Primary care for diabetes mellitus patients from the perspective of the care model for chronic conditions

Alcohol abuse in older adults with type 2 diabetes mellitus in primary health care: a cross-sectional study

This cross-sectional study aimed to analyze alcohol abuse in older adults with type 2 diabetes mellitus in primary health care. Household data were collected from March to October 2018 in the Family Health Strategy in Ribeirão Preto, São Paulo through face-to-face interviews with a form application. The pattern of alcohol consumption was estimated with the Alcohol Use Disorders Identification Test-C. A total of 338 older adults with type 2 diabetes mellitus participated, and 19.2% (95%CI 15.0-23.4) engaged in alcohol abuse. Among them, we observed a higher frequency of males (63.1%), aged 60 to 64 years (35.4%), economic class C (49.2%), 1-4 schooling years (53.8%), and multimorbidity (92.3%). There was a negative association between alcohol abuse and drug therapy adherence (PR = 0.55; 95%CI 0.36-0.86). The frequency of alcohol abuse and non-adherence to drug treatment among those with a high consumption pattern is troubling since it can lead to diabetes complications. Therefore, we underscore the importance of multidimensional elderly care and health education in primary care.

Factors associated with demand for emergency medical services by people with hypertension and diabetes

OBJECTIVES

to analyze the association between recurrence of emergency service visits due to lack of blood pressure and/or glycemic control with sociodemographic variables and disease registration in Primary Care.

METHODS

quantitative study, which consulted medical records of people who attended these services two or more times for 26 months. Descriptive statistics and multiple logistic regression models were used in analysis.

RESULTS

most people did not have hypertension and/or diabetes record in their Primary Care records. The absence of this record was more frequent in males, aged between 18 and 59 years, with low education and lack of blood pressure. There was association between greater number of people seeking these services in the same year and not monitoring the chronic condition in specialized care.

CONCLUSIONS

people who do not follow up hypertension and/or diabetes in Primary Care are more likely to need assistance due to blood pressure and/or glycemic management.

Physicians' and nurses' perspective on chronic disease care practices in Primary Health Care in Brazil: a qualitative study

BACKGROUND

Primary health care-oriented systems provide better healthcare, especially for chronic diseases. This study analyzed the perspectives of physicians and nurses performing care for patients with chronic diseases in Primary Health Care in a Brazilian city.

METHODS

A qualitative study was conducted in Vitória da Conquista, Bahia, Brazil, using semi-structured interviews with five physicians and 18 nurses. The interview included questions from an analytical matrix based on three dimensions of healthcare practices: organizational, technical care, and biopsychosocial, following a deductive approach. The interviews were fully transcribed and analyzed using a thematic categorical approach.

RESULTS

The results indicated that the provision of chronic care occurs in a comprehensive way. Potentialities were identified in the diversification of access, offer of care actions and technologies, integration of teamwork, and bringing together social networks to foster autonomy and self-care. Weaknesses were mostly related to the high number of people in the teams, follow-up of several cases, high turnover of support teams, low integration of Primary Health Care with other levels, difficulties in intersectoral articulation and family participation in care.

CONCLUSION

The multidimensional assessment of health care practices aimed at individuals with chronic noncommunicable diseases was useful to portray the strengths and weaknesses of the services. It also ratifies the need to consider the importance of and investment in primary health care by offering the necessary technical, political, logistical and financial support to the units, to ensure the sustainability of the actions by nurses, doctors and entire team.

Weakening of nurses practice delivering same day-access in primary care

OBJECTIVE

To identify and analyze the weaknesses of the nurse's practice in meeting spontaneous demands in primary care units in the city of Rio de Janeiro.

METHOD

Qualitative study carried out in Rio de Janeiro, in 2016, with 20 nurses recruited unintentionally. The focus group and simple observation were applied, and data were subjected to thematic content analysis.

RESULTS

The spontaneous demand service causes tensions and work overload. Nurses and community health agents are primarily responsible for organizing access.

FINAL CONSIDERATIONS

There was a lack of understanding of the practice of spontaneous demand as part of care management, in addition to a polysemy related to the term. While for some, welcoming practices means greater autonomy, incorporating a larger scope of actions related to care and expanding their clinical practice; for others, they represent a stage that precedes medical consultation and a disorganizing element of care.

Self-care among people with Diabetes Mellitus and quality of care in Primary Health Care

OBJECTIVES

to verify the adherence to self-care activities among people with diabetes mellitus and its association with quality of care received in Primary Care.

METHODS

a cross-sectional study with 329 people with diabetes assisted in Primary Care. Sociodemographic and self-care data were collected. To assess quality of care in Primary Care, secondary data from the Access and Quality Improvement Program were used. For comparisons between adherence to self-care activities and quality of care received in Primary Care, the Kruskal-Wallis Test was used.

