Using the Translating Research into Practice framework to develop a diabetes prevention intervention in primary care: a mixed-methods study

BACKGROUND

Pre-diabetes affects one-third of US adults and increases the risk of type 2 diabetes. Effective evidence-based interventions, such as the Diabetes Prevention Program, are available, but a gap remains in effectively translating and increasing uptake of these interventions into routine care.

METHODS

We applied the Translating Research into Practice (TRiP) framework to guide three phases of intervention design and development for diabetes prevention: (1) summarise the evidence, (2) identify local barriers to implementation and (3) measure performance. In phase 1, we conducted a retrospective cohort analysis of linked electronic health record claims data to evaluate current practices in the management of pre-diabetes. In phase 2, we conducted in-depth interviews of 16 primary care physicians, 7 payor leaders and 31 patients to elicit common barriers and facilitators for diabetes prevention. In phase 3, using findings from phases 1 and 2, we developed the core elements of the intervention and performance measures to evaluate intervention uptake.

RESULTS

In phase 1 (retrospective cohort analysis), we found few patients with pre-diabetes received diabetes prevention interventions. In phase 2 (stakeholder engagement), we identified common barriers to include a lack of knowledge about pre-diabetes among patients and about the Diabetes Prevention Program among clinicians. In phase 3 (intervention development), we developed the START Diabetes Prevention Clinical Pathway as a systematic change package to address barriers and facilitators identified in phases 1 and 2, performance measures and a toolkit of resources to support the intervention components.

CONCLUSIONS

The TRiP framework supported the identification of evidence-based care practices for pre-diabetes and the development of a well-fitted, actionable intervention and implementation plan designed to increase treatment uptake for pre-diabetes in primary care settings. Our change package can be adapted and used by other health systems or clinics to target prevention of diabetes or other related chronic conditions.

Making prediabetes visible in primary health care: a qualitative study of health care professionals' perspectives

BACKGROUND

People with prediabetes are at high risk of developing type 2 diabetes and its complications, such as cardiovascular diseases and premature mortality. Primary prevention and health maintenance are therefore imperative. Evidence has shown that prediabetes can be prevented or delayed with behavioural change, mainly in eating habits and physical activity. Interventions that use a person-centered approach can lead to improvements in self-management, quality of life, and health outcomes. Nevertheless, there is a need for further research that engages healthcare professionals and people with prediabetes in constructing and implementing preventive programs. The purpose of this study is to explore and describe how healthcare professionals perceive prediabetes, the current challenges in its detection and treatment, and what is needed to improve quality of care.

METHODS

This qualitative study was conducted in Region Stockholm. A total of 26 primary health care professionals participated in individual interviews: 15 diabetes nurses and/or district nurses, five general practitioners, five dietitians, and one physiotherapist. Interview transcripts were analyzed with qualitative content analysis.

RESULTS

The analysis revealed two main themes that emphasize the need to make prediabetes more visible in primary health care. Despite the healthcare professionals' engagement and their motivation to improve prediabetes care, ad hoc practices and the absence of clear screening guidelines and referral pathways made it harder to focus on primary prevention. Supporting professionals in implementing structured care for people with prediabetes might encourage more efficient interprofessional collaboration and contribute to better strategies for promoting behavioural change.

CONCLUSIONS

Establishing prediabetes care guidelines, supporting health care professionals´ knowledge and skills in prediabetes care, and implementing interprofessional referral pathways are some steps to enhance prediabetes detection and care precedence in primary health care. These steps could lead to more preventive care and ensure patient safety and health care equity.

Prevalence of increased risk of type 2 diabetes in general practice: a cross-sectional study in Norway

BACKGROUND

Type 2 diabetes (T2D) is a global public health problem, but the onset can be delayed or prevented with adequate intervention in individuals with increased risk. Therefore, a major challenge in general practice is to identify individuals at risk of diabetes. However, limited knowledge is available about the prevalence of high diabetes risk individuals in a primary care population. In a cohort of consecutive patients in general practice we examined the prevalence of known diabetes and estimated risk of diabetes using The Finnish Diabetes Risk Score (FINDRISC) calculator, by sociodemographic and clinical characteristics.

METHODS

This study was a cross-sectional study conducted in four general practices in Western and Eastern Norway. A total of 1682 individuals, 20-80 years of age, were assessed for eligibility from May to December 2019. We excluded patients who actively declined participation (n = 112), were lost because of various organization challenges (n = 103) and patients who did not fulfil the inclusions criteria (n = 63). Diabetes prevalence and prevalence of individuals at risk of T2D with 95% confidence intervals (CI) were estimated for the total sample, by age group and for men and women separately. We tested for differences between groups using t-test for continuous variables and chi-square test (Pearson Chi-Square) for categorical variables.

