Understanding the diversity and dynamics of living with diabetes: a feasibility study focusing on the case

Rethinking how we understand individual healthcare needs for people living with long-term conditions: a qualitative study

It has been suggested that we need to 'Think Differently' about how we organise care for people with long-term conditions. Current approaches prioritise reducing population disease burden, meaning health need is defined predominantly in terms of disease status, or even risk of disease. However, the result is care which overburdens some individuals. The World Health Organisation has described the need to view health as a 'resource for living' and not an end in itself. This study considers whether this view of health offers an alternative view of healthcare need in people living with long-term conditions. We know that chronic disease can be disruptive for some people; but not all. Our research question asked: Why do people experience long-term conditions differently, and what are the implications for understanding healthcare need? Our phenomenographic study involved qualitative interviews with 24 people living with at least one of the three conditions (diabetes, depression and chronic pain) and explored resources for and demands on daily living. Interviews all took place during 2012 and 2013. A narrative form analysis identified three patterns of illness experience (Gliding Swan, Stormy Seas and Stuck Adrift). Narrative content analysis revealed four factors explaining the variation: personalising care, existence of meaningful anchors, partnership and excess demands. We thus propose three new categories of healthcare need described by a consideration of health as a resource for living: Resilient, Vulnerable and Disconnected. We discuss how the emerging findings may offer scope to develop new needs assessment and patient-reported outcome measure tools. And so, offer a different way of thinking about the organisation for care for people with long-term conditions.

Influence of primary care practices on patients' uptake of diabetic retinopathy screening: a qualitative case study

Background

The NHS Diabetic Eye Screening Programme aims to reduce the risk of sight loss among people with diabetes in England by enabling prompt diagnosis of sight-threatening retinopathy. However, the rate of screening uptake between practices can vary from 55% to 95%. Existing research focuses on the impact of patient demographics but little is known about GP practice-related factors that can make a difference.

Aim

To identify factors contributing to high or low patient uptake of retinopathy screening.

Design and setting

Qualitative case-based study; nine purposively selected GP practices (deprived/affluent; high/low screening uptake) in three retinopathy screening programme areas.

Methods

Semi-structured interviews were conducted with patients, primary care professionals, and screeners. A comparative case-based analysis was carried out to identify factors related to high or low screening uptake.

Results

Eight possible factors that influenced uptake were identified. Five modifiable factors related to service and staff interactions: communication with screening services; contacting patients; integration of screening with other care; focus on the newly diagnosed; and perception of non-attenders. Three factors were non-modifiable challenges related to practice location: level of deprivation; diversity of ethnicities and languages; and transport and access. All practices adopted strategies to improve uptake, but the presence of two or more major barriers made it very hard for practices to achieve higher uptake levels.

Conclusions

A range of service-level opportunities to improve screening attendance were identified that are available to practices and screening teams. More research is needed into the complex interfaces of care that make up retinopathy screening.

Matching patients to an intervention for back pain: classifying patients using a latent class approach

RATIONALE, AIMS AND OBJECTIVES

Classification of patients with back pain in order to inform treatments is a long-standing aim in medicine. We used latent class analysis (LCA) to classify patients with low back pain and investigate whether different classes responded differently to a cognitive behavioural intervention. The objective was to provide additional guidance on the use of cognitive behavioural therapy to both patients and clinicians.

METHOD

We used data from 407 participants from the full study population of 701 with complete data at baseline for the variables the intervention was designed to affect and complete data at 12 months for important outcomes. Patients were classified using LCA, and a link between class membership and outcome was investigated. For comparison, the latent class partition was compared with a commonly used classification system called Subgroups for Targeted Treatment (STarT).

RESULTS

Of the relatively parsimonious models tested for association between class membership and outcome, an association was only found with one model which had three classes. For the trial participants who received the intervention, there was an association between class membership and outcome, but not for those who did not receive the intervention. However, we were unable to detect an effect on outcome from interaction between class membership and the intervention. The results from the comparative classification system were similar.

CONCLUSION

We were able to classify the trial participants based on psychosocial baseline scores relevant to the intervention. An association between class membership and outcome was identified for those people receiving the intervention, but not those in the control group. However, we were not able to identify outcome associations for individual classes and so predict outcome in order to aid clinical decision making. For this cohort of patients, the STarT system was as successful, but not superior.

Case typologies, chronic illness and primary health care

RATIONALE AND AIMS AND OBJECTIVES

When assessing patients, clinicians use typologies developed through their own particular clinical experience. Our aim was to develop a typology, based on the patient's perspective and not specific to one illness, with the potential to enhance person-centred clinical follow-up of those living with chronic illness.

METHODS

We applied the qualitative comparative method of analysis to interview data from 37 people living with type 2 diabetes or with chronic back pain, recruited from UK General Practices. Informed by theory on time and complexity, analysis focused on the ongoing adjustments made by individuals living with chronic illness (their dynamic) in current time. Health professionals (n = 20) and people living with diabetes or living with back pain (n = 14) refined and validated the typology in five focus groups.