RESULTS

better adherence to the diet, blood glucose monitoring and medication use were observed among people with diabetes treated in Primary Care with better coordination of care, agenda organization, and equipment. Foot examination, despite the inverse relationship with quality of care, proved to be desirable.

CONCLUSIONS

adherence to self-care among people with diabetes was associated with quality of care received in Primary Care.

Receiving spontaneous demand in Primary Care: nurses' learning needs

OBJECTIVE

Identify nurse's learning needs to be related to the reception with risk classification of spontaneous demand in Primary Health Care.

METHOD

Quality study including 15 nurses from Primary Health Care through participatory observation, application of semi-structured instrument, focus group, and of thematic content analysis.

RESULTS

80% of nurses never used the risk classification protocol in Primary Health Care. Knowledge gaps involving clinical aspects of care; protocol management, and the nurse's role; and the historic, structural and cultural contradictions of the care model were confirmed.

FINAL CONSIDERATIONS

The recognition of learning needs for nurses that work in Primary Health Care implies in the construction or improvement of knowledge in order to develop, along with the health team, a risk classification of spontaneous demand, which requires a change in the education and continuity of their qualification for work and at work.

Effects of nurse-led web-based interventions on people with type 2 diabetes mellitus: A systematic review and meta-analysis

INTRODUCTION

Diabetes mellitus is an expanding global health problem. Currently, the home management of diabetes is mainly led by a multidisciplinary team based on telemedicine. However, the role nurses play in it remains inconclusive. This study aimed to investigate the effectiveness of nurse-led web-based intervention on glycated haemoglobin, blood pressure and lipid profile in patients with type 2 diabetes.

METHODS

An exhaustive systematic literature search was undertaken using the following databases: PubMed, Web of Science, Embase, The Cochrane Central Register of Controlled Trials and CINAHL. Two investigators independently extracted data and assessed the quality of the studies by examining the risk of bias and using Modified Jadad Score system. We conducted a meta-analysis of randomized controlled trials that had been published from inception to July 2020, using Review Manager 5.3.

RESULTS

Eleven randomized controlled trials were selected that included 2063 participants. Meta-analyses results indicated significant effects on not only glycated haemoglobin (pooled mean difference (MD) = -0.40, 95% confidence interval (CI): -0.5 to -0.26, p < 0.00001), but also on systolic blood pressure (pooled MD = -1.91, 95% CI: -3.73 to -0.09, p = 0.04) and low density lipoprotein (pooled standardized MD = -0.29, 95% CI: -0.44 to -0.15, p < 0.0001). There were no effects of nurse-led web-based intervention on fasting blood glucose, diastolic blood pressure, high density lipoprotein, body mass index and triglycerides.

DISCUSSION

Nurse-led web-based intervention is a promising way to complement routine clinical care. However, the specific intervention content and intervention media still need to carry out large-scale well-designed randomized controlled trials. Systematic review registration: PROSPERO CRD 42020204565.

Adesão ao autocuidado de pessoas com Diabetes Mellitus na Atenção Primária: estudo de método misto

Resumo Objetivo elaborar um modelo interpretativo sobre a adesão ao autocuidado de pessoas com Diabetes Mellitus na Atenção Primária à Saúde. Método estudo de método misto realizado em quatro Unidades Básicas de Saúde. O estudo quantitativo transversal foi composto por 329 participantes, elegeram-se variáveis sociodemográficas e clínicas e o questionário de atividades de autocuidado. No estudo qualitativo, com 31 participantes, utilizou-se a vertente construtivista da Teoria Fundamentada nos Dados. Os dados foram analisados utilizando-se a estatística descritiva e a codificação inicial e focalizada. Resultados a maioria dos participantes é do sexo feminino, casada, com um a cinco anos de estudo, aposentada e com renda de um a três salários-mínimos. Obteve-se baixa adesão à alimentação saudável, à atividade física e ao monitoramento glicêmico. A adesão desejável foi relacionada ao uso de medicamentos e cuidados com os pés. Na etapa qualitativa, obteve-se como fenômeno: Enfrentando a complexidade do tratamento do Diabetes Mellitus e buscando o autocuidado. Este foi sustentado por duas categorias: Encontrando as dificuldades para seguir o tratamento e Valorizando os aspectos facilitadores do tratamento que deram subsídios para a elaboração do modelo. Conclusões e implicações para a prática foi elaborado um modelo interpretativo cujos elementos demonstram a complexidade do fenômeno e contribuem para a adesão ao autocuidado nessa população.

Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review

BACKGROUND

Given that most evidence-based recommendations for managing type 2 diabetes mellitus (T2DM) are generated in high-income settings, significant challenges for their implementation exist in Latin America and the Caribbean region (LAC), where the rates of T2DM and related mortality are increasing. The aim of this study is to identify the facilitators and barriers to successful management of T2DM in LAC, from the perspectives of patients, their families or caregivers, healthcare professionals, and/or other stakeholders.

METHODS

We conducted a systematic review in MEDLINE, Web of Science, SciELO, and LILACS. We included studies of disease management, prevention of complications and risk factor management. We qualitatively synthesized the verbatim text referring to barriers and/or facilitators of diabetes management according to the Theoretical Domain Framework and described their relative frequencies.

FINDINGS

We included 60 studies from 1,595 records identified. 54 studies (90%) identified factors related to the environmental context and resources, highlighting the importance of questions related to health care access or lack of resources in the health system, and the environmental context and living conditions of the patients. Issues related to "social influences" (40 studies) and "social/professional role and identity" (37 studies) were also frequently addressed, indicating the negative impact of lack of support from family and friends and clinicians' paternalistic attitude. 25 studies identified patients beliefs as important barriers, identifying issues such as a lack of patients' trust in the effectiveness of the medication and/or the doctor's advice, or preferences for alternative therapies.

CONCLUSIONS

Successful diabetes management in LAC is highly dependent on factors that are beyond the control of the individual patients. Successful disease control will require emphasis on public policies to reinforce health care access and resources, the promotion of a patient-centred care approach, and health promoting infrastructures at environmental level.

Evaluating the effectiveness of a support programme for people with type 2 diabetes mellitus in primary care: an observational prospective study in Ecuador

BACKGROUND

The success of primary health care relies on the integration of empowered practitioners with cooperative patients regardless of socioeconomic status. Using resources efficiently would help to improve healthcare promotion and reduce complications of chronic non-communicable diseases (NCDs). The importance of network support programmes relies on the fact that they allow to accurately deliver medical care by shaping a sense of community and purpose among the patients.

AIM

To evaluate the effectiveness of a network support programme for patients with type 2 diabetes mellitus (T2DM).

DESIGN & SETTING

A centre-based observational prospective study took place in a primary care setting in Ecuador.

METHOD

The impact of the diabetes care programme was assessed by comparing initial and final metabolic characteristics and outcomes of 593 patients with T2DM, followed-up from April 2007 to December 2017, using paired sample t-test. Electrocardiograms (ECGs), ankle-brachial indexes (ABIs), ocular fundus, and monofilament neuropathy tests were assessed with the McNemar test to evaluate complications at the beginning and end of the study.

RESULTS

Glycated haemoglobin (HbA1c), lipid profile, and systolic blood pressure (SBP) showed statistically significant decreases between the initial measurement (IMs) and final measurements (FMs). In the FM, significantly lower HbA1c, diastolic blood pressure (DBP), and atherogenic index were found. Despite the length of time since diagnosis, during the follow-up time, long-term micro- and macro-vascular complications, such as ocular fundus, serum creatinine, and ABI, remained unchanged throughout the period of active participation in this healthcare programme.

CONCLUSION

This study demonstrates the feasibility of reducing plasma glucose, plasma lipids, and long-term complications in patients with T2DM by implementing a network support programme, which involves the medical team and patients themselves in an environment with limited resources.

Utilização do paradigma da complexidade no campo da saúde: revisão de escopo

RESUMO Objetivo Analisar o conhecimento sobre a utilização do paradigma da complexidade em pesquisas no campo da saúde. Método Revisão de escopo com artigos publicados nos últimos 10 anos, em inglês, espanhol ou português, com o uso do paradigma da complexidade do autor Edgar Morin. Resultados Retornaram 302 publicações, das quais 54 permaneceram após as etapas de seleção. A maioria dos estudos foram: realizados no Brasil; com publicações no ano de 2017; com produção uniprofissional; artigos empíricos e qualitativos. Em 47,05% dos estudos não se realizou a triangulação das técnicas de coleta de dados; foram referenciadas 20 obras do autor e 83,33% utilizaram o paradigma da complexidade como referencial teórico. Conclusão Observou-se uma tímida utilização do paradigma da complexidade nas pesquisas no campo da saúde e destaca-se a necessidade de maior apropriação conceitual no seu uso enquanto um referencial teórico nas pesquisas.

National rates of emergency department visits associated with diabetes in Saudi Arabia, 2011-2015

BACKGROUND

Despite the fact that diabetes is an important component of the burden of disease on the individual and on the national healthcare systems in Saudi Arabia, knowledge of the volume of emergency department (ED) visits for diabetes is unclear.

OBJECTIVE

Examine changes in ED visit rates associated with diabetes.

DESIGN

Retrospective.

SETTINGS

Governmental hospitals.

