Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands

Participatory Development of an Integrated, eHealth-Supported, Educational Care Pathway (Diabetes Box) for People With Type 2 Diabetes: Development and Usability Study

BACKGROUND

Type 2 diabetes (T2D) tremendously affects patient health and health care globally. Changing lifestyle behaviors can help curb the burden of T2D. However, health behavior change is a complex interplay of medical, behavioral, and psychological factors. Personalized lifestyle advice and promotion of self-management can help patients change their health behavior and improve glucose regulation. Digital tools are effective in areas of self-management and have great potential to support patient self-management due to low costs, 24/7 availability, and the option of dynamic automated feedback. To develop successful eHealth solutions, it is important to include stakeholders throughout the development and use a structured approach to guide the development team in planning, coordinating, and executing the development process.

OBJECTIVE

The aim of this study is to develop an integrated, eHealth-supported, educational care pathway for patients with T2D.

METHODS

The educational care pathway was developed using the first 3 phases of the Center for eHealth and Wellbeing Research roadmap: the contextual inquiry, the value specification, and the design phase. Following this roadmap, we used a scoping review about diabetes self-management education and eHealth, past experiences of eHealth practices in our hospital, focus groups with health care professionals (HCPs), and a patient panel to develop a prototype of an educational care pathway. This care pathway is called the Diabetes Box (Leiden University Medical Center) and consists of personalized education, digital educational material, self-measurements of glucose, blood pressure, activity, and sleep, and a smartphone app to bring it all together.

RESULTS

The scoping review highlights the importance of self-management education and the potential of telemonitoring and mobile apps for blood glucose regulation in patients with T2D. Focus groups with HCPs revealed the importance of including all relevant lifestyle factors, using a tailored approach, and using digital consultations. The contextual inquiry led to a set of values that stakeholders found important to include in the educational care pathway. All values were specified in biweekly meetings with key stakeholders, and a prototype was designed. This prototype was evaluated in a patient panel that revealed an overall positive impression of the care pathway but stressed that the number of apps should be restricted to one, that there should be no delay in glucose value visualization, and that insulin use should be incorporated into the app. Both patients and HCPs stressed the importance of direct automated feedback in the Diabetes Box.

CONCLUSIONS

After developing the Diabetes Box prototype using the Center for eHealth and Wellbeing Research roadmap, all stakeholders believe that the concept of the Diabetes Box is useful and feasible and that direct automated feedback and education on stress and sleep are essential. A pilot study is planned to assess feasibility, acceptability, and usefulness in more detail.

Social support via Internet communication technology for diabetes self-management: a scoping review

Background

The global prevalence of diabetes has been increasing over the past 30 years, leading to a rise in complications; diabetes is the leading cause of amputations, blindness, and kidney failure in developed countries. Diabetes self-management is challenging due to the complex lifestyle changes required. Social support from family and friends plays a crucial role in overcoming barriers to healthy behavior choices. Integrating Internet and communication technologies with social support interventions has the potential to improve diabetes self-management.

Methods

A scoping review was conducted by searching PubMed, Ovid, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Association for Computing Machinery (ACM) Digital Library databases for studies combining diabetes, Internet and communication technologies, and social support interventions. Inclusion criteria focused on adult patients with diabetes and primarily Internet and communication technologies-based strategies to initiate and enhance social support. Data abstraction included study population, design, outcomes, social support domains emphasized, support relationship intervention strategy, and Internet and communication technologies modality.

Results

The review identified 39 articles and 33 unique studies representing 27 unique interventions utilizing peer web forums, interactive voice recordings, messaging-based interventions (including Short Message Service and instant messaging), and email as Internet and communication technologies modalities. Various outcomes were reported, including improvements in perception of social support, psychosocial well-being, behavior changes, and clinical outcomes. Existing support relationships may be more effective in promoting behavior change and clinical outcomes compared to developing new relationships. Studies that explicitly measured patients' perception of support consistently showed improvements in psycho-social, behavioral, and clinical outcomes.

Conclusions

This scoping review highlights the pivotal role of social support in diabetes self-management. By integrating Internet and communication technologies into interventions, diverse modalities such as web forums and text messaging have shown promise in enhancing patients' perception of support and improving psychosocial well-being, behavior changes, and clinical outcomes. The emphasis on leveraging existing support relationships, rather than establishing new ones, underscores the effectiveness of personalized, patient-centered approaches. These findings provide essential insights for healthcare strategies, emphasizing the need to harness technology and existing social networks to empower individuals in managing diabetes effectively.

Dietary knowledge assessment among the patients with type 2 diabetes in Madinah: A cross-sectional study

Background

There is a huge burden of nutrition-related non-communicable diseases, and diabetes is one of the leading chronic nutrition-related diseases affecting more than 500 million people globally. Collecting information regarding the awareness of dietary and nutrition knowledge among diabetic patients is the first step to developing a disease prevention program. Thus, this study primarily aims at assessing the dietary awareness of diabetes patients attending the diabetic centre in Madinah governorate, Saudi Arabia.

Methods

The study was started in November 2020 and ended in October 2021. The study participants (315) were type 2 diabetes mellitus (T2DM) patients attending a diabetic centre in Madinah, Saudi Arabia. A self-prepared dietary knowledge questionnaire (DKQ) was used in this research. The variables include balanced diet, food type, food choice, carbohydrate, protein, and fat. Knowledge score was, and the total score was levelled/categorized into 'good', 'average', and 'poor'. Data were analysed by SPSS v.26.

Results

The study results identified the current knowledge of T2DM patients about different dietary items. The knowledge score of 62.2% of participants showed an average level of dietary knowledge, which is statistically significant. When we separately evaluated their understanding of different dietary components, we found that T2DM patients had poor knowledge of carbohydrates (30.15%), fat, food choices (47.7%), and type (34.6%). However, they had acceptable knowledge of proteins (56.5%).

Conclusion

Our participants exhibited acceptable knowledge about proteins but poorer knowledge of other food groups. A healthy, well-balanced diet is essential for excellent glycaemic control. Educating and arranging a health education program regarding dietary knowledge is recommended, specially designed for diabetic patients so that patients can opt for a healthier lifestyle.

Perceptions and experiences of primary healthcare providers toward interprofessional collaboration in chronic disease management in Hue, Vietnam

In Vietnam, each primary care community health center (CHC) consists of a multi-professional team with six disciplines, including a physician, assistant physician, nurse, pharmacist, midwife, and Vietnamese traditional physician, who are able to meet the majority of patient's needs at the primary care level. How they collaborate, especially in chronic disease management (CDM), is still limited described in the literature. This study aims to gain insight into the perceptions and the experiences of primary health care providers (PHCPs) toward interprofessional collaboration (IPC) in CDM in CHCs in (Hue) Vietnam. A qualitative study of descriptive phenomenology was performed using two focus groups and 15 semi-structured interviews with PHCPs from six professions relevant to CDM in CHCs. The data were analyzed using NVivo 12.0 with a thematic analysis method by a multiprofessional research team. From the analysis, the data were classified into three main themes: "lack of collaborative practice," "knowledge," and "facilitators and barriers to IPC." This study provided evidence of the awareness that actual collaboration in daily care is fragmentarily organized and that PHCPs try to finish their tasks within their profession. PHCPs work multiprofessionally and lack shared decision-making in patient-centered care. There is a need to develop an interprofessional education program and training to address these deficiencies in the Vietnamese context to improve interprofessional collaboration in health care.

Exploring facilitators and barriers to patient-provider communication regarding diabetes self-management

Objective

Long-term type 2 diabetes management requires open communication between a patient and their provider for self-care adherence. This study explored facilitators and barriers to diabetes-specific communication in West Virginia, a medically underserved state with the highest prevalence of diabetes (16.2%) in the U.S.

Methods

A secondary qualitative analysis was conducted using data from semi-structured interviews (n = 34) and 4 focus groups (n = 23) with participants of a diabetes education program. Transcripts were analyzed using thematic analysis.

Results

Three facilitators to patient-provider communication emerged: "Patient-Provider Partnership", "Provider Accessibility", and "Empowerment Through Education". Partnership with providers, especially those who were accessible outside of scheduled appointments, and empowerment obtained through diabetes education facilitated diabetes-specific patient-provider communication. However, barriers included "Providers' Focus on 'Numbers' Rather than Patient Concerns", "Patient Lack of Preparation for Appointments", and "Providers 'Talking Down to' Patients".

Conclusion

The findings highlight patient- and provider-related factors that impact diabetes-specific communication.

