Implementing a community specialist team to support the delivery of integrated diabetes care: experiences in Ireland during the COVID-19 pandemic.

Background: While models of integrated care for people with chronic conditions have demonstrated promising results, there are still knowledge gaps about how these models are implemented in different contexts and which strategies may best support implementation. We aimed to evaluate the implementation of a multidisciplinary diabetes Community Specialist Team (CST) to support delivery of integrated type 2 diabetes care during COVID-19 in two health networks. Methods: A mixed methods approach was used. Quantitative data included administrative data on CST activity and caseload, and questionnaires with GPs, practice nurses (PN) and people with type 2 diabetes. Qualitative data were collected using semi-structured interviews and focus groups about the service from CST members, GPs, PNs and people with type 2 diabetes. We used the Consolidated Framework for Implementation Research framework to explain what influences implementation and to integrate different stakeholder perspectives. Results: Over a 6-month period (Dec 2020-May 2021), 516 patients were seen by podiatrists, 435 by dieticians, and 545 by CNS. Of patients who had their first CST appointment within the previous 6 months (n=29), 69% (n=20) waited less than 4 weeks to see the HCP. During initial implementation, CST members used virtual meetings to build ' rapport' with general practice staff, supporting ' upskilling' and referrals to the CST. Leadership from the local project team and change manager provided guidance on how to work as a team and ' iron out' issues. Where available, shared space enhanced networking between CST members and facilitated joint appointments. Lack of administrative support for the CST impacted on clinical time. Conclusions: This study illustrates how the CST benefited from shared space, enhanced networking, and leadership. When developing strategies to support implementation of integrated care, the need for administrative support, the practicalities of co-location to facilitate joint appointments, and relative advantages of different delivery models should be considered.

Delivering value-based healthcare for people with diabetes in a national publicly funded health service: Lessons from Ireland and Wales.

The term value-based healthcare (VBHC) describes an approach to the organization and delivery of care that emphasizes reducing the cost of care while improving outcomes. This involves increased investment earlier in the care pathway e.g., in the prevention, timely diagnosis, and screening for complications in order to maximize the overall impact of care. Key elements of VBHC include the collection and interpretation of relevant data to drive quality improvement and appropriateness of care, a focus on a continuum of care from prevention through to complications, an awareness of the financial drivers of the cost of care and a recognition that meaningful outcomes of care are those that are important to patients. Although VBHC has its origins in North America and has mostly been applied to private health systems, the principles can also be applied to national health services. In publicly funded health systems, where resources are finite, VBHC initiatives aim to eliminate ineffective care that has no beneficial impact or added value for patients and to optimize patient outcomes by delivering care that meets the changing healthcare needs of a population over time. The National Health Service in Wales has established a VBHC Office and has begun to realize the benefits of adopting VBHC approaches. The Irish Health Service Executive (HSE) can learn from the approaches used in Wales. In this paper we explore some of the principles of VBHC through case studies from Ireland and Wales highlighting how national health services are using VBHC to achieve improvement in outcomes for people living with diabetes.

Assessing the effectiveness of a goal-setting session as part of a structured group self-management education programme for people with type 2 diabetes.

OBJECTIVES: To measure the number of people who have identified a behaviour change goal and completed an action-plan to meet their goal on completion of a diabetes self-management education programme (DSME) and level of success in sustaining their action-plan. The DSME people attended was Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND). METHODS: Copies of action-plans were collected from participants. Postal questionnaires were sent to participants one week and three months following DESMOND to assess factors associated with setting and sustaining action-plans. RESULTS: 92% (253/275) of participants completed an action-plan. Reducing weight was the area most targeted. Physical activity was the most common goal. 68% (187/275) returned a three month questionnaire. 96% indicated they were still working on their action plan, with 87% reporting they were always/usually meeting their action-plan. 22% said they had discussed their goal with a health care professional (HCP) following DESMOND. CONCLUSIONS: Goal-setting as part of a DSME can lead to behaviour change. PRACTICE IMPLICATIONS: Goal-setting as part of a DSME enables participants to set and attain behaviour change goals. Informing HCPs of a person's action-plan following a DSME may further support a person undertaking behaviour change.

Is diabetes self-management education still the Cinderella of diabetes care?

This paper reflects on the status of diabetes self-management education (DSME) as a branch of diabetology in Europe and discusses some opportunities for better supporting DSME delivery. DSME (also commonly known as Therapeutic Patient Education) has been evolving as a therapy for diabetes for decades. As a continent, Europe is fortunate to have nurtured many pioneers in DSME, and currently has many experts in the field progressing the knowledge base and striving to improve access to DSME for people with diabetes. While there is a wide variety of DSME programmes being delivered throughout Europe, for most people diabetes education is not truly embedded in routine clinical care, being seen as more of an optional add-on to conventional therapies. In comparison to drugs and devices, DSME lacks investment, and funding for DSME research lags far behind other therapies. The rigour with which forms of DSME are developed and evaluated varies, and there is a lack of European quality standards. To try to address some of these deficiencies, greater pan-European collaboration and leadership is required.