RESULTS

Of 1404 individuals, 132 reported known diabetes, yielding a prevalence of 9.9% (95% CI 8.4-11.6). Among participants without a known diagnosis of diabetes, the following estimates of elevated risk assessment scores were found: FINDRISC score ≥ 11 32.8% (95% CI 30.3-35.4) and FINDRISC ≥ 15 10.0% (95% CI 8.6-11.9). Comparable results were found between the sexes.

CONCLUSIONS

Detection of unknown diabetes and individuals with increased risk, is of high public health relevance for early implementation of preventive measures aimed to reduce the risk of diabetes and its complications through lifestyle modification. A simple, non-expensive questionnaire, such as FINDRISC, may be valuable as an initial screening method in general practice to identify those in need for preventive measures.

Assessment of prediabetes knowledge among adults in Al-Madinah, Saudi Arabia

Background: Prediabetes is a serious health condition which can be treated with changes to lifestyle behaviour. It is a significant warning sign of being at high risk of developing type 2 diabetes. This study aims to assess knowledge of prediabetes and its associated risk factors in the community of Al-Madinah, Saudi Arabia (SA). Methods: A cross-sectional study was conducted among adult respondents in Al-Madinah in 2022. A sample size of 397 participants completed a validated self-administrated survey and data were analysed using descriptive statistics (numbers, percentages, mean and standard deviation). Results: Of the 397 participants who responded to the survey, 56.7% were aged between 21 and 25 years old, with more than half (51.9%) being male and the majority being more educated (72%). Among the participants, 14.1%, 34.3% and 51.5% had a high, moderate and poor knowledge of prediabetes, respectively. Overall, there was a statistically significant association between age (>25 years old) (p = 0.003), gender difference (p = 0.006), and prediabetes knowledge. Conclusion: Knowledge of prediabetes is important in the prevention of type 2 diabetes. The population of Al-Madinah demonstrated a low level of prediabetes knowledge; therefore, the design and implementation of community-based intervention programmes with an emphasis on raising prediabetes awareness is crucial. Policymakers, organisations and partnerships will be required to develop a well-designed and effective programme.

Engaging Payors and Primary Care Physicians Together in Improving Diabetes Prevention

BACKGROUND

Type 2 diabetes can be prevented through lifestyle programs like the Diabetes Prevention Programs (DPP), but few people with prediabetes participate in them, in part because their insurance does not reliably cover DPPs. Prior studies have not focused on payor-level barriers.

OBJECTIVE

To understand barriers to DPP uptake that exist and intersect at different levels (patients, PCPs, and payors) to inform strategies to improve diabetes prevention in primary care settings through interviews with PCPs and payors.

DESIGN

From May 2020 to October 2021, we conducted remote, semi-structured interviews with PCPs and payors.

PARTICIPANTS

PCPs were from primary care practices affiliated with one mid-Atlantic academic system. Payor leaders were from regional commercial, Medicare, and Medicaid plans.

APPROACH

Using a standardized interview guide focused on barriers, facilitators, and potential intervention components, interviews were audio-recorded using Zoom and professionally transcribed. Two reviewers double-coded transcripts using the framework analytic approach.

KEY RESULTS

We interviewed 16 PCPs from 13 primary care clinics and 7 payor leaders representing 6 insurance plans. Two themes emerged from PCP reports of patient-level barriers: (1) lack of programs and insurance coverage of resources to address nutrition and exercise and (2) inadequate resources to address social determinants of health that impact diabetes prevention. Among barriers PCPs faced, we identified two themes: (1) low PCP knowledge about DPPs and misperceptions of insurance coverage of DPPs and (2) inadequate clinical staff to address diabetes prevention. Barriers common to PCPs and payors included (1) absence of prediabetes quality measures and (2) inadequate engagement of PCPs and patients with payors.

CONCLUSIONS

Discussions with PCPs and payors revealed systemic barriers that suggest important priorities to improve prediabetes clinical care, including universal coverage of DPPs, clarity about coverage benefits, data reporting and outreach by payors to PCPs, and adoption of appropriate prediabetes quality measures.