Innovation

Previous interventions have trained providers in communication skills. Despite some success, challenges in implementation remain considering providers' limited time and overwhelming demands. This study suggests that diabetes education programs incorporating communication and self-advocacy skills could be a promising alternative as they can empower patients to communicate their diabetes-specific needs/preferences with providers.

Barriers and Facilitators in Access to Diabetes, Hypertension, and Dyslipidemia Medicines: A Scoping Review

Objective: Identify barriers and facilitators in access to medicines for diabetes, hypertension, and dyslipidemia, considering patient, health provider, and health system perspectives.

Methods: Scoping review based on Joanna Briggs methodology. The search considered PubMed, Cochrane Library, CINAHL, Academic Search Ultimate, Web of Science, SciELO Citation Index, and grey literature. Two researchers conducted screening and eligibility phases. Data were thematically analyzed.

Results: The review included 219 documents. Diabetes was the most studied condition; most of the evidence comes from patients and the United States. Affordability and availability of medicines were the most reported dimension and specific barrier respectively, both cross-cutting concerns. Among high- and middle-income countries, identified barriers were cost of medicines, accompaniment by professionals, long distances to facilities, and cultural aspects; cost of transportation emerges in low-income settings. Facilitators reported were financial accessibility, trained health workers, medicines closer to communities, and patients’ education.

Conclusion: Barriers and facilitators are determined by socioeconomic and cultural conditions, highlighting the role of health systems in regulatory and policy context (assuring financial coverage and free medicines); providers’ role bringing medicines closer; and patients’ health education and disease management.

Perceptions of Key Informant Health Professionals before implementing tighter glycaemic targets for women with gestational diabetes mellitus in New Zealand

Background

Tighter glycaemic targets may be of benefit for women with GDM and their infants. Barrier and enabler identification prior to implementation of tighter glycaemic targets for women with GDM may support a successful transition.

Methods

A cross-sectional questionnaire survey was conducted among Key Informant Health Professionals in ten hospitals in New Zealand. The survey assessed what was currently working using less tight glycaemic targets; what barriers and enablers were considered likely when introducing tighter glycaemic targets and whether these perceptions differed by health professional groups.

Results

Sixty Key Health Informant Health Professionals completed the survey. When using the lower glycaemic targets, participants considered that women with GDM found the targets easy to use and that collaborative collegial support was effective. No significant barriers were identified. Perceived enablers identified prior to implementation of tighter targets included receiving collegial support (40, 67%), attending education sessions (38, 63%), use of pocket prompt cards (31, 52%), availability of wall charts (25, 42%) and glycaemic target reminder stickers (24, 40%). For health professionals referring into the Diabetes in Pregnancy Service effective communication (50, 83%) was considered important. Perceived barriers were confusion over glycaemic targets use (27 (45%), not being informed of the glycaemic target change (31, 52%), non-involvement with multidisciplinary decisions (29, 48%) and increased difficulty of blood glucose control for women (48, 80%). Overall, barriers and enablers between Health Professional groups did not differ.

Discussion

Key Informant Health Professionals reported effective communication as a key perceived enabler and that woman would find it more difficult to control their blood glucose concentrations. Education sessions, multidisciplinary engagement, wall charts and stickers were considered effective to overcome the perceived barriers. Further research is needed to assess if the barriers perceived were realised and if the perceived enablers supported the implementation of the tighter glycaemic targets effectively.

Barriers and facilitators on the implementation of physical activity in Primary Health Care: A systematic review

Barriers and facilitators influence the implementation of physical activity (PA) in Primary Health Care (PHC). This study aimed to analyze the scientific evidence on barriers and facilitators perceived by stakeholders on the implementation of PA in PHC.The search databases consisted of Web of Science, Medline, Scopus, and Lilacs. Two independent researchers reviewed the eligibility criteria and extracted and coded the information according to the Theoretical Domains Framework (TDF). The Consolidated Criteria for Reporting Qualitative Research was used to report the quality of the included studies. We analyzed 8.471 studies but included only 16. The studies identified 54 different reports on barriers and 48 on facilitators. Reports were often identified in the "environmental context and resources" domain, with 27 reports on barriers and 27 on facilitators. We found 25 reports of barriers and 16 of facilitators in the TDF domains that demonstrate professional profile characteristics. The low expectations in the professional profile for the implementation can influence the context and the organizational climate to identify more barriers than facilitators.

Facilitators of and Barriers to Lifestyle Support and eHealth Solutions: Interview Study Among Health Care Professionals Working in Cardiac Care

BACKGROUND

Cardiovascular diseases (CVDs) pose a significant health threat and reduce both people's life expectancy and quality of life. Healthy living is a key component in the effective prevention and treatment of CVD. However, health care professionals (HCPs) experience difficulties in supporting lifestyle changes among their patients. eHealth can provide a solution to these barriers.

OBJECTIVE

This study aims to provide insights into the factors HCPs find important in the support of patients with CVD in the uptake of and adherence to a healthy lifestyle and the perceived facilitators of and barriers to using eHealth to provide lifestyle support to patients with CVD.

METHODS

In-depth interviews were conducted with 16 Dutch HCPs specializing in lifestyle support in cardiac care.

RESULTS

We identified 13 themes, of which the first 12 concerned lifestyle support in general and were related to intervention, patient, or health care. Throughout these themes, the use of eHealth reoccurred as a potential facilitator of or solution to barriers to lifestyle support. Our final theme specifically concerned barriers to the adoption and usability of eHealth.

CONCLUSIONS

HCPs do recognize the potential advantages of eHealth while experiencing barriers to using digital tools. Incorporating their needs and values in the development of lifestyle support programs, especially eHealth, could increase their use and lead to a more widespread adoption of eHealth into health care.

Managing diabetes mellitus with comorbidities in primary healthcare facilities in urban settings: a qualitative study among physicians in Odisha, India

Aim

To explore the perceived barriers and facilitators in the management of the patients having diabetes with comorbidities by primary care physicians.

Methods

A qualitative In-Depth Interview study was conducted among the primary care physicians at seventeen urban primary health care centres at Bhubaneswar city of Odisha, India. The digitally recorded interviews were transcribed verbatim and translated into English. The data were analysed using thematic analysis.

Results

Barriers related to physicians, patients and health system were identified. Physicians felt lack of necessary knowledge and skills, communication skills and overburdening due to multiple responsibilities to be major barriers to quality care. Patients’ attitude and beliefs along with socio-economic status played an important role in treatment adherence and in the management of their disease conditions. Poor infrastructure, irregular medicine supply, and shortage of skilled allied health professionals were also found to be barriers to optimal care delivery, as was the lack of electronic medical records and personal treatment records.

Conclusion

Comprehensive guidelines with on the job training for capacity building of the physicians and creation of multidisciplinary teams at primary care level for a more holistic approach towards management of diabetes with comorbidities could be the way forward to optimal delivery of care.

Evidence-based early stage type 2 diabetes follow-up in Belgian primary care practices: Impact of multi-professional teams and care protocols

AIM

The aim of this research is to explore the current early-stage diabetes mellitus type 2 care in Belgian general practices. This, to find out if the care is provided according to the proposed evidence-based national diabetes care guideline. Additionally, this research aims to detect which person and practice characteristics can be associated with a more evidence-based care provision.

METHODS

People were included in the study if they were recently diagnosed with type 2 diabetes by the participating practice. Practice and person characteristics, and clinical parameter monitoring and lifestyle monitoring data were collected by using a questionnaire and a topic list.

RESULTS

A total of 27 general practices participated and a total of 249 people were included through their patient records. People monitored in a practice according to a self-developed protocol were 5.5 times more likely to have a better clinical parameter follow-up. Larger practices (>2000 patients), follow-up by general practitioners and practice nurses together and according to self-developed protocols were associated with a significantly better lifestyle follow-up.

CONCLUSION

Practices providing multidisciplinary diabetes care, in collaboration with practice nurses, and with diabetes care based on self-developed protocols achieved a more comprehensive follow-up.

Global survey investigating causes of treatment inertia in type 2 diabetes cardiorenal risk management

AIM

To explore reasons behind treatment inertia in current approaches to early cardiorenal risk management in type 2 diabetes (T2D).

METHODS

A global, web-based, quantitative panel survey of primary care physicians (PCPs) and primary care diabetes specialists treating people living with T2D. The questions covered current management of T2D, particularly the use of sodium-glucose co-transporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and dipeptidyl peptidase-4 inhibitors as second-/third-line therapies.

RESULTS

Of 1677 respondents from 18 countries who completed the survey, 73.4% were responsible for second-/third-line therapy initiation. Two thirds had modified treatment decisions based on recent cardiovascular outcomes trials (CVOTs). Respondents cited restricted access to therapies and limits on regular appointments as the greatest barriers to second-/third-line therapy prescription. Although 81.6% agreed that early intensification to second-/third-line therapies is associated with clinical benefits, 46.1% of respondents still reserve these for later lines of therapy, and 23.8% would not consider changing therapeutic approach in patients with well-controlled T2D but increasing cardiovascular risk.