RESULTS

We identified the following types of dynamic: past reminders, stuck and struggling, becalmed, and submerged. Among interviewees who provided data at different time points, we found some transformed from one dynamic type to another.

CONCLUSION

This typology may aid personalization of treatment decisions and could be extended to other chronic illness.

Linking people with long-term health conditions to healthy community activities: development of Patient-Led Assessment for Network Support (PLANS)

OBJECTIVE

To combine insights from service users with long-term conditions (LTCs) to assist the development of a community referral intervention designed to promote engagement and improve access to health-relevant resources.

BACKGROUND

Social deprivation and reduced access to resources have been causally linked with social isolation and the ability to manage LTCs. Participation in meaningful activity has been associated with positive health benefits, and strategies to promote access to community activities have shown some potential to improve outcomes for people with LTCs. This suggests the need to develop an engagement and referral intervention in partnership with service users and community groups as part of mainstream self-care support.

METHOD

A series of focus groups and interviews with members of community groups in Greater Manchester designed as an iterative and collaborative approach to elicit the role of personal and community networks that support long-term condition management (LTCM) to develop a community referral tool.

RESULTS

Participants reported a broad range of resources relevant to LTCM that often went beyond the usual concerns associated with self-care. This helped to inform a tool (PLANS) to tailor access to types of community-based resources which can support LTCM.

CONCLUSIONS

Understanding the everyday challenges of living with a LTC highlighted the importance of connecting and engaging with localized support for people. In response to this, we developed an intervention (PLANS) which tailors access to local resources based on personal preferences, needs and acceptability to encourage service users to engage with sustainable health choices.

Qualitative outcome assessment and research on chronic disease management in general practice. Highlights from a keynote lecture, EGPRN May 2011, Nice

At its 2011 conference in Nice, France, the European General Practice Research Network (EGPRN), considered the issue of Relevant Outcome Measures in General Practice Research into Chronic Diseases. This paper, which is adapted from a keynote lecture given during that conference, considers the role of qualitative outcome assessments in research. Such assessments have a great deal in common with the patient-centred approach of general practice as they can capture the overall state of a patient rather than capturing only certain aspects. Research suggests that patients can be categorized, based on qualitative outcome assessment, and over time might change category. This approach to assessment brings to our attention alternative ways of considering the future: future as currently being made or future as predictable, at least to some extent. Although general practice needs the evidence from research that predicts the future, it also needs to engage in research that seeks to understand patients as they make their future, and to understand the impact of clinical interventions on this process.

"They're made in factories and not by witches on the allotment": a qualitative study of midlife women in the united kingdom, exploring their approaches to complementary and alternative medicines

This article explores midlife women's experiences and approaches related to complementary and alternative therapies (CAMS). Ninety-six midlife women were asked about their use of CAMs as part of their overall approach to midlife health. Qualitative thematic analysis was combined with a case-based approach. Women set their experience of CAMs in the context of conventional medicine taking and discussed their safety and different uses. For treatments requiring direct contact with a practitioner, accessibility and quality of the relationship were crucial. Four overall approaches could be discerned (political-critical, pragmatic, careful and wellbeing-oriented) that dynamically interacted with women's experiences.

Living with diabetes: rationale, study design and baseline characteristics for an Australian prospective cohort study

Background

Diabetes mellitus is a major global public health threat. In Australia, as elsewhere, it is responsible for a sizeable portion of the overall burden of disease, and significant costs. The psychological and social impact of diabetes on individuals with the disease can be severe, and if not adequately addressed, can lead to the worsening of the overall disease picture. The Living With Diabetes Study aims to contribute to a holistic understanding of the psychological and social aspects of diabetes mellitus.

Methods/Design

The Living With Diabetes Study is a 5-year prospective cohort study, based in Queensland, Australia. The first wave of data, which was collected via a mailed self-report survey, was gathered in 2008, with annual collections thereafter. Measurements include: demographic, lifestyle, health and disease characteristics; quality of life (EQ-5D, ADDQoL); emotional well-being (CES-D, LOT-R, ESSI); disease self-management (PAM); and health-care utilisation and patient-assessed quality of care (PACIC). 29% of the 14,439 adults who were invited to participate in the study agreed to do so, yielding a sample size of 3,951 people.

Discussion

The data collected by the Living With Diabetes Study provides a good representation of Australians with diabetes to follow over time in order to better understand the natural course of the illness. The study has potential to further illuminate, and give a comprehensive picture of the psychosocial implications of living with diabetes. Data collection is ongoing.

Protecting generalism: moving on from evidence-based medicine?

Quality of decision making in modern health care is defined with reference to evidence-based medicine. There are concerns that this approach is insufficient for, and may thus threaten the future of, generalist primary care. We urgently need to extend our account of quality of knowledge use and decision making in order to protect and develop the discipline. Interpretive medicine describes an alternative framework for use in generalist care. Priorities for clinical practice and research are identified.

