Improving the quality of diabetes care in a real world community context: influences, trends, and the implementation of a model of integrated care
University College Cork
Background and aim: Despite consensus on what optimal diabetes care should look like, this is not always achieved in ‘real world’ practice. Attention has shifted from solely testing the effectiveness of interventions to improve diabetes care, to also trying to uncover the influences, the how and why they work. Integrated care, organising care delivery within and between services, is a strategy to improve the quality of diabetes care; however, few studies have examined its implementation and whether quality improvements can be sustained. This thesis aims to understand whether and how integrated diabetes care can improve and sustain the quality of care in a real world community context using two approaches to integrated care in the Irish health system, a bottom-up locally-driven (structured primary care) initiative and recent top-down nationally-led reforms (a new model of integrated care supported by diabetes nurse specialists (DNS)). Methods: A systematic review comprising a narrative synthesis and meta-analysis was conducted to identify the evidence on physician and practice factors associated with the quality of diabetes primary care management. Trends in process of care recording and intermediate patient clinical outcomes (i.e. risk factors; blood pressure, cholesterol, HbA1c, creatinine) were examined over time using a series of cross-sections (1998, 2003, 2008, and 2016) from an existing structured primary care initiative. Data from the original cohort enrolled in this programme in 1999, were used to examine all-cause mortality and survival among people with diabetes, comparing mortality to the general population using Standardised Mortality Ratios (SMR). Excess mortality was compared with international estimates. The intended role of both hospital and community DNS is to support integrated care by managing patients with complicated type 2 diabetes, liaise with other professionals, deliver professional and patient education, and clinics. A national survey of DNS was conducted to examine their role. Interviews and focus groups were conducted with DNS, purposively sampled by region and type (hospital or community-based), to understand how they support the implementation of integrated care, including what factors influence their behaviours. Results: Physician factors (female gender, younger age, and a higher volume of patients with diabetes), and practice factors (Electronic Health Record (EHR) and low deprivation) were associated with higher quality of care. Process of care recording delivered by the structured care programme improved significantly over time (p < 0.001), although there was levelling-off in later years. Mortality among the original cohort was greater than the background population (overall SMR = 1.20 (95% Confidence Interval: 1.01-1.42)) though lower than some international estimates. Most DNS preformed their intended role. However, nurse-led clinics had variable support from other specialities, and access to the community DNS service was not available to all GPs. From qualitative analysis there was evidence that community DNS had to adapt and use initiative to make integrated care ‘workable’: responding to the lack of an integrated EHR between primary and secondary care by using workarounds, adapting to the lack of multidisciplinary team “safety net” in the community by working more autonomously, linking in with professional networks as an alternative ‘safety net’, managing role misconceptions by colleagues and managers, and adapting their service to “blend in” with differences in diabetes care organisation and experience at practices. Conclusions Integrated diabetes care within primary care is feasible in a real world community setting, achieving improvements over time, and integrated care across services is ‘workable’ through innovation and adaptation in a complex healthcare context. To scale up integrated care nationally, making this model available to all patients, practices may need targeted support, based on physician practice profile or other factors (e.g. information systems, deprivation, experience) to improve and organise diabetes care delivery. To embed and sustain integrated care requires system-level investment in building a supportive culture (e.g. acceptance of new roles, supporting professional networks) and infrastructure (e.g. integrated EHRs, access to specialists in the community or across boundaries). Integrated care should continue to be evaluated as services are delivered, recognising the local and system-level context (e.g. physician factors, EHRs, role understanding, available community resources) can challenge efforts to improve care. There is a need to learn from service delivery as it is implemented and consider how to guide adaptations to ensure integrated care in the real world is both ‘workable’ and effective.
Diabetes , Quality improvement , Integrated care , Primary care
Riordan, F. M. 2018. Improving the quality of diabetes care in a real world community context: influences, trends, and the implementation of a model of integrated care. PhD Thesis, University College Cork.