CONCLUSIONS

Substantial barriers still prevent optimization of primary setting T2D patient care. Education programs which enable PCPs to translate CVOT evidence into clinical benefits for patients with T2D could address many of the remaining knowledge gaps identified.

Perceptions of collaborative care team members on facilitators and barriers to care and glycosylated hemoglobin level as a diabetes quality metric at a federally qualified health center in Texas

OBJECTIVES

Facilitators and barriers to collaborative patient care have been explored in previous studies. Few studies provide information about collaborative care team (CCT) members' roles in treating patients with diabetes and how CCT members should be evaluated for their contributions to diabetes care. To describe the roles and responsibilities of CCT members at CommUnityCare (CUC), a federally qualified health center in Central Texas; identify the facilitators and barriers affecting referrals to other CCT members within CUC; explore the facilitators and barriers to collaborative patient care at CUC; and assess CCT members' perceptions of quality metrics for diabetes care.

METHODS

A cross-sectional design was used. Data was collected by a survey and semistructured interviews of CCT members. The survey (32 questions) assessed roles and responsibilities, including the percentage of time spent on clinic activities, referral criteria, perceptions of quality diabetes care, and facilitators and barriers to care. The interview (32 questions) gathered a description of the CCT member's role, referral process, and ideas for diabetes quality metrics. Descriptive statistics and content analysis were used for data analysis.

RESULTS

Twenty-two CCT members (4 diagnosticians, 4 clinical pharmacists, 4 behavioral health professionals, 4 registered dietitians, 2 community health workers, and 4 care managers) participated in this study. Co-location (54%) and professional relationships with coworkers (32%) facilitated referrals to other CCT members. Appointment availability (32%) and lack of referral criteria knowledge (27%) were barriers to other CCT member referrals. Seventy-five percent of the dietitians and care managers thought that the glycosylated hemoglobin (A1C) level was a good quality metric for diabetes care, followed by 50% of the clinical pharmacists, 25% of the behavioral health counselors, and 0% of the community health workers and diagnosticians.

CONCLUSION

Co-location and professional relationships facilitated referrals to CCT members, whereas lack of CCT member availability and lack of referral criteria knowledge were barriers to CCT referrals. Metrics other than the lowering of the A1C level should be further explored to assess the quality of diabetes care.

Perceived Barriers, Benefits, Facilitators, and Attitudes of Health Professionals Towards Multidisciplinary Team Care in Type 2 Diabetes Management: A Systematic Review

BACKGROUND

The need for a multidisciplinary team approach to provide physical exercise, diet, behavioral change, and insulin therapy in type 2 diabetes mellitus (T2DM) treatment has long been recognized. However, often patients with T2DM do not have access to a multidisciplinary team.

INTRODUCTION

In developing countries, most patients with T2DM receive their diabetes care in the office of an internist or family practice physician or in a primary level health center with a general practitioner. Knowledge of healthcare professionals regarding the perceived barriers, attitudes, facilitators, and benefits of a multidisciplinary team approach in T2DM treatment can help facilitate the implementation of multidisciplinary care in T2DM.

METHODS

A systematic search strategy was performed in six databases (PubMed, Web of Science, CINAHL, EMBASE, MEDLINE, and Cochrane) using different keyword combinations to identify studies describing the healthcare professionals' views of multidisciplinary team care in T2DM. A textual narrative synthesis was used to analyze data. The Critical Appraisals Skills Programme (CASP) tool for qualitative studies was used to assess the risk of bias and transferability.

RESULTS

The views of health professionals about multidisciplinary team care in T2DM were categorized into six major factors, namely working collaboratively to foster supportive relationships; strong committed organizational and team leadership; diversity in expertise, with team members tailored to local circumstances; shared goals and approaches to ensure consistency of message; clear and open communication with the team and with patients; and the patient at the center of decision- making.

CONCLUSION

There is a huge gap in shared roles among health professionals in T2DM therapy. Hence, there is a need for allied health professionals such as physiotherapists, dieticians, and psychologists with expertise in diabetes to explore primary healthcare, barriers and facilitators to the successful integration of multidisciplinary team, seamlessly distributedinto three hierarchal levels, namely health management, health professionals, and diabetic patients.

Achievement of guideline targets of glycemic and non-glycemic parameters in North Indian type 2 diabetes mellitus patients: A retrospective analysis

BACKGROUND AND AIMS

Though, the prevalence of diabetes is increasing in the worldwide, achievement of glycemic and non-glycemic targets remain suboptimal. We conducted this retrospective cross-sectional study at two endocrine clinics of Aligarh (Uttar Pradesh) in north India.

MATERIALS AND METHODS

After screening the records of 13800 patients, 12140 patients of type 2 diabetes mellitus who were attending the clinic regularly every three to four months, were included in the final analysis. The data regarding patient's height, weight, body mass index, blood pressure, blood glucose, HbA1c, lipid profile and complications were obtained.

RESULTS

Mean age was 49.7 ± 11.3 years; males and females were almost equal in number. 2891 (23.8%) subjects were of age less than 40 years. 9614 (80%) patients had diabetes duration of less than 5 years. 3311 (27.3%) subjects were having an HbA1c of <7%, HbA1c 7-8% in 3711 (30.5%), HbA1c 8-9% in 2653 (21.9%) whereas HbA1c of >9% in 2465 (20.3%) subjects. The microvascular complications; diabetic nephropathy, diabetic neuropathy and diabetic retinopathy were present in 7.5%, 14.9% and 16.2% respectively. Hypertension was present in 25.8% and coronary artery disease was present in 15.5% of patients. Overall 27.3%, 41.7%, 44.1%, 45.3% and 67.7% of patients achieved their HbA1c, triglyceride, HDL, LDL and hypertension targets respectively, as per American Diabetes Association 2020 guidelines.

CONCLUSION

Despite availability of multiple drugs and guidelines, the attainment rates of glycemic and non-glycemic targets remain suboptimal. A more aggressive approach in the treatment of type 2 diabetes is required.

Multidisciplinary team approach to diabetes. An outlook on providers' and patients' perspectives

OBJECTIVE/BACKGROUND

This study sought to uncover the perspectives of various stakeholders towards multidisciplinary team (MDT) care, discover new understandings and help inform current practice on MDT care for diabetic patients.

METHODS

5 electronic databases were searched for articles that evaluated patients' and providers' perspectives on type 2 Diabetes Mellitus (T2DM) MDT management. Articles retrieved were sieved, coded and findings were analytically themed together in accordance to Thomas and Harden methodology.

RESULTS

15 articles were identified with three common themes: interactions between healthcare providers, benefits to patients and constraints and facilitators of the healthcare system. Trust and synergistic teamwork are important factors in promoting effective care. Patients commended MDT's improved accessibility and convenience and felt more welcomed. Often plagued by poor support, lack of manpower and resources, MDTs are less efficient and incapable of realizing their full potential.

CONCLUSION

This review illustrates that the MDT model does improve diabetes treatment outcome, help prevent or reduce complications. Nevertheless, the MDT model can be a double-edged sword as poor interactions between HCPs can hamper quality patient care. The current MDT model is also based on available resources of the health system. More effort is needed to modify the MDT model to meet the changing needs of patients.

Healthcare professionals' perceptions of the role of a multidisciplinary approach in improving the care of patients with advanced chronic kidney disease

OBJECTIVE

To explore and understand the experiences of healthcare professionals (HCPs) delivering care in a multidisciplinary care (MDC) clinic for advanced chronic kidney disease (CKD) patients.

METHODS

This is a qualitative study based on semi-quantitative questionnaire and semi-structured interviews with thematic analysis and deductive mapping onto the Theoretical Framework of Acceptability. Sixteen HCPs caring for advanced CKD patients in a MDC clinic in a tertiary teaching hospital in Singapore were recruited based on maximum variation sampling procedures.

RESULTS

The majority of the HCPs were supportive of a MDC clinic. There was a positive overall opinion of the programme [median 7.0 of 10.0 (IQR 7.0-8.0)], high satisfaction ratings for interaction with other members of team [6.9 (5.3-8.0)] and time spent with patients [7.0 (5.3-7.0)]. Thematic analysis of the interviews identified the value of MDC clinic in the provision of one-stop care, the improvement in communication and collaboration between HCPs, the facilitation of patient activation to make planned kidney care decisions, and the optimisation of medications. The main challenges were lack of continuity of care, manpower constraints, poor patient navigation between HCPs, poor patient attendance with allied HCPs, and the perception of increased cost and time spent by patients in each MDC clinic visit. The proposed interventions were notification of patients beforehand of the MDC clinic schedule and provision of navigation to patients within the MDC clinic.