Patient engagement with a diabetes self-management intervention

OBJECTIVES

To explore how people living with type 2 diabetes self-manage their condition in everyday life and the impact of the Diabetes Manual programme, a one-to-one structured educational intervention aiming to increase skills and confidence for self-management.

METHOD

Semi-structured interviews with 12 participants on the Diabetes Manual trial, sampled purposively according to baseline self-efficacy and educational attainment.

RESULTS

When describing their experience of living with diabetes, there was little difference between intervention and control participants, although those who had received the programme talked more about the use of blood glucose self-assessment. Programme users were grouped into three categories, Programme Engagers (n = 2), Programme Browsers (n = 4) and Information Seekers (n = 6). Of the two participants engaging with the programme, one described a very positive experience, the other felt unsupported by their practice. None noticed a difference in the approach used by their health professional. Participants' approach to the Diabetes Manual programme suggests they will continue to use it as a resource in the future.

CONCLUSION

Participants used the Diabetes Manual programme in different ways, choosing the timing and depth of engagement. Their experience suggests that the programme requires close communication and openness towards collaborative approaches to improve skills and confidence for self-management.

Developing evidence for how to tailor medical interventions for the individual patient

We aim to answer the question: How can we develop an evidence base that will assist tailoring health interventions to individual patients? Using social theory and interview data from people living with chronic illness, we developed a new approach to analysis. Individuals were considered as emergent complex systems, adjusting and adapting within their environment and sometimes transforming. The notion of illness trajectory brought our attention to data in the interviews about the "emergent present," the current period of time when all domains of life, from across time, have expression. We summarized patterns of adjustment and adaptation within the emergent present for people living with chronic back pain, depression, and diabetes. We considered the potential of this analysis approach to inform medical decision making. Our analysis approach is the first step in developing a categorization of individuals that might be useful in tailoring health care interventions to the individual.

The importance of organizational characteristics for improving outcomes in patients with chronic disease: a systematic review of congestive heart failure

Background

Despite applications of models of care and organizational or system-level interventions to improve patient outcomes for chronic disease, consistent improvements have not been achieved. This may reflect a mismatch between the interventions and the nature of the settings in which they are attempted. The application of complex adaptive systems (CAS) framework to understand clinical systems and inform efforts to improve them may lead to more successful interventions. We performed a systematic review of interventions to improve outcomes of patients with congestive heart failure (CHF) to examine whether interventions consistent with CAS are more likely to be effective. We then examine differences between interventions that are most effective for improving outcomes for patients with CHF versus previously published data for type 2 diabetes to explore the potential impact of the nature of the disease on the types of interventions that are more likely to be effective.

Methods

We conducted a systematic review of the literature between 1998 and 2008 of organizational interventions to improve care of patients with CHF. Two independent reviewers independently assessed studies that met inclusion criteria to determine whether each reported intervention reflected one or more CAS characteristics. The effectiveness of interventions was rated as either 0 (no effect), 0.5 (mixed effect), or 1.0 (effective) based on the type, number, and significance of reported outcomes. Fisher's exact test was used to examine the association between CAS characteristics and intervention effectiveness. Specific CAS characteristics associated with intervention effectiveness for CHF were contrasted with previously published data for type 2 diabetes.

Results and discussion

Forty-four studies describing 46 interventions met eligibility criteria. All interventions utilized at least one CAS characteristic, and 85% were either 'mixed effect' or 'effective' in terms of outcomes. The number of CAS characteristics present in each intervention was associated with effectiveness (p < 0.001), supporting the idea that interventions consistent with CAS are more likely to be effective. The individual CAS characteristics associated with CHF intervention effectiveness were learning, self-organization, and co-evolution, a finding different from our previously published analysis of interventions for diabetes. We suggest this difference may be related to the degree of uncertainty involved in caring for patients with diabetes versus CHF.

Conclusion

These results suggest that for interventions to be effective, they must be consistent with the CAS nature of clinical systems. The difference in specific CAS characteristics associated with intervention effectiveness for CHF and diabetes suggests that interventions must also take into account attributes of the disease.

Leaders, leadership and future primary care clinical research

BACKGROUND

A strong and self confident primary care workforce can deliver the highest quality care and outcomes equitably and cost effectively. To meet the increasing demands being made of it, primary care needs its own thriving research culture and knowledge base.

METHODS

Review of recent developments supporting primary care clinical research.

RESULTS

Primary care research has benefited from a small group of passionate leaders and significant investment in recent decades in some countries. Emerging from this has been innovation in research design and focus, although less is known of the effect on research output.

CONCLUSION

Primary care research is now well placed to lead a broad re-vitalisation of academic medicine, answering questions of relevance to practitioners, patients, communities and Government. Key areas for future primary care research leaders to focus on include exposing undergraduates early to primary care research, integrating this early exposure with doctoral and postdoctoral research career support, further expanding cross disciplinary approaches, and developing useful measures of output for future primary care research investment.