Patient and Provider Prediabetes Knowledge, Attitudes, and Behaviors in a Large Urban Family Medicine Practice

One-third of U.S. adults have prediabetes, but only 11% are aware of their condition. Many do not receive education or treatment. The purpose of this study is to understand family medicine providers’ and patients’ attitudes, knowledge, and behaviors regarding prediabetes and its management, to guide future management interventions. Cross-sectional surveys of providers ( n = 54, 57% response rate) and patients with prediabetes ( n = 148, 16.5% response rate) were administered at a large urban academic family medicine practice. Nearly all providers agree prediabetes screening is important, but over half were unaware of the national Diabetes Prevention Program (DPP) and most do not prescribe metformin to eligible patients. Over half of patients reported being told they have prediabetes but <5% had been referred to DPP and over half were unaware of medication options. In open-ended responses, providers suggested nutrition counseling resources and an improved DPP referral process to improve prediabetes care. Patients requested clear diagnosis, education on treatment options, and nutritional counseling. This study indicates that notable gaps continue to exist in provider and patient understanding and management of prediabetes, suggesting that interventions to improve prediabetes care should include more effective counseling on diagnosis and treatment and expanding access to nutrition and educational resources.

A diagnosis of prediabetes when combined with lifestyle advice and support is considered helpful rather than a negative label by a demographically diverse group: A qualitative study

AIMS

The aim of this study was to explore the experience and perceptions of a diagnosis of prediabetes among a demographically diverse sample of New Zealanders who had, and had not, regressed to normoglycaemia following participation in a primary care nurse-delivered intervention for 6 months. The sample included Indigenous Māori who have high rates of diabetes and associated co-morbidities.

METHODS

A purposefully selected sample of 58 people with prediabetes and BMI >25 kg/m², stratified by male/female, Māori/non-Māori, and those who had/had not regressed to normoglycaemia, after completing 6-months of a prediabetes intervention were interviewed. Interviews were audio-recorded and transcribed. Data were analysed by thematic analysis.

RESULTS

Most participants recalled being shocked when told they had prediabetes, but they did not perceive the diagnosis to be a label in a negative sense, and some, described the diagnosis as helpful. Participants appreciated knowing that prediabetes could be reversed, and the opportunity to be able to take supported action and make lifestyle changes through the nurse-delivered prediabetes lifestyle intervention. Participants' clear preference was to take control and make dietary changes, not to take Metformin.

CONCLUSIONS

Prediabetes was not considered a negative label, but an opportunity, when coupled with a primary care nurse-delivered dietary intervention.

Facilitators and Barriers to Uptake of Community-Based Diabetes Prevention Program Among Multi-Ethnic Asian Patients With Prediabetes

OBJECTIVE

This study aimed to identify facilitators and barriers to the uptake of a community-based diabetes prevention program (DPP) from the perspectives of decliners with prediabetes in a multi-ethnic Asian community.

METHODS

Semi-structured interviews were conducted with 29 individuals with prediabetes who declined participation in a large community-based diabetes prevention program in Singapore. Thematic analysis was undertaken to identify themes, which were subsequently mapped onto the Capacity-Opportunity-Motivation and Behavior model (COM-B).

RESULTS

We identified 16 key themes under three COM-B domains. Health status at the time of invitation, perceived ability of self-management, understanding of prediabetes condition and/or the program intention (Capability) were important determinants. Family commitment had the strong potential to enable or hinder physical and social Opportunity related to participation. Many participants desired involvement of physician as part of program invitation and component. Fear of exacerbation coupled with an automatic aversion for suffering influenced Motivation for participation.

CONCLUSION

Identifying facilitators and barriers embedded in the COM-B will assist systematic program modifications to increase participation of individuals with prediabetes. How information about modifiable risk factors is communicated by physicians at the point of diagnosis and program introduction is key to participation. Co-locating programs with family activity, development of mHealth, readiness assessment, and tailored explanation of program purpose may increase participation. These findings will be used to guide future national interventions in the community to ensure successful implementation.

Diabetes Prevention in a U.S. Healthcare System: A Portrait of Missed Opportunities

INTRODUCTION

Type 2 diabetes is a widespread, preventable illness. The U.S. Preventive Services Task Force (USPSTF) has screening guidelines for diabetes prevention. The aim is to establish the extent to which U.S. Preventive Services Task Force's guidelines for prediabetes screening, diagnosis, and treatment are followed in a large health system and to identify missed opportunities for diabetes prevention.

METHODS

A comprehensive analysis of the electronic health records for the entire patient population of a large health center between August 1, 2019 and October 31, 2020 was analyzed, focusing on 21,448 patients eligible for prediabetes screening according to USPSTF recommendations. Compliance with U.S. Preventive Services Task Force recommendations for screening, diagnosis, and treatment was assessed.