CONCLUSION

A multidisciplinary care clinic for advanced chronic kidney disease patients was viewed positively by the majority of the healthcare professionals, with areas for improvement.

Views of People with Diabetes Regarding Their Experiences of the Facilitators and Barriers in Type 1 Diabetes Inpatient Care: An Interpretative Phenomenological Analysis

BACKGROUND

The aim of this study was to comprehend how people with diabetes view their experiences of the possible barriers and facilitators in inpatient care for type 1 diabetes from non-specialized nurses.

DESIGN

An interpretative phenomenology analysis (IPA) was conducted.

METHODS

The sample consisted of people with type 1 diabetes 1 (n = 24) who use the services of the state hospitals in Cyprus. The data were collected in two phases: firstly, focus groups with people with diabetes (n = 2) were conducted and analysed, and then individual semi-structured interviews with people with diabetes (n = 12) were conducted.

RESULTS

It is evident from the findings that people with diabetes experienced several barriers in diabetes inpatient care, which is concerning since this can have adverse effects on patients' outcomes. No facilitators were reported.

CONCLUSION

Significant results were found in relation to the barriers to diabetes inpatient care. Crucially, the findings demonstrate that all these factors can negatively affect the quality of care of patients with diabetes, and most of these factors are related not only to diabetes care but also generally to all patients who receive inpatient care. Interestingly, no participant reported any facilitators to their care, which further affected the negative perceptions of the care received.

Challenges to cross-sectoral care experienced by professionals working with patients living with low back pain: a qualitative interview study

BACKGROUND

While interdisciplinary, cross-sectoral collaboration promotes the effectiveness of rehabilitation programmes for persons with low back pain, challenges remain for this process. Few studies have explored challenges to cross-sectoral care as experienced by all the involved professionals across sectors during a course of treatment. The aim of this study was to explore challenges to cross-sectoral care as experienced by professionals involved in the course of treatment for patients with low back pain.

METHOD

This semi-structured, qualitative interview study included 28 health care professionals and 8 social workers who interacted with patients with low back pain. A systematic text condensation method was used to analyse data. Nvivo was used to structure and thematise the interview data.

RESULTS

Professionals expressed challenges in relation to a lack of collaboration, knowledge sharing and acknowledgement of one other and they appeared to differ in their approach to patients with pain or patients with limited function. Additional challenges included time constraints, availability and subjective approaches to managing guidelines for low back pain. A lack of a common information technology (IT) registration system and limited knowledge of the work of other professions disrupted knowledge sharing among sectors.

DISCUSSION

The different approach to patients with pain or patients with limited function challenged mutual understanding and collaboration among professionals. The lack of mutual understanding and knowledge of each other's work appeared to create an environment of disrespect and distrust among professionals that generated feelings of a lack of acknowledgement from other health care professionals.

CONCLUSION

To provide cross-sectoral care, we must ensure that professionals work together towards transparent and informed transitions from one sector to the next. This study contributes to the existing literature by presenting challenges to cross-sectoral care that are experienced by the diverse groups of professionals involved in a course of treatment for patients with low back pain.

Improving the structure of diabetes care in primary care: A pilot study

AIM

The aim of this pilot study was to determine whether glycemic control can be improved in patients with type 2 diabetes by implementing a workshop model to improve the structure of diabetes care at primary health care centers (PHCCs).

METHODS

The intervention consisted of 4 workshops at 12 PHCCs with HbA1c >70 mmol/mol (high HbA1c). Each PHCC could choose how many workshops they wished to attend and was to be represented by the manager, a diabetes nurse, and a GP. Participants analyzed the structure of diabetes care at their PHCC and developed an action plan to improve it. The percentage of patients with high HbA1c at baseline, 12, and 24 months was collected. Qualitative content analysis was also conducted.

RESULTS

All PHCCs reduced the percentage of patients with high HbA1c 12 months after the intervention, but not all maintained the reduction at 24 months. Participants experienced structuring diabetes care as central to reducing the percentage of patients with high HbA1c. Pillars of structured diabetes care included establishing routines, working in teams, and having and implementing an action plan.

CONCLUSIONS

Working with the structure of diabetes care improved care structure and had a positive impact on HbA1c. To sustain the positive impact, PHCCs had to set long-term goals and regularly evaluate performance.

Organizational Conditions That Impact the Implementation of Effective Team-Based Models for the Treatment of Diabetes for Low Income Patients-A Scoping Review

Background: Team-based care models (TBC) have demonstrated effectiveness to improve health outcomes for vulnerable diabetes patients but have proven difficult to implement in low income settings. Organizational conditions have been identified as influential on the implementation of TBC. This scoping review aims to answer the question: What is known from the scientific literature about how organizational conditions enable or inhibit TBC for diabetic patients in primary care settings, particularly settings that serve low-income patients? Methods: A scoping review study design was selected to identify key concepts and research gaps in the literature related to the impact of organizational conditions on TBC. Twenty-six articles were finally selected and included in this review. This scoping review was carried out following a directed content analysis approach. Results: While it is assumed that trained health professionals from diverse disciplines working in a common setting will sort it out and work as a team, co-location, and health professions education alone do not improve patient outcomes for diabetic patients. Health system, organization, and/or team level factors affect the way in which members of a care team, including patients and caregivers, collaborate to improve health outcomes. Organizational factors span across seven categories: governance and policies, structure and process, workplace culture, resources, team skills and knowledge, financial implications, and technology. These organizational factors are cited throughout the literature as important to TBC, however, research on the organizational conditions that enable and inhibit TBC for diabetic patients is extremely limited. Dispersed organizational factors are cited throughout the literature, but only one study specifically assesses the effect of organizational factors on TBC. Thematic analysis was used to categorize organizational factors in the literature about TBC and diabetes and a framework for analysis and definitions for key terms is presented. Conclusions: The review identified significant gaps in the literature relating to the study of organizational conditions that enable or inhibit TBC for low-income patients with diabetes. Efforts need to be carried out to establish unifying terminology and frameworks across the field to help explain the relationship between organizational conditions and TBC for diabetes. Gaps in the literature include research be based on organizational theories, research carried out in low-income settings and low and middle income countries, research explaining the difference between the organizational conditions that impact the implementation of TBC vs. maintaining or sustaining TBC and the interaction between organizational factors at the micro, meso and macro level and their impact on TBC. Few studies include information on patient outcomes, and fewer include information on low income settings. Further research is necessary on the impact of organizational conditions on TBC and diabetic patient outcomes.

Healthcare professionals' perspectives of barriers and facilitators in implementing physical activity programmes delivered to cancer survivors in a shared-care model: a qualitative study

BACKGROUND

The positive impact of physical activity programmes has been recognised, but the current uptake is low. Authorities believe delivering these programmes in a shared-care model is a future perspective. The present study aimed to identify the barriers and facilitators affecting physical activity programme implementation in a shared-care model delivered with the cooperation of all the types of healthcare professionals involved.

METHODS

Thirty-one individual interviews with primary healthcare professionals (PHPs) and four focus group interviews with 39 secondary healthcare professionals (SHPs) were undertaken. We used Grol and Flottorp's theoretical models to identify barriers and facilitators in six domains: (1) physical activity programmes, (2) patients, (3) healthcare professionals, (4) social setting, (5) organisation and (6) law and governance.

RESULTS

In the domain of physical activity programmes, those physical activity programmes that were non-tailored to the patients' needs impeded successful implementation. In the domain of healthcare professionals, the knowledge and skills pertaining to physical activity programmes and non-commitment of healthcare professionals impeded implementation. HCPs expressed their concerns about the negative influence of the patient's social network. Most barriers occurred in the domain of organisation. The PHPs and SHPs raised concerns about ineffective collaboration and networks between hospitals. Only the PHPs raised concerns about poor communication, indeterminate roles, and lack of collaboration with SHPs. Insufficient and unclear insurance coverage of physical activity programmes was a barrier in the domain of law and governance.

CONCLUSIONS

Improving the domain of organisation seems the most challenging because the collaboration, communication, networks, and interactive roles between the PHPs and SHPs are all inadequate. Survivor care plans, more use of health information technology, improved rehabilitation guidelines, and better networks might benefit implementing physical activity programmes.