Barriers and facilitators associated with attendance at hospital diabetes clinics among young adults (15-30 years) with type 1 diabetes mellitus: a systematic review.

Regular clinic attendance is recommended to facilitate self-management of diabetes. Poor attendance is common among young adults with type 1 diabetes mellitus (DM). This systematic review aimed to produce a narrative synthesis of the evidence regarding factors which promote or impede regular attendance at adult diabetes clinics among young adults (15-30 years) with type 1 DM. Studies reporting facilitators and barriers to clinic attendance were identified by searching four electronic databases, checking reference lists, and contacting diabetes research networks. A total of 12 studies (8 quantitative and 4 qualitative) met the inclusion criteria. Young adult's experiences transitioning from paediatric to adult diabetes care can influence attendance at the adult clinic positively if there is a comprehensive transition programme in place, or negatively if the two clinics do not communicate and provide adequate support. Post-transition, relationship development and perceptions of the value of attending the clinic are important for regular attendance. Controlled research is required to better understand decisions to attend or not attend outpatient services among people with chronic conditions. Service delivery must be sensitive to the developmental characteristics of young adults and tailored support may be required by young adults at greatest risk of non-attendance.

Differences in the structure of outpatient diabetes care between endocrinologist-led and general physician-led services.

BACKGROUND: Despite a shift in diabetes care internationally from secondary to primary care, diabetes care in the Republic of Ireland remains very hospital-based. Significant variation in the facilities and resources available to hospitals providing outpatient diabetes care have been reported in the UK. The aim of this study was to ascertain the structure of outpatient diabetes care in public hospitals in the Republic of Ireland and whether differences existed in services provided across hospitals. METHODS: We conducted a cross sectional observational study of the 36 public general hospitals providing adult outpatient diabetes care in the Republic of Ireland. Data relating to numbers of specialist medical, nursing and allied health professionals, waiting times for new and return patients, patterns of discharge back to primary care and engagement in quality improvement initiatives were recorded. RESULTS: Thirty-five of the 36 eligible hospitals participated in the study. Sixty percent of these had at least one consultant endocrinologist in post, otherwise care delivery was led by a general physician. Waiting times for newly diagnosed patients exceeded six months in 30% of hospitals and this was higher where an endocrinologist was in place (47% V 7%, p = 0.013). Endocrinologists were more likely to have developed subspecialty clinics, access to allied health professionals and engage more in quality improvement initiatives but less likely to discharge patients back to primary care than general physicians (76 v 29%, p = 0.005). CONCLUSIONS: Variations exist in the structure and provision of diabetes care in Irish hospitals. Endocrinology-led services have more developed subspecialty structures and access to specialist allied health professionals and engage more in quality improvement initiatives. Nonetheless, waiting times are longer and discharge rates to primary care are lower than for non-specialty led services. Further studies to determine the extent to which case-mix variation accounts for these observations are warranted. Aspects of hospital-based outpatient care could be developed further to ensure equitable services are provided nationally. At a time when the delivery of diabetes services in primary care is being promoted, further research is warranted on the factors influencing the successful transition to primary care.

Preferences for involvement in treatment decision-making generally and in hormone replacement and urinary incontinence treatment decision-making specifically.

OBJECTIVE: To explore whether preferences for involvement in treatment decision-making change depending on the context and factors associated with preferences. METHODS: A national telephone survey of 1000 randomly selected Norwegian women aged 18 years or over using the Control Preferences Scale (CPS) to assess preferences. RESULTS: More women preferred an active role when asked about hormone replacement therapy (HRT) and urinary incontinence (UI) treatment decision-making specifically than when asked a question about preferences for involvement when generally making treatment decisions. Higher education and very good general health were significantly associated with preferring an active role in HRT and UI treatment decision-making. A negative attitude towards HRT was also significantly associated with preferring an active role when considering HRT. Women with higher educational levels were significantly more likely to choose an option from the CPS that indicated a preference for wanting more involvement in HRT decision-making compared to treatment decision-making generally. CONCLUSIONS: Women's preferences for involvement in treatment decision-making change depending on the context as do factors associated with role preferences. PRACTICE IMPLICATIONS: Health care professionals need to be aware that patients' preferences may change depending on the context of the treatment decision.

Preferences for involvement in treatment decision-making among Norwegian women with urinary incontinence.

BACKGROUND: Current health policies advocate patient participation in treatment decision-making. Objective. To explore whether role preferences among women with urinary incontinence (UI) change depending on the treatment decision-making context. We also explore what factors are associated with role preferences and changes in role preferences. METHODS: A national telephone survey of 265 women with UI identified from 1,000 randomly selected Norwegian women aged 18 or over. The interview included questions on socioeconomic factors, general health status, UI-related factors, and role preferences. Women were categorised as preferring an 'active', 'collaborative', or 'passive' role in treatment decision-making based on their selection of a response from the Control Preferences Scale. RESULTS: Women's preferences changed significantly when considering UI treatment decision-making compared to treatment decision-making generally (p<0.001). A total of 60% preferred an active role in UI treatment decisions compared to 38% when considering treatment decision-making generally. Multivariable analyses found that higher education was significantly associated with preferring an active role in general treatment decision-making. For UI treatment decision-making, women aged 60 or over and those who were married or had a partner were less likely to prefer an active compared to a collaborative role. CONCLUSIONS: Women with UI prefer a more active role when considering UI treatment decision-making compared to treatment decision-making generally. Factors associated with role preferences vary depending on the decision-making context, with older women and those who were married or had a partner less [corrected] likely to prefer an active role when considering UI treatment decision-making.