METHODS

Publicly available records of health statistics published by the Saudi Ministry of Health from 2011 through 2015 were used to extract data on ED visits related to diabetes. ED visits associated with diabetes were compared over time and by gender. We calculated diabetes-specific rates per 10000 persons for each sex category by dividing the total number of diabetes-associated ED visits in that category by the sex-specific population. We calculated the rate difference (RD) with 95% CI between 2011 and 2015.

MAIN OUTCOME MEASURES

Diabetes-specific rates per 10000 persons for each sex category.

RESULTS

Total annual visits to the ED for management of diabetes increased from 617683 cases in 2011 to 748605 in 2015. The annual number of ED visits associated with diabetes increased by 21% over the study period (20% for males and 23% for females). Compared to males, females had a larger increase in visit rates from 240.5 to 249.8 visits per 10000 women over the study years (RD, 9.6 per 10000 persons, 95% CI -16.4 to 26.6 versus 5.7 per 10 000 persons, 95% CI-13.6 to 18.3 ; P=.01).

CONCLUSION

Although diabetes-associated ED visit rates dramatically increased in 2012, they remained relatively stable after 2012 to the end of the study period. More effective preventive diabetes programs that prevent the use of ED visits and other expensive healthcare resources among people with diabetes are needed.

LIMITATIONS

We had no information on the specific indications for the reported ED visits. These estimates may represent a lower bound on ED visits associated with diabetes since the private sector was not included.

CONFLICT OF INTEREST

None.

Models of care for chronic conditions in low/middle-income countries: a 'best fit' framework synthesis

Management of chronic conditions is a challenge for healthcare delivery systems world over and especially for low/middle-income countries (LMIC). Redesigning primary care to deliver quality care for chronic conditions is a need of the hour. However, much of the literature is from the experience of high-income countries. We conducted a synthesis of qualitative findings regarding care for chronic conditions at primary care facilities in LMICs. The themes identified were used to adapt the existing chronic care model (CCM) for application in an LMIC using the ‘best fit’ framework synthesis methodology. Primary qualitative research studies were systematically searched and coded using themes of the CCM. The results that could not be coded were thematically analysed to generate themes to enrich the model. Search strategy keywords were: primary health care, diabetes mellitus type 2, hypertension, chronic disease, developing countries, low, middle-income countries and LMIC country names as classified by the World Bank. The search yielded 404 articles, 338 were excluded after reviewing abstracts. Further, 42 articles were excluded based on criteria. Twenty-four studies were included for analysis. All themes of the CCM, identified a priori, were represented in primary studies. Four additional themes for the model were identified: a focus on the quality of communication between health professionals and patients, availability of essential medicines, diagnostics and trained personnel at decentralised levels of healthcare, and mechanisms for coordination between healthcare providers. We recommend including these in the CCM to make it relevant for application in an LMIC.

Training in diabetes education: meanings attributed by primary care nurses

OBJECTIVE

seize meanings attributed by primary care nurses to training in diabetes education.

METHOD

exploratory and descriptive study, with a qualitative approach, with twenty primary care nurses; semistructured interview script, with interviews processed in the IRaMuTeQ software and analyzed through the Descending Hierarchical Classification. The results were subsidized in the Representational Theory of Meaning.

RESULTS

nurse training in diabetes education is insufficient for holistic action, although it allows the community to be instrumentalized in specific issues about the disease, using the limited tools available, especially lectures. Nurses find themselves in a context of challenges, improvisations, weaknesses, and limitations that determine the meaning attributed to diabetes education and subsequent actions.

CONCLUSION

the meanings attributed by the nurses revealed an incipient training, which limits the quality of care provided and instigates the search for qualification.

Assessment of the quality of primary care for the elderly according to the Chronic Care Model

OBJECTIVE

to evaluate the quality of care provided to older people with diabetes mellitus and/or hypertension in the Primary Health Care (PHC) according to the Chronic Care Model (CCM) and identify associations with care outcomes.

METHOD

cross-sectional study involving 105 older people with diabetes mellitus and/or hypertension. The Patient Assessment of Chronic Illness Care (PACIC) questionnaire was used to evaluate the quality of care. The total score was compared with care outcomes that included biochemical parameters, body mass index, pressure levels and quality of life. Data analysis was based on descriptive statistics and multiple logistic regression.

RESULTS

there was a predominance of females and a median age of 72 years. The median PACIC score was 1.55 (IQ 1.30-2.20). Among the PACIC dimensions, the "delivery system design/decision support" was the one that presented the best result. There was no statistical difference between the medians of the overall PACIC score and individual care outcomes. However, when the quality of life and health satisfaction were simultaneously evaluated, a statistical difference between the medians was observed.

CONCLUSION

the low PACIC scores found indicate that chronic care according to the CCM in the PHC seems still to fall short of its assumptions.