Quality and barriers of outpatient diabetes care in rural health facilities in Uganda - a mixed methods study

BACKGROUND

Despite the increasing burden of diabetes in Uganda, little is known about the quality of type 2 diabetes mellitus (T2DM) care especially in rural areas. Poor quality of care is a serious limitation to the control of diabetes and its complications. This study assessed the quality of care and barriers to service delivery in two rural districts in Eastern Uganda.

METHODS

This was a mixed methods cross-sectional study, conducted in six facilities. A randomly selected sample of 377 people with diabetes was interviewed using a pre-tested interviewer administered questionnaire. Key informant interviews were also conducted with diabetes care providers. Data was collected on health outcomes, processes of care and foundations for high quality health systems. The study included three health outcomes, six elements of competent care under processes and 16 elements of tools/resources and workforce under foundations. Descriptive statistics were computed to determine performance under each domain, and thematic content analysis was used for qualitative data.

RESULTS

The mean age of participants was 49 years (±11.7 years) with a median duration of diabetes of 4 years (inter-quartile range = 2.7 years). The overall facility readiness score was 73.9%. Inadequacies were found in health worker training in standard diabetes care, availability of medicines, and management systems for services. These were also the key barriers to provision and access to care in addition to lack of affordability. Screening of clients for blood cholesterol and microvascular complications was very low. Regarding outcomes; 56.8% of participants had controlled blood glucose, 49.3% had controlled blood pressure; and 84.0% reported having at least one complication.

CONCLUSION

The quality of T2DM care provided in these rural facilities is sub-optimal, especially the process of care. The consequences include sub-optimal blood glucose and blood pressure control. Improving availability of essential medicines and basic technologies and competence of health workers can improve the care process leading to better outcomes.

The Role of Nurses and the Facilitators and Barriers in Diabetes Care: A Mixed Methods Systematic Literature Review

Background: The aim of this review is to identify the roles and activities of nurses working with people with diabetes and to examine the facilitators and barriers in caring for such people. Methods: A systematic review was conducted. From 531 abstracts reviewed, 29 studies were included (18 studies comprised questionnaire surveys, one was an intervention study, two used both questionnaires and interviews, and eight of them used interviews). Barriers and facilitators were extracted and combined using qualitative synthesis. Results: The literature review revealed three major roles and a number of barriers. A model for achieving enhanced nursing care of patients with diabetes has been developed according to the findings of this literature. Specifically, a stepladder suggesting that through better nursing training and education and by providing adequate resources, time, and synergies to diabetes specialists, nurses will be able to correctly perform their diabetes care roles, which include patient education, advanced care, and psychological support. Conclusions: Taking into serious consideration that a large number of hospital users are people with diabetes and that there is an inconsistency among countries about the work settings of Diabetes Specialist Nurses (DSNs), it is important to give greater focus to inpatient care and perhaps to enhance nurses’ roles by eliminating any barriers that prevent them from providing adequate quality care. Furthermore, integrated care involving the role of DSNs within the inpatient care would have been more beneficial for patients.

Recommendations for integrating physiotherapy into an interprofessional outpatient care setting for people living with HIV: a qualitative study

OBJECTIVES

To identify factors to consider when integrating physiotherapy (PT) into an interprofessional outpatient HIV care setting from the perspective of healthcare professionals and adults living with HIV.

DESIGN

We conducted a qualitative descriptive study using semi-structured interviews (healthcare professionals) and focus groups (adults living with HIV). We asked participants their perspectives on barriers, facilitators and strategies to accessing and participating in outpatient PT, important characteristics physiotherapists should possess working in outpatient HIV care, content and structure of PT delivery, and programme evaluation.

RECRUITMENT AND SETTING

We purposively sampled healthcare professionals based on their experiences working in interprofessional HIV care and recruited adults with HIV via word of mouth and in collaboration with an HIV-specialty hospital in Toronto, Canada. Interviews were conducted via Skype or in-person and focus groups were conducted in-person at the HIV-specialty hospital.

PARTICIPANTS

12 healthcare professionals with a median of 12 years experience in HIV care, and 13 adults living with HIV (11 men and 2 women) with a median age of 50 years and living with a median of 6 concurrent health conditions in addition to HIV.

RESULTS

Overall impressions of PT in outpatient HIV care and factors to consider when implementing PT into an interprofessional care setting include: promoting the role of, and evidence for, PT in outpatient HIV care, structuring PT delivery to accommodate the unique needs and priorities of adults living with HIV, working collaboratively with a physiotherapist on the healthcare team and evaluating rehabilitation as a component of interprofessional care.

CONCLUSIONS

Multiple factors exist for consideration when implementing PT into an interprofessional outpatient HIV care setting. Results provide insight for integrating timely and appropriate access to evidence-informed rehabilitation for people living with chronic and episodic illness, such as HIV.

Attitudes towards, facilitators and barriers to the provision of diabetes self-care support: A qualitative study among healthcare providers in Ghana

STATEMENT OF THE PROBLEM

Self-care support provided by healthcare providers (HCPs) is critical to diabetes self-care. However, a number of barriers prevent HCPs from providing self-care support to people with diabetes. We explored attitudes towards, barriers and facilitators of the provision of diabetes self-care support among Ghanaian HCPs.

METHODS

Fourteen semi-structured interviews were conducted among HCPs recruited from three diabetes clinics in Tamale, Ghana. All interviews were digitally recorded and transcribed verbatim. Transcripts were coded and analysed thematically.

RESULTS

HCPs reported a sense of responsibility and urgency to provide self-care education to diabetes patients; while believing it was the patients' responsibility to self-care for their diabetes condition. Accordingly, HCPs perceived their role to be limited to information sharing rather than behaviour change interventions. Facilitators to the provision of self-care support included patients' motivation, and team work among healthcare professionals. Barriers that hindered self-care support included language barriers and poor inter-professional collaboration. Furthermore, HCPs discussed that they felt inadequately trained to provide self-care support. Healthcare-system-related barriers were inadequate office space, lack of professional development programmes, high patient numbers, inadequate staff numbers, inadequate health insurance and a lack of sufficient supplies and equipment in the hospital.

CONCLUSION

HCPs attitudes were generally favourable towards supporting self-care, albeit with a focus on information provision rather than behaviour change. Training in effective strategies for providing self-care support are needed, and better use of the resources that are available.

Patient-Sharing Relations in the Treatment of Diabetes and Their Implications for Health Information Exchange: Claims-Based Analysis

Background

Health information exchange (HIE) among care providers who cooperate in the treatment of patients with diabetes mellitus (DM) has been rated as an important aspect of successful care. Patient-sharing relations among care providers permit inferences about corresponding information-sharing relations.

Objectives

This study aimed to obtain information for an effective HIE platform design to be used in DM care by analyzing patient-sharing relations among various types of care providers (ToCPs), such as hospitals, pharmacies, and different outpatient specialists, within a nationwide claims dataset of Austrian DM patients. We focus on 2 parameters derived from patient-sharing networks: (1) the principal HIE partners of the different ToCPs involved in the treatment of DM and (2) the required participation rate of ToCPs in HIE platforms for the purpose of effective communication.

Methods

The claims data of 7.9 million Austrian patients from 2006 to 2007 served as our data source. DM patients were identified by their medication. We established metrics for the quantification of our 2 parameters of interest. The principal HIE partners were derived from the portions of a care provider’s patient-sharing relations with different ToCPs. For the required participation rate of ToCPs in an HIE platform, we determine the concentration of patient-sharing relations among ToCPs. Our corresponding metrics are derived in analogy from existing work for the quantification of the continuity of care.

Results

We identified 324,703 DM patients treated by 12,226 care providers; the latter were members of 16 ToCPs. On the basis of their score for 2 of our parameters, we categorized the ToCPs into low, medium, and high. For the most important HIE partner parameter, pharmacies, general practitioners (GPs), and laboratories were the representatives of the top group, that is, our care providers shared the highest numbers of DM patients with these ToCPs. For the required participation rate of type of care provide (ToCP) in HIE platform parameter, the concentration of DM patient-sharing relations with a ToCP tended to be inversely related to the ToCPs member count.

Conclusions

We conclude that GPs, pharmacies, and laboratories should be core members of any HIE platform that supports DM care, as they are the most important DM patient-sharing partners. We further conclude that, for implementing HIE with ToCPs who have many members (in Austria, particularly GPs and pharmacies), an HIE solution with high participation rates from these ToCPs (ideally a nationwide HIE platform with obligatory participation of the concerned ToCPs) seems essential. This will raise the probability of HIE being achieved with any care provider of these ToCPs. As chronic diseases are rising because of aging societies, we believe that our quantification of HIE requirements in the treatment of DM can provide valuable insights for many industrial countries.