The role of general practitioners in the initial management of women with urinary incontinence in France, Germany, Spain and the UK.

OBJECTIVE: To describe the role of general practitioners (GPs) in the initial management of women with urinary incontinence (UI) in four European countries with different healthcare systems. METHODS: Cross-sectional community postal survey of 2953 women with UI in France, Germany, Spain and the UK. RESULTS: Forty-eight per cent of community-dwelling women with UI had discussed their UI with a doctor. More women discussed UI in France and Germany than in the UK and Spain. The patient usually raised the issue during consultations for some other reason. Fear of or actual deterioration in UI was the most important reason for discussing UI. Overall, 52% of incontinent women first discussed their UI with a GP, and almost a third of women reported having all their UI discussions in a GP setting. Twenty-nine per cent of women reported that GPs had either recommended treatment or monitoring of their condition before beginning treatment, and 24% reported that the GP had referred them to another doctor for evaluation and treatment. Most women in the UK first discussed UI with a GP, whereas in Germany most discussed UI with a specialist. In Spain and France, about half the women first discussed their UI with a GP. CONCLUSION: GPs are involved to varying degrees in the initial management of UI in France, Germany, Spain and the UK. Even in countries where women have a choice of whether to see a GP or specialist about UI, many choose to have their first contact with a GP.

General preferences for involvement in treatment decision making among European women with urinary incontinence.

Current health care policies advocate patient participation in treatment decision making. Little evidence on possible differences between European women's preferences for involvement in this process exists. In this study we explore preferences for involvement in treatment decision making in 15 European countries in a sample of 9434 women seeking treatment for urinary incontinence in an outpatient setting. Their generally preferred role in treatment decisions was assessed using the Control Preferences Scale. Results show variations within and between countries in preferences for involvement in treatment decision making. The 'collaborative role' was the most preferred role in Austria, Belgium, Denmark, France, Germany, Ireland, Sweden, Switzerland, the Netherlands and the UK. In Greece, Portugal and Spain the 'passive role' was most preferred. Over a third of women in Denmark, Finland and Norway preferred an 'active role'. Multinominal regression analyses found that, after adjusting for case mix and factors previously associated with role preferences, country membership was strongly associated with role preferences, with women living in Southern European countries preferring a more passive role. Such clear differences are of interest in the current health care environment where active patient participation is being encouraged. Greater efforts need to be made to establish whether patient preferences are genuine or merely a learned response influenced by cultural attitudes and traditions so that a balance can be struck between assisting women to play a more active role in the treatment decision-making process without disregarding some women's genuine preferences to play a more passive role.

Consumer involvement in decisions about what health-related research is funded.

OBJECTIVES: To consider whether, why and how research funders involve consumers in decisions about what health-related research is funded. METHODS: Postal survey and semi-structured interviews with UK funders of health-related research. RESULTS: Organisations that fund research have diverse goals and remits, and perceive themselves to be accountable in different ways and to different groups. They have a variety of reasons for involving consumers in decisions about what research is funded, but also a number of concerns about doing so-particularly about the ways in which consumer input might 'distort' the research agenda. Research funders use several types of decision-making structures and processes to identify and prioritise topics in which they want to invest and to select between research proposals. They involve consumers in these structures and processes in diverse ways. Little is known about the actual effects of this involvement, but the nature and extent of consumer influence on the research agenda is likely to be moderated by a number of factors, including the types of consumers involved, the particular structures and processes in which they are involved, the timing of their input and the different ways in which they are asked to contribute in relation to others. CONCLUSIONS: Diverse research funding organisations are now involving consumers in the various approaches that they take to identify and prioritise research topics and to decide which proposals they will fund. The future development of their activities could usefully be informed by careful consideration not just of consumer involvement but of the implications of the various structures and processes that shape research agendas. The appropriateness of particular forms of consumer involvement should be considered in the broader context of the features of the whole research funding system, including the values implicit within it.

Consumer involvement in research projects: the activities of research funders.

This paper reports findings from a postal questionnaire survey and in-depth interviews with UK funders of health-related research that explored whether, why and how they promote consumer involvement in research projects. Many UK funders of health-related research are adopting a policy of promoting consumer involvement in research projects. Telephone interviews revealed they have several reasons for doing so, and that they vary in the ways they encourage and support researchers to involve consumers. For some, descriptions of consumer involvement in a research proposal are important for project funding decisions. They recognized a need for flexibility when assessing consumer involvement in different contexts. We suggest that funders should continue to work to clarify what they consider to be the parameters of acceptability in terms of consumer involvement and ensure that 'flexible' criteria are fairly applied. Researchers should be aware of particular funders' views when applying for project funding.