RESULTS

Of the 21,448 patients identified as eligible for prediabetes screening, 13,465 (62.8%) were screened in accordance with the USPSTF recommendations. Of those patients screened, 3,430 met the requirements for a prediabetes diagnosis. Only 185 (5.4%) of patients who screened positive for prediabetes received a formal diagnosis of prediabetes, and no patients who received a diagnosis received appropriate treatment for their prediabetes. Women were more likely than men to be screened (p<0.001), and non-Hispanic Whites were less likely than non-Hispanic Blacks and Hispanics to be formally diagnosed even after screening positive (p<0.001).

CONCLUSIONS

Although a majority of eligible patients receive appropriate screening for prediabetes, diagnosis and treatment of patients who screen positive for prediabetes is not common practice. Future research and policy may benefit from a focus on classifying diabetes prevention as a quality metric and incentivizing behaviors consistent with diabetes prevention.

Health Care Providers' Knowledge, Attitudes, and Practices and the Association With Referrals to the National Diabetes Prevention Program Lifestyle Change Program

Purpose

To examine how health care providers’ knowledge, attitudes, and practices affect their referrals to the National Diabetes Prevention Program.

Design

Cross-sectional, self-report data from DocStyles—a web-based survey

Setting

USA

Sample

Practicing family practitioners, nurse practitioners, pharmacists, and internists, n = 1,503.

Measures

Questions regarding health care providers’ knowledge, attitudes, and practices and their referrals to the National Diabetes Prevention Program.

Analysis

Bivariate and multivariate analyses were used to calculate predictive margins and the average marginal effect.

Results

Overall, 15.2% of health care providers (n = 1,503) reported making a referral to the National Diabetes Prevention Program. Health care providers were more likely to make referrals if they were familiar with the program (average marginal effect = 36.0%, 95% CI: 29.1%, 42.8%), reported knowledge of its availability (average marginal effect=49.1%, 95% CI: 40.2%, 57.9%), believed it was important to make referrals to the program (average marginal effect = 20.7%, 95% CI: 14.4%, 27.0%), and used electronic health records to manage patients with prediabetes (average marginal effect = 9.1%, 95% CI: 5.4%, 12.7%). Health care providers’ demographic characteristics had little to no association with making referrals.

Conclusion

Making referrals to the National Diabetes Prevention Program was associated with health care providers’ knowledge of the program and its reported availability, their attitudes, and their use of the electronic health record system to manage patients with prediabetes.

Facilitators to referrals to CDC's National Diabetes Prevention Program in primary care practices and pharmacies: DocStyles 2016-2017

Despite evidence of the effectiveness of behavioral change interventions for type 2 diabetes prevention, health care provider referrals to organizations offering the National Diabetes Prevention Program (National DPP) lifestyle change program (LCP) remain suboptimal. This study examined facilitators of LCP referrals among primary care providers and pharmacists (providers). We analyzed data on 1956 providers from 2016 to 2017 DocStyles web-based surveys. Pearson chi-square or Fisher's exact tests were used for bivariate associations between facilitators, provider characteristics, and their self-reported referral and bi-directional referral (where they received patient status updates back from the LCPs) to an LCP. Multiple logistic regressions were used to estimate the effects of facilitators to referral practices, controlling for providers' characteristics. Geocoding was done at the street level for in-person, public LCP class locations and at the zip code level for survey respondents to create a density measure for LCP availability within 10 miles. Overall, 21% of providers referred their patients with prediabetes to LCPs, and 6.4% engaged in bi-directional referral. Provider practices that established clinical-community linkages (CCLs) with LCPs (AOR = 4.88), used electronic health records (EHRs) to manage patients (AOR = 2.94), or practiced within 10 miles of an in-person, public LCP class location (AOR = 1.49) were more likely to refer. Establishing CCLs with LCPs (AOR = 8.59) and using EHRs (AOR = 1.86) were also facilitators of bi-directional referral. This study highlights the importance of establishing CCLs between provider settings and organizations offering the National DPP LCP, increasing use of EHRs to manage patients, and increasing availability of in-person LCP class locations near provider practices.