Interprofessional collaboration in diabetes care: perceptions of family physicians practicing in or not in a primary health care team

BACKGROUND

In Canada, most patients with type 2 diabetes mellitus (T2DM) are cared for in the primary care setting in the practices of family physicians. This care is delivered through a variety of practice models ranging from a single practitioner to interprofessional team models of care. This study examined the extent to which family physicians collaborate with other health professionals in the care of patients with T2DM, comparing those who are part of an interprofessional health care team called a Primary Care Network (PCN) to those who are not part of a PCN.

METHODS

Family physicians in Alberta, Canada were surveyed to ascertain: which health professionals they refer to or have collaborative arrangements with when caring for T2DM patients; satisfaction and confidence with other professionals' involvement in diabetes care; and perceived effects of having other professionals involved in diabetes care. Chi-squared and Fishers Exact tests were used to test for differences between PCN and non-PCN physicians.

RESULTS

170 (34%) family physicians responded to the survey, of whom 127 were PCN physicians and 41 were non-PCN physicians (2 not recorded). A significantly greater proportion of PCN physicians vs non-PCN physicians referred patients to pharmacists (23.6% vs 2.6%) or had collaborative working arrangements with diabetes educators (55.3% vs 18.4%), dietitians (54.5% vs 21.1%), or pharmacists (43.1% vs 21.1%), respectively. Regardless of PCN status, family physicians expressed greater satisfaction and confidence in specialists than in other family physicians or health professionals in medication management of patients with T2DM. Physicians who were affiliated with a PCN perceived that interprofessional collaboration enabled them to delegate diabetes education and monitoring and/or adjustment of medications to other health professionals and resulted in improved patient care.

CONCLUSIONS

This study sheds new insight on the influence that being part of a primary care team has on physicians' practice. Specifically, supporting physicians' access to other health professionals in the primary care setting is perceived to facilitate interprofessional collaboration in the care of patients with T2DM and improve patient care.

Barriers to diabetic self-care: A qualitative study of patients' and healthcare providers' perspectives

AIMS AND OBJECTIVES

To explore patient and healthcare provider (HCP) perspectives about patients' barriers to the performance of diabetic self-care behaviours in Ghana.

BACKGROUND

Sub-Saharan African urban populations are increasingly affected by type 2 diabetes due to nutrition transition, sedentary lifestyles and ageing. Diabetic self-care is critical to improving clinical outcomes. However, little is known about barriers to diabetic self-care (diet, exercise, medication taking, self-monitoring of blood glucose and foot care) in sub-Saharan Africa.

DESIGN

Qualitative study that followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

METHODS

Semi-structured interviews were conducted among 23 people living with type 2 diabetes and 14 HCPs recruited from the diabetes clinics of three hospitals in Tamale, Ghana. Interviews were audiotaped and transcribed verbatim. The constant comparative method of data analysis was used and identified themes classified according to constructs of the theory of planned behaviour (TPB): attitudes/behavioural beliefs, subjective norms and perceived behavioural control.

RESULTS

Barriers relating to attitudes included misconceptions that diabetes was caused by spiritual forces or curses, use of herbal medicines, intentional nonadherence, difficulty changing old habits, and feeling or lacking motivation to exercise. Barriers relating to subjective norms were inadequate family support, social stigma (usually by spouses and other members of the community) and cultural beliefs. Perceived behavioural control barriers were poor income levels, lack of glucometers, busy work schedules, long distance to the hospital and inadequate access to variety of foods due to erratic supply of foods or seasonality.

CONCLUSIONS

Both patients and HCPs discussed similar barriers and those relating to attitude and behavioural control were commonly discussed.

RELEVANCE TO CLINICAL PRACTICE

Interventions to improve adherence to diabetic self-care should focus on helping persons with diabetes develop favourable attitudes and how to overcome behavioural control barriers. Such interventions should have both individualised and community-wide approaches.

Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature

BACKGROUND

Strategic purchasing of health care services has become a key policy measure on the path to achieving universal health coverage. National provider payment systems for health services are typically characterized by mixes of provider payment methods with each method associated with distinct incentives for provider behaviours. Reaching incentive alignment across methods is critical to enhancing the effectiveness of strategic purchasing.

METHODS

A structured literature review was conducted to synthesize the evidence on how purposively aligned mixed provider payment systems affect health expenditure growth management, efficiency, and equity in access to services with a particular focus on coordinated and/or integrated care management.

RESULTS

The majority of the 37 reviewed articles focused on high-income countries with 74% from the US. Four categories of payment mixes were examined in this review: blended payment, bundled payment, cost-containment reward models, and aligned cost sharing mechanisms. Blended payment models generally reported moderate to no substantive reductions in expenditure growth, but increases in health system efficiency. Bundled payment schemes consistently report increases in efficiency and corresponding cost savings. Cost-containment rewards generated cost savings that can contribute to effective management of health expenditure growth. Evidence on aligned cost-sharing is scarce.

CONCLUSION

There is lacking evidence on when and how mixed provider payment systems and cost sharing practices align towards achieving goals. A guiding framework for how to study and evaluate mixed provider payment systems across contexts is warranted. Future research should consider a conceptual framework explicitly acknowledging the complex nature of mixed provider payment systems.

Effectiveness of the "Create Sensitivity" Caring Model on Blood Glucose/ Glycosylated Hemoglobin and Quality of Life in Patients With Type 2 Diabetes

OBJECTIVE

This study aimed to determine the effectiveness of the "Create Sensitivity" caring model on blood glucose/ glycosylated hemoglobin and quality of life in patients with type 2 Diabetes.

METHODS

This study enrolled 70 patients from an educational hospital in Kurdistan, Iran. The model was implemented among the test group over a period of 3 months. Blood glucose/ glycosylated hemoglobin and patients' quality of life were measured before and after intervention. Data were analyzed using version 21 of the statistical software SPSS.

RESULTS

After the intervention, significant differences existed between the test and control groups both in blood glucose levels (means, 146.4 ± 51.3 mg/dl and 175.6 ± 59.8 mg/dl, respectively; P=0.032) and in glycosylated hemoglobin (means, 67.89 ± 13.34 mmol/mol and 80.03 ± 17.234 mmol/mol, respectively; P= 0.002). Additionally, there was also a significant difference between the quality of life of the patients in test group (mean, 58.25 ± 5.3) and that in the control group (mean, 47.02 ± 4.5) (P= 0.0001).

CONCLUSION

Use of this model was associated with reducing fasting blood glucose and glycosylated hemoglobin and increasing the total mean of quality of life in the patients in the test group. So, the application of this model is recommended.

'Physical activity, that's a tricky subject.' Experiences of health care professionals with physical activity in type 2 diabetes care

BACKGROUND

Based on a growing body of epidemiological and biomedical studies, physical activity (PA) is considered a cornerstone in type 2 diabetes treatment. However, it is also a practice embedded in daily life and, as such, may produce certain frictions as a topic in health care. The aim of this article is to give in-depth insight into experiences of health care professionals with the delivery of PA counselling to people with type 2 diabetes.

METHODS

This study is based on in-depth interviews with 24 Dutch professionals providing care to people with type 2 diabetes. They were asked to tell about their experiences with PA in different roles, both in their professional and personal lives. The interviews were audio-recorded and transcribed verbatim. Data analysis followed a narrative approach with not only a focus on what was told, but also on how this was constructed in interaction with the interviewer, the cultural resources that were drawn on and inconsistencies or alternatives that were presented. This narrative focus was used to explore how professionals made sense of their experiences with PA counselling within the wider sociocultural context.

RESULTS

While the professionals view PA as a foundation of type 2 diabetes treatment, they experience it to be a tricky subject. Two main areas of tension were identified: (1) the understanding of patient behaviour; and (2) professionals' views on responsibilities, both on their responsibilities as professionals and their notions on who is responsible for behaviour change.

CONCLUSIONS

Health care professionals providing PA counselling to people with type 2 diabetes have to navigate between possibilities within the diabetes care framework, options for an embedding of PA in the patient's lifeworld, and the professionals' opinions on and experiences with PA and healthy living from their own lifeworld. This makes PA a complex topic of care.

Multidisciplinary collaboration in primary care: a systematic review

BACKGROUND

Several studies have discussed the benefits of multidisciplinary collaboration in primary care. However, what remains unclear is how collaboration is undertaken in a multidisciplinary manner in concrete terms.

OBJECTIVE

To identify how multidisciplinary teams in primary care collaborate, in regards to the professionals involved in the teams and the collaborative activities that take place, and determine whether these characteristics and practices are present across disciplines and whether collaboration affects clinical outcomes.

METHODS

A systematic literature review of past research, using the MEDLINE, ScienceDirect and Web of Science databases.

