dc.check.chapterOfThesis	5, 7
dc.check.embargoformat	Both hard copy thesis and e-thesis	en
dc.check.info	Chapters 5 (pp. 156-188) and 7 (pp. 213-304) are restricted to everyone for one year	en
dc.check.opt-out	Not applicable	en
dc.check.reason	This thesis is due for publication or the author is actively seeking to publish this material	en
dc.contributor.advisor	Brugha, Ruairí	en
dc.contributor.advisor	Perry, Ivan J.	en
dc.contributor.advisor	Bradley, Colin P.	en
dc.contributor.author	McHugh, Sheena M.
dc.contributor.funder	Health Research Board	en
dc.date.accessioned	2013-12-18T16:18:00Z
dc.date.available	2014-12-19T05:00:05Z
dc.date.issued	2013
dc.date.submitted	2013
dc.description.abstract	Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.	en
dc.description.sponsorship	Health Research Board (Grant No: PHD/2007/16)	en
dc.description.status	Not peer reviewed	en
dc.description.version	Accepted Version
dc.format.mimetype	application/pdf	en
dc.identifier.citation	McHugh, S. M. 2013. The quality of diabetes care in the community: practice, policy and culture. PhD Thesis, University College Cork.	en
dc.identifier.endpage	397
dc.identifier.uri	https://hdl.handle.net/10468/1285
dc.language.iso	en	en
dc.publisher	University College Cork	en
dc.rights	© 2011, Sheena M. McHugh	en
dc.rights.uri	http://creativecommons.org/licenses/by-nc-nd/3.0/	en
dc.subject	Diabetes	en
dc.subject	Health services research	en
dc.subject	Quality of care	en
dc.subject.lcsh	Diabetes--Treatment.	en
dc.subject.lcsh	Diabetes--Ireland.	en
dc.subject.lcsh	Public health--Ireland.	en
dc.thesis.opt-out	false
dc.title	The quality of diabetes care in the community: practice, policy and culture	en
dc.type	Doctoral thesis	en
dc.type.qualificationlevel	Doctoral Degree (Structured)	en
dc.type.qualificationname	PhD (Health Services Research)	en
ucc.workflow.supervisor	i.perry@ucc.ie

The quality of diabetes care in the community: practice, policy and culture

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