Perceptions of the primary health care team about the implementation of integrated care of patients with type 2 diabetes and hypertension in Slovenia: qualitative study.

BACKGROUND: Integrated care involves good coordination, networking, and communication within health care services and externally between providers and patients or informal caregivers. It affects the quality of services, is more cost-effective, and contributes to greater satisfaction among individuals and providers of integrated care. In our study, we examined the implementation and understanding of integrated care from the perspective of providers - the health care team - and gained insights into the current situation. METHODS: Eight focus groups were conducted with health care teams, involving a total of 48 health care professionals, including family physicians, registered nurses, practice nurses, community nurses, and registered nurses working in a health education center. Prior to conducting the focus groups, a thematic guide was developed based on the literature and contextual knowledge with the main themes of the integrated care package. The analysis was conducted using the NVivo program. RESULTS: We identified 12 main themes with 49 subthemes. Health care professionals highlighted good accessibility and the method of diagnostic screening integrated with preventive examinations as positive aspects of the current system of integrated care in Slovenia. They mentioned the good cooperation within the team, with the involvement of registered nurses and community nurses being a particular advantage. Complaints were made about the high workload and the lack of workforce. They feel that patients do not take the disease seriously enough and that patients as teachers could be useful. CONCLUSION: Primary care teams described the importance of implementing integrated care for diabetes and hypertension patients at four levels: Patient, community, care providers, and state. Primary care teams also recognized the importance of including more professionals from different health care settings on their team.

Person-Centred Diabetes Care: Examining Patient Empowerment and Diabetes-Specific Quality of Life in Slovenian Adults with Type 2 Diabetes.

Patient empowerment is crucial for promoting and strengthening health. We aimed to assess patient empowerment and diabetes-specific health-related quality of life (HRQoL) in adults with type 2 diabetes (T2D). A multi-centre, cross-sectional survey was conducted among adults with T2D in urban and rural primary care settings in Slovenia between April and September 2023. The survey utilised convenience sampling and included sociodemographic and clinical data, the Diabetes Empowerment Scale (DES), and the Audit of Diabetes-Dependent QoL (ADDQoL). The study included 289 people with T2D and a mean age of 67.2 years (SD 9.2). The mean overall DES score was 3.9/5 (SD 0.4). In a multivariable linear regression model, higher empowerment was significantly associated with residing in a rural region (p = 0.034), higher education (p = 0.028), and a lack of comorbid AH (p = 0.016). The median overall ADDQoL score was -1.2 (IQR [-2.5, -0.6]). The greatest negative influence of diabetes on HRQoL was observed in the domain 'Freedom to eat', followed by 'Freedom to drink', 'Leisure activities', and 'Holidays'. Despite high empowerment among adults with T2D, the condition still imposes a personal burden. Integrated primary care models should prioritise the importance of implementing targeted interventions to enhance diabetes empowerment, address comorbidities, and improve specific aspects of QoL among individuals with T2D.

Facilitators and Barriers to Scaling-Up Integrated Care for Arterial Hypertension and Type 2 Diabetes in Slovenia: Qualitative Study.

Introduction: Arterial hypertension and type 2 diabetes are significant contributors to global non-communicable disease-related mortality. Integrated care, centred on person-centred principles, aims to enhance healthcare quality and access, especially for vulnerable populations. This study investigates integrated care for these diseases in Slovenia, providing a comprehensive analysis of facilitators and barriers influencing scalability. Methods: Qualitative methods, including focus group discussions and semi-structured interviews, were employed in line with the grounded theory approach. Participants represented various levels (micro, meso and macro), ensuring diverse perspectives. Data were collected from May 2019 to April 2020, until reaching saturation. Transcripts were analysed thematically using NVivo software. Results: Nine categories emerged: Governance, Health financing, Organisation of healthcare, Health workforce, Patients, Community links, Collaboration/Communication, Pharmaceuticals, and Health information systems. Some of identified barriers were political inertia and underutilisation of research findings in practice; outdated health financing system; accessibility challenges, especially for vulnