subscales. Those 70 years or older had lower mean total and subscale scores compared to younger patient groups.

A higher number of diabetes visits were associated with higher total scores; a higher number of emergency department visits were associated with lower total scores. The effects of healthcare utilisation on subscale scores varied.

Conclusions

These results provide insight into variations in the quality of provided care and can be used for targeting initiatives towards improving diabetes care. Factors important to the quality of perceived care are having a GP or hospital outpatient clinic as the primary organization. Also having a higher number of visits to the two organizations are perceived as higher quality of care as well as participating in a rehabilitation program. Floor and ceiling effects were comparable to an evaluation of the PACIC questionnaire in a Danish population. Yet, floor effects suggest a need for further evaluation and possible improvement of the PACIC questionnaire in a Danish setting. Total PACIC scores were lower than in other healthcare systems, possible being a result of different contexts and cultures, and of a need for improving diabetes care in Denmark.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07051-6.

Perceived quality of care among people with type 2 diabetes mellitus in the north east region of peninsular Malaysia

BACKGROUND

People with type 2 diabetes mellitus (T2DM) are best managed by a chronic care model that is associated with enhanced quality of care and improved patient outcome. Assessing patients' perceived quality of care is crucial in improving the healthcare delivery system. Hence, this study determined the perceived quality of care among people with T2DM and explored its associations with (i) sociodemographic and clinical characteristics and (ii) types of healthcare clinics to guide future planning.

METHODS

A cross-sectional study involving 20 primary healthcare clinics in the North East Region of Peninsular Malaysia and people with T2DM as the sampling unit was conducted from February to May 2019. The pro forma checklist, interview-guided Skala Kepuasan Interaksi Perubatan-11, and Patient Assessment of Chronic Illness Care (Malay version; PACIC-M) questionnaire were used for data collection. Univariate analysis and linear regression were used to determine the status of perceived quality of care and the factors associated with the perceived quality of care, respectively.

RESULTS

Overall, data from 772 participants were analyzed. The majority was from the Malay ethnic group (95.6%) with a mean (standard deviation [SD]) glycated hemoglobin A1c (HbA1c) level of 8.91% (2.30). The median (interquartile range [IQR]) of the number of medical officers available at each clinic was 6 (7), with Family Doctor Concept (FDC) clinics having a higher number of medical officers than non-FDC clinics (p = 0.001). The overall mean (SD) PACIC-M score was 2.65 (0.54) with no significant difference between scores of patients treated in the two clinic types (p = 0.806). Higher perceived quality of care was associated with lower number of medical officers (adjusted regression coefficient [Adj.β], - 0.021; p-value [p], 0.001), and greater doctor-patient interaction in all domains: distress relief (Adj.β, 0.033; p, < 0.001), rapport (Adj.β, 0.056; p, < 0.001), and interaction outcome (Adj.β, 0.022; p, 0.003).

CONCLUSION

Although there was no significant difference found between clinic type, this study reflects that patients are comfortable when managed by the same doctor, which may support a better doctor-patient interaction. A larger specialized primary care workforce could improve diabetes care in Malaysia.

Screening for type 2 diabetes mellitus

BACKGROUND

Diabetes mellitus, a metabolic disorder characterised by hyperglycaemia and associated with a heavy burden of microvascular and macrovascular complications, frequently remains undiagnosed. Screening of apparently healthy individuals may lead to early detection and treatment of type 2 diabetes mellitus and may prevent or delay the development of related complications.

OBJECTIVES

To assess the effects of screening for type 2 diabetes mellitus.

SEARCH METHODS

We searched CENTRAL, MEDLINE, LILACS, the WHO ICTRP, and ClinicalTrials.gov from inception. The date of the last search was May 2019 for all databases. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials involving adults and children without known diabetes mellitus, conducted over at least three months, that assessed the effect of diabetes screening (mass, targeted, or opportunistic) compared to no diabetes screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for potential relevance and reviewed the full-texts of potentially relevant studies, extracted data, and carried out 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool. We assessed the overall certainty of the evidence using the GRADE approach.