RESULTS

Four types of team composition were identified: specialized teams, highly multidisciplinary teams, doctor-nurse-pharmacist triad and physician-nurse centred teams. Four types of collaboration within teams were identified: co-located collaboration, non-hierarchical collaboration, collaboration through shared consultations and collaboration via referral and counter-referral. Two combinations were commonly repeated: non-hierarchical collaboration in highly multidisciplinary teams and co-located collaboration in specialist teams. Fifty-two per cent of articles reported positive results when comparing collaboration against the non-collaborative alternative, whereas 16% showed no difference and 32% did not present a comparison.

CONCLUSION

Overall, collaboration was found to be positive or neutral in every study that compared collaboration with a non-collaborative alternative. A collaboration typology based on objective measures was devised, in contrast to typologies that involve interviews, perception-based questionnaires and other subjective instruments.

Gaps and barriers in the control of blood glucose in people with type 2 diabetes

BACKGROUND

Glycaemic control is suboptimal in a large proportion of people with type 2 diabetes who are consequently at an increased and avoidable risk of potentially severe complications. We sought to explore attitudes and practices among healthcare professionals that may contribute to suboptimal glycaemic control through a review of recent relevant publications in the scientific literature.

METHODS

An electronic search of the PubMed database was performed to identify relevant publications from January 2011 to July 2015. The electronic search was complemented by a manual search of abstracts from key diabetes conferences in 2014/2015 available online.

RESULTS

Recently published data indicate that glycaemic control is suboptimal in a substantial proportion (typically 40%-60%) of people with diabetes. This is the case across geographic regions and in both low- and higher-income countries. Therapeutic inertia appears to be an important contributor to poor glycaemic control in up to half of people with type 2 diabetes. In particular, prescribers are often willing to tolerate extended periods of 'mild' hyperglycaemia as well as having low expectations for their patients. There are often delays of 3 years or longer in initiating or intensifying glucose-lowering therapy when needed.

CONCLUSION

Many people with type 2 diabetes are failed by current management, with approximately half not achieving or maintaining appropriate target blood glucose levels, leaving these patients at increased and avoidable risk of serious complications. Review criteria: The methodology of this review article is detailed in the 'Methods' section.

Resource allocation and organisational features in Swedish primary diabetes care: Changes from 2006 to 2013

AIMS

To compare the resource allocation and organisational features in Swedish primary diabetes care for patients with type 2 diabetes mellitus (T2DM) between 2006 and 2013.

METHODS

Using a repeated cross-sectional study design, questionnaires covering personnel resources and organisational features for patients with T2DM in 2006 and 2013 were sent to all Swedish primary health care centres (PHCCs) during the following year. In total, 684 (74.3%) PHCCs responded in 2006 and 880 (76.4%) in 2013.

RESULTS

Compared with 2006, the median list size had decreased in 2013 (p<0.001), whereas the median number of listed patients with T2DM had increased (p<0.001). Time devoted to patients with T2DM and diabetes-specific education levels for registered nurses (RNs) had increased, and more PHCCs had in-house psychologists (all p<0.001). The use of follow-up systems and medical check-ups had increased (all p<0.05). Individual counselling was more often based on patients' needs, while arrangement of group-based education remained low. Patient participation in setting treatment targets mainly remained low.

CONCLUSIONS

Even though the diabetes-specific educational level among RNs increased, the arrangement of group-based education and patient participation in setting treatment targets remained low. These results are of concern and should be prioritised as key features in the care of patients with T2DM.

Identifying health service barriers in the management of co-morbid diabetes and chronic kidney disease in primary care: a mixed-methods exploration

BACKGROUND

Co-morbid diabetes and chronic kidney disease (CKD) are common in primary care but health care can be suboptimal.

OBJECTIVE

In this multi-centre mixed-methods study, we investigated GPs' perspectives on health service barriers in managing diabetes and CKD as an initial step towards health care improvement.

METHODS

Four focus groups were conducted among GPs in Australia's two largest cities. Transcripts underwent content analysis to inform development of a survey exploring health service barriers. This survey was then emailed/mailed to 840 GPs. Statistical analyses were performed using STATA v2.1.

RESULTS

Responses were received from 13.7% of GPs (n = 115), mean (±SD) age 55.3 (10.1) years and mean duration of practice 26.6 (10.6). The majority (88.4%) reported wanting to manage diabetes and CKD in primary care with specialist assistance. However, 34.8% were unclear about the definition of CKD with 73.2% wanting more education. Access to specialist services was problematic with 39.3% and 28.2% reporting the process of referring patients to diabetes or CKD services, respectively, as hard. Coordination of care was also a problem with 35.6% unclear about each health care provider's role, 50.5% believing patients faced difficulties due to poor coordination across providers and 51.6% reporting duplication of tests.

CONCLUSIONS

GPs expressed a clear interest in being the principal health care providers for patients with co-morbid diabetes and CKD. Supporting GPs and health care improvement focusing on overcoming reported barriers such as inadequate knowledge about CKD, access to specialist services and coordination of care may improve outcomes for people with co-morbid diabetes and CKD.

Patients' readiness to receive psychosocial care during nurse-led routine diabetes consultations in primary care: A mixed methods study

BACKGROUND

Patients with type 2 diabetes mellitus face several emotional and social consequences of their chronic illness in their everyday life. Symptoms of distress and depression are prevalent. For providing psychosocial self-management support, nurses in primary care were trained to identify patients with psychosocial problems during routine medically-shaped diabetes consultations. However, detection rates appeared to be strikingly low.

OBJECTIVES

Our study aimed to examine patients' readiness to discuss psychosocial problems with nurses during diabetes consultations.

DESIGN

A mixed methods design was used in which qualitative data collection was followed up by quantitative data collection.

SETTING

Diabetes care in a regional group of family practices in the south of the Netherlands.

PARTICIPANTS

Type 2 diabetes patients with psychosocial problems, determined by a self-administered questionnaire.

METHODS

First, in-depth interviews (n=12) were conducted about patients' experiences with routine diabetes consultations and their perspective on a biopsychosocial care approach. Based on a qualitative content analysis, a structured questionnaire was designed to further explore the findings among a larger group of patients. This questionnaire was completed by 205 patients. The questionnaire included 14 items measuring patients' agreement with statements about diabetes care and the role of the nurse to focus on patients' emotional and social functioning.

RESULTS

The interviews showed that patients view a diabetes consultation primarily as a biomedical check-up, and do not perceive discussion of psychosocial well-being as an integral part of diabetes management. More than 90% of the sample showed a positive attitude towards current diabetes consultations. Patients' intentions and perceived needs regarding a biopsychosocial care approach of the nurse were variable. Younger patients seemed more open to discussing psychosocial problems with the nurse than patients over 65. Patients' openness to discussing psychosocial problems was not significantly (p<0.05) associated with the nurses being trained in the biopsychosocial self-management approach.

CONCLUSION

Patients see primary care nurses primarily as specialists regarding the biomedical management of diabetes. Although patients seemed to support the ideal of integrated care, they did not expect a discussion about psychosocial problems in diabetes consultations. The incorporation of systematic detection of patients with psychosocial problems in diabetes care requires endeavours to make patients acquainted with the new role of the nurse.

Local networks of community and healthcare organisations: a mixed methods study

BACKGROUND

Local collaboration of community organisations and healthcare organisations is seen as relevant for the efficiency and efficacy of health and social care because of their potential role in providing social involvement which may reduce the need for the utilisation of formal services. Care organisations connect to each other in different ways, thus comprising an organisational network. This study aimed to describe and explore organisational networks with respect to their activities for people with diabetes mellitus type 2 and potential mechanisms of effective collaboration. Collaboration could include, for example, referring to each other and organising activities together. Potential mechanisms are navigation, negotiation and contagion.

METHODS

A mixed methods study was conducted in an urban and a rural area in the Netherlands. The participating organisations were mentioned by a sample of diabetes patients in these regions and by organisations' representatives in a snowballing procedure. Next a quantitative survey and a semi-structured interview were conducted, including 35 representatives of these local organisations. The social network analysis methods was used to map and characterise the organisational networks based on results from the survey. A thematic analysis of interviews was undertaken to identify how three mechanisms (navigation, negotiation and contagion) were used in the collaboration.

RESULTS

Both interviews and network structures showed evidence of navigation-related mechanisms. Organisations referred patients with diabetes to services within their organisation or to relevant services provided by other organisations. Hardly any negotiation or contagion-related mechanisms were identified. If negotiation between organisations was found, it seemed externally enforced. The density, centrality, and reciprocity in the networks seemed low to facilitate contagion of practices. Some organisations reported actions that could have impacted on contagion. Representatives emphasized the need of network collaboration with local or regional community and healthcare organisations.