A community-based prediabetes knowledge assessment among Saudi adults in Al-Ahsa region, 2018

Background: Prediabetes has been considered to be a reversible condition; a modification of lifestyle and other intervention can be successfully applied during the prediabetes period to prevent the development of type 2 diabetes. The purpose of the present study was to assess knowledge of prediabetes and its risk factors for the community in the Al-Ahsa region. Design and method: A cross-sectional community-based study was conducted in the Al-Ahsa region from mid-to-late December 2018. A sample size of 812 was determined using a single-proportion formula. Results: Of the 812 respondents who gave consent to participate in the interview; the male to female ratio was 1.1:1. 13.2% of the respondents reported that they had diabetes. Among the respondents, 87.1% had a high level of knowledge of prediabetes, while 12.9% had low-to-moderate knowledge. 84% of males 40 years of age or older, 88.7% (384) of people with university or higher education, and 95.1% (78) of people who worked as health practitioners had high knowledge of prediabetes. Overall, there was a statistically significant association between age and prediabetes knowledge (χ2 =5.006, p=0.025). Occupation also showed a significant statistical association with prediabetes knowledge (χ2 =9.85, p=0.02). Conclusion: Knowledge is considered an important factor in the prevention of prediabetes and diabetes. People in Al-Ahsa demonstrated a high level of knowledge regarding some risk factors for prediabetes. However, there were a number of deficiencies in the knowledge of prediabetes risk factors and preventive measures as well as in general knowledge of prediabetes, which may lead to a high prevalence of prediabetes and diabetes.

Primary Care Cluster RCT to Increase Diabetes Prevention Program Referrals

INTRODUCTION

The Diabetes Prevention Program, an intensive lifestyle change program, effectively reduces the risk of progression from prediabetes to type 2 diabetes but is underutilized. An implementation study using formative research was undertaken to increase Diabetes Prevention Program referrals at a primary care clinic.

STUDY DESIGN

A pragmatic, cluster randomized, mixed-methods study.

SETTING/PARTICPANTS

Clusters were teams of primary care clinicians from 2 primary care clinics. The 3 intervention clusters had 8-11 clinicians, and the 3 control clusters had 7-20 clinicians.

INTERVENTION

Implementation activities occurred from December 2017 to February 2019. The activities included targeted clinician education, a prediabetes clinician champion, and a custom electronic health record report identifying patients with prediabetes.

MAIN OUTCOME MEASURES

The primary outcome was referral of patients with prediabetes to the institutional Diabetes Prevention Program. Study data, including patient demographic and clinical variables, came from electronic health record. Interviews with clinicians evaluated the implementation strategies. Generalized estimating equation analyses that accounted for multiple levels of correlation and interview content analysis occurred in 2019.

RESULTS

Study clinicians cared for 2,992 patients with a prediabetes diagnosis or HbA1c indicative of prediabetes (5.7%-6.4%). Clinicians in the intervention clusters referred 6.9% (87 of 1,262) of patients with prediabetes to the Diabetes Prevention Program and those in the control clusters referred 1.5% (26 of 1,730). When adjusted for patient age, sex, race, HbA1c value, HbA1c test location, and insurance type, intervention clinicians had 3.85 (95% CI=0.40, 36.78) greater odds of referring a patient with prediabetes to the Diabetes Prevention Program. The 11 interviewed intervention clinicians had mixed opinions about the utility of the interventions, reporting the prediabetes clinic champion (n=7, 64%) and educational presentations (n=6, 55%) as most helpful.

CONCLUSIONS

Intervention clinicians were more likely to make Diabetes Prevention Program referrals; however, the study lacked power to achieve statistical significance. Clinician interviews suggested that intervention components that triggered Diabetes Prevention Program referrals varied among clinicians.

Falling into a deep dark hole: Tongan people's perceptions of being at risk of developing type 2 diabetes

Background

Prediabetes is a precursor for type 2 diabetes. Compared to the New Zealand/European and other population groups (24.6%), the prevalence of prediabetes is higher within Pacific groups (29.8%). The diagnosis of prediabetes presents a potential opportunity to intervene to prevent progression to type 2 diabetes.

Objective

To develop an understanding of how being ‘at risk’ of developing type 2 diabetes is perceived by Tongan people with prediabetes living in Auckland, New Zealand.

Methods

The Kakala and Talanga Tongan methodologies underpinned this study. Twelve one‐on‐one, semi‐structured interviews with Tongan patients who had prediabetes from a primary health‐care clinic in Auckland, New Zealand, were conducted. Thematic analysis was used to identify recurrent themes from the data.

Results

Participants were not aware of their prediabetes diagnosis, emotions associated with the diagnosis reflected fear and disbelief and a perception of imminent danger. Family history informed perceptions of the risk of developing type 2 diabetes. Participants could not differentiate prediabetes from type 2 diabetes, and recollections of being ‘back in the Islands’ of Tonga were consistent with healthy lifestyles.

Conclusions

Prediabetes appeared to be poorly understood and was believed to be irreversible, which could discourage behaviour change, social and physical improvements in health. Appropriate culturally tailored messages to accompany a prediabetes diagnosis, including cause and management, would be beneficial for Pacific peoples.