MAIN RESULTS

We screened 4651 titles and abstracts identified by the search and assessed 92 full-texts/records for inclusion. We included one cluster-randomised trial, the ADDITION-Cambridge study, which involved 20,184 participants from 33 general practices in Eastern England and assessed the effects of inviting versus not inviting high-risk individuals to screening for diabetes. The diabetes risk score was used to identify high-risk individuals; it comprised variables relating to age, sex, body mass index, and the use of prescribed steroid and anti-hypertensive medication. Twenty-seven practices were randomised to the screening group (11,737 participants actually attending screening) and 5 practices to the no-screening group (4137 participants). In both groups, 36% of participants were women; the average age of participants was 58.2 years in the screening group and 57.9 years in the no-screening group. Almost half of participants in both groups were on antihypertensive medication. The findings from the first phase of this study indicate that screening compared to no screening for type 2 diabetes did not show a clear difference in all-cause mortality (hazard ratio (HR) 1.06, 95% confidence interval (CI) 0.90 to 1.25, low-certainty evidence). Screening compared to no screening for type 2 diabetes mellitus showed an HR of 1.26, 95% CI 0.75 to 2.12 (low-certainty evidence) for diabetes-related mortality (based on whether diabetes was reported as a cause of death on the death certificate). Diabetes-related morbidity and health-related quality of life were only reported in a subsample and did not show a substantial difference between the screening intervention and control. The included study did not report on adverse events, incidence of type 2 diabetes, glycosylated haemoglobin A1c (HbA1c), and socioeconomic effects.

AUTHORS' CONCLUSIONS

We are uncertain about the effects of screening for type 2 diabetes on all-cause mortality and diabetes-related mortality. Evidence was available from one study only. We are therefore unable to draw any firm conclusions relating to the health outcomes of early type 2 diabetes mellitus screening. Furthermore, the included study did not assess all of the outcomes prespecified in the review (diabetes-related morbidity, incidence of type 2 diabetes, health-related quality of life, adverse events, socioeconomic effects).

Determinants Of Patient Experience With Low Back Pain Interdisciplinary Care: A Pre-Post Interventional Study

Background and purpose

Measuring patients’ experiences of health services has become an essential part of quality of care reporting and a means for identifying opportunities for improvement. This study aimed to evaluate change in patient experience in an interdisciplinary primary care program and to estimate the impact on patient experience of sociodemographic, function, pain and general health status, resource utilization, and process variables.

Patients and methods

A 6-month interdisciplinary care program for individuals with low back pain (LBP) was implemented at four primary care settings and evaluated using an observational pre/post study design. The change in patient experience was evaluated using the Patient Assessment of Chronic Illness Care questionnaire (PACIC) completed at baseline and 6 months post-intervention (n=132). Descriptive and multivariable analyses were performed using SAS version 9.3.

Results

The average patient age was 57 (SD: 14) years of age and the majority were female (53%). The mean overall PACIC score was 2.6 (SD: 1.1) at baseline and 3.6 (SD: 0.9) at 6 months. The experience of care improved for 62% of the participants based on the minimal clinically important difference (MCID). No significant determinants of overall PACIC change score were identified in the multivariable regression models.

Conclusion

The lack of association of hypothesized determinants requires further examination of the properties of the PACIC and with a larger sample. Future investigation is needed on the relationship between improved patient experience and outcomes.

The use of the Patient Assessment of Chronic Illness Care (PACIC) instrument in diabetes care: a systematic review and meta-analysis

Purpose

The Patient Assessment of Chronic Illness Care (PACIC) was created to assess whether provided care is congruent with the Chronic Care Model, according to patients. We aimed to identify all studies using the PACIC in diabetic patients to explore (i) how overall PACIC scores varied across studies and (ii) whether scores varied according to healthcare delivery, patient and instrument characteristics.

Data sources

MEDLINE, Embase, PsycINFO, CINAHL and PubMed Central (PMC), from 2005 to 2016.

Study selection

Studies of any design using the PACIC in diabetic patients.

Data extraction and synthesis

We extracted data on healthcare delivery, patient, and instrument characteristics, and overall PACIC score and standard deviation. We performed random-effects meta-analyses and meta-regressions.