CONCLUSION

The study suggests that navigation to resources is a relevant theme in organisational networks, which could be targeted by interventions. More research is needed to explore the relevance of other network-related mechanisms.

Improving the informational continuity of care in diabetes mellitus treatment with a nationwide Shared EHR system: Estimates from Austrian claims data

PURPOSE

Shared Electronic Health Record (EHR) systems, which provide a health information exchange (HIE) within a community of care, were found to be a key enabler of informational continuity of diabetes mellitus (DM) care. Quantitative analyses of the actual contribution of Shared EHR systems to informational continuity of care are rare. The goal of this study was to quantitatively analyze (i) the degree of fragmentation of DM care in Austria as an indicator for the need for HIE, and (ii) the quantity of information (i.e. number of documents) from Austrian DM patients that would be made available by a nationwide Shared EHR system for HIE.

METHODS

Our analyses are based on social security claims data of 7.9 million Austrians from 2006 and 2007. DM patients were identified through medication data and inpatient diagnoses. The degree of fragmentation was determined by the number of different healthcare providers per patient. The amount of information that would be made available by a nationwide Shared EHR system was estimated by the number of documents that would have been available to a healthcare provider if he had access to information on the patient's visits to any of the other healthcare providers. As a reference value we determined the number of locally available documents that would have originated from the patient's visits to the healthcare provider himself. We performed our analysis for two types of systems: (i) a "comprehensive" Shared EHR system (SEHRS), where each visit of a patient results in a single document (progress note), and (ii) the Austrian ELGA system, which allows four specific document types to be shared.

RESULTS

391,630 DM patients were identified, corresponding to 4.7% of the Austrian population. More than 90% of the patients received health services from more than one healthcare provider in one year. Both, the SEHRS as well as ELGA would have multiplied the available information during a patient visit in comparison to an isolated local EHR system; the median ratio of external to local medical documents was between 1:1 for a typical visit at a primary care provider (SEHRS as well as ELGA) and 39:1 (SEHRS) respectively 28:1 (ELGA) for a typical visit at a hospital.

CONCLUSIONS

Due to the high degree of care fragmentation, there is an obvious need for HIE for Austrian DM patients. Both, the SEHRS as well as ELGA could provide a substantial contribution to informational continuity of care in Austrian DM treatment. Hospitals and specialists would have gained the most amount of external information, primary care providers and pharmacies would have at least doubled their available information. Despite being the most important potential feeders of a national Shared EHR system according to our analysis, primary care providers will not tap their full corresponding potential under the current implementation scenario of ELGA.

Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil

Although integrated healthcare networks (IHNs) are promoted in Latin America in response to health system fragmentation, few analyses on the coordination of care across levels in these networks have been conducted in the region. The aim is to analyse the existence of healthcare coordination across levels of care and the factors influencing it from the health personnel' perspective in healthcare networks of two countries with different health systems: Colombia, with a social security system based on managed competition and Brazil, with a decentralized national health system. A qualitative, exploratory and descriptive-interpretative study was conducted, based on a case study of healthcare networks in four municipalities. Individual semi-structured interviews were conducted with a three stage theoretical sample of (a) health (112) and administrative (66) professionals of different care levels, and (b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes. The results reveal poor clinical information transfer between healthcare levels in all networks analysed, with added deficiencies in Brazil in the coordination of access and clinical management. The obstacles to care coordination are related to the organization of both the health system and the healthcare networks. In the health system, there is the existence of economic incentives to compete (exacerbated in Brazil by partisan political interests), the fragmentation and instability of networks in Colombia and weak planning and evaluation in Brazil. In the healthcare networks, there are inadequate working conditions (temporary and/or part-time contracts) which hinder the use of coordination mechanisms, and inadequate professional training for implementing a healthcare model in which primary care should act as coordinator in patient care. Reforms are needed in these health systems and networks in order to modify incentives, strengthen the state planning and supervision functions and improve professional working conditions and skills.

Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

BACKGROUND

Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals.

AIM

To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians' and nurses' perceived influences on care.

DESIGN AND SETTING

Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework.

METHOD

Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians' or nurses' perceived influences on treatment goals for type 2 diabetes.

RESULTS

A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification.

CONCLUSION

Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than 'one size fits all' approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians' skills and emotions around treatment intensification and facilitation of patient behaviour change.

Selection of Treatment Strategies among Patients with Type 2 Diabetes Mellitus in Malaysia: A Grounded Theory Approach

BACKGROUND

Diabetes Mellitus is a multifaceted chronic illness and its life-long treatment process requires patients to continuously engage with the healthcare system. The understanding of how patients manoeuvre through the healthcare system for treatment is crucial in assisting them to optimise their disease management. This study aims to explore issues determining patients' treatment strategies and the process of patients manoeuvring through the current healthcare system in selecting their choice of treatment for T2DM.

METHODS

The Grounded Theory methodology was used. Twelve patients with Type 2 Diabetes Mellitus, nine family members and five healthcare providers from the primary care clinics were interviewed using a semi-structured interview guide. Three focus group discussions were conducted among thirteen healthcare providers from public primary care clinics. Both purposive and theoretical samplings were used for data collection. The interviews were audio-taped and transcribed verbatim, followed by line-by-line coding and constant comparison to identify the categories and core category.

RESULTS

The concept of "experimentation" was observed in patients' help-seeking behaviour. The "experimentation" process required triggers, followed by information seeking related to treatment characteristics from trusted family members, friends and healthcare providers to enable decisions to be made on the choice of treatment modalities. The whole process was dynamic and iterative through interaction with the healthcare system. The decision-making process in choosing the types of treatment was complex with an element of trial-and-error. The anchor of this process was the desire to fulfil the patient's expected outcome.

CONCLUSION

Patients with Type 2 Diabetes Mellitus continuously used "experimentation" in their treatment strategies and help-seeking process. The "experimentation" process was experiential, with continuous evaluation, information seeking and decision-making tinged with the element of trial-and-error. The theoretical model generated from this study is abstract, is believed to have a broad applicability to other diseases, may be applied at varying stages of disease development and is non-context specific.

Barriers to the Prevention and Treatment of Geriatric Diabetes

Health care providers need to empower older patients with individualized care plans to improve glycemic control and outcomes.

The implementation of national action program diabetes in the Netherlands: lessons learned

BACKGROUND

Over the past decade, the National Action program Diabetes (NAD) was implemented in the Netherlands. Its aim was to introduce the Care Standard (CS) for diabetes by means of a specific implementation plan and piloting in several regions. This study aimed to provide insight into the implementation of the NAD as, coupled with the introduction of the CS, it may function as an example for similar approaches in other countries.

METHODS

A series of quantitative studies (participants 2010: N = 1726, participants 2013: N = 1370 & participants pilot regions 2013: N = 168) and qualitative studies (participants 2010: N = 18 and participants 2013: N = 4) was conducted among health care professionals (HCPs). In addition, two quantitative studies were conducted among type 1 and 2 patients (participants 2010: N = 573; participants 2013: N = 5056).

RESULTS

Overall, positive changes in diabetes care were detected in the period 2010 - 2013. In 2013 significantly more HCPs were familiar with the CS (43.7 versus 37.6 %) and more HCPs perceived themselves to be working largely or completely in accordance with the CS (89.2 versus 79.0 %) than in 2010. A comparison of the results in specific pilot regions with the rest of the country revealed that HCPs in these regions scored significantly more positively on implementation and appreciation of the CS. This positive trend was reflected by the high levels of reported patient satisfaction and involvement in treatment. HCPs who were in possession of the CS had significantly better scores on the implementation of several elements of the CS than HCPs who were not in possession of the CS.

CONCLUSION

The CS has become more prominent and embedded in daily health care practice. In retrospect the CS has provided momentum for the realization of various processes relating to the wider implementation of standards to improve the care for people with other chronic diseases in the Netherlands. Experiences with the NAD and CS underline the need to move towards an integrated multidisciplinary approach of diabetes care worldwide.

Hospital-based integrated diabetes care management: an overview

To provide continuous, accessible, and quality care, a diabetes share-care program has been in place in Taiwan for several years. Lukang Christian Hospital, a member of the diabetes share-care network, endeavors to provide "patient-centered" care aimed at increasing care quality and reducing diabetic complications. Information technology has been employed by the hospital for monitoring care quality and analyzing cost-effectiveness. Structured health-care programs have also been developed to ensure the completeness of diabetes care and to encourage self-management of individuals at high risk for diabetes. The implementation of these strategies has led to progressive improvement in quality measures and spawned novel and creative ways to deliver care services.