Results

We identified 34 studies including 25 942 patients from 13 countries, mostly in North America and Europe, using different versions of the PACIC in 11 languages. The overall PACIC score fluctuated between 1.7 and 4.2, with a pooled score of 3.0 (95% confidence interval 2.8-3.2, 95% predictive interval 1.9-4.2), with very high heterogeneity (I2 = 99%). The PACIC variance was not explained by healthcare delivery or patient characteristics, but by the number of points on the response scale (5 vs. 11) and the continent (Asia vs. others).

Conclusion

The PACIC is a widely used instrument, but the direct comparison of PACIC scores between studies should be performed with caution as studies may employ different versions and the influence of cultural norms and language on the PACIC score remains unknown.

Diabetes care: Comparison of patients' and healthcare professionals' assessment using the PACIC instrument

RATIONALE, AIMS AND OBJECTIVE

Whereas the Patient Assessment of Chronic Illness Care (PACIC) instrument measures the extent to which care received by patients is congruent with the Chronic Care Model, the 5As model emphasizes self-management and community resources, 2 key components of the Chronic Care Model. We aimed at comparing evaluation of diabetes care, as reported by patients with diabetes and healthcare professionals (HCPs), using these instruments.

METHODS

Two independent samples, patients with diabetes (n = 395) and HCPs (including primary and secondary care physicians and nurses; n = 287), responded to the 20-item PACIC and the six 5As model questions. The PACIC-5A (questions scored on a 5-point scale, 1 = never to 5 = always) was adapted for HCPs (modified-PACIC-5A). In both samples, means and standard deviations for each question as well as proportions of responses to each response modality were computed, and an overall score was calculated for the 20-item PACIC.

RESULTS

Patients' and HCPs' overall scores were 2.6 (SD 0.9) and 3.6 (SD 0.5), respectively, with HCPs reporting higher scores for all questions except 1. Patients' education and self-management, referral/follow-up and participation in community programs were rated as low by patients and HCPs.

CONCLUSION

Healthcare professionals, particularly diabetes specialists, tended to report better PACIC scores than patients, suggesting that care was not reported similarly when received or provided. Evaluation differences might be reduced by a closer collaboration between patients and HCPs, as well as the implementation of community-based interventions considering more patients' perspectives such as patients' education and self-management.

The effectiveness and cost effectiveness of the PAtient-Centred Team (PACT) model: study protocol of a prospective matched control before-and-after study

BACKGROUND

The present study protocol describes the evaluation of a comprehensive integrated care model implemented at two hospital sites at the University Hospital of North Norway (UNN). The PAtient Centred Team (PACT) model includes proactive, patient-centred interdisciplinary teams that aim to improve the continuum and quality of care of frail elderly patients and reduce health care costs. The main objectives of the evaluation are to analyse the effectiveness and cost effectiveness of using patient-centred teams as part of routine service provision for this patient group. The evaluation will analyse the effect on patient health and functional status, patient experiences and hospital utilisation, and it will conduct an economic evaluation. This paper describes the PACT model and the rationale for and design of the planned effectiveness and cost-effectiveness study.

METHODS/DESIGN

This is a prospective, non-randomised matched control before-and-after intervention study. Patients in the intervention group will be recruited from the hospital sites that have implemented the PACT model. The controls will be recruited from two hospitals without the model. The control patients and the index patients will be matched according to sex, age and number of long-term conditions. The study aims to include 600 patients in each group, which will provide sufficient power to detect a clinical change in the primary outcome. The primary outcome is the physical dimension of the Short Form Health Survey (SF-36). Secondary outcomes are the Patient Generated Index (PGI), the Patient Activation Measure (PAM), the Patient Assessment of Chronic Illness Care (PACIC), hospitalisation and length of stay. The cost-effectiveness study takes a health provider perspective and calculates the cost per quality-adjusted life-years (QALYs) gained. The data will be collected at baseline, 6 and 12 months. The data will be analysed using techniques and models that recognise the lack of randomisation and the correlation of cost and effect data.

DISCUSSION

The study results will provide knowledge about whether the integrated care model implemented at UNN improves the quality of care for the frail elderly with multiple conditions. The study will establish whether the PAC. T model improves health and functional status and is cost effective compared to the usual care for this patient group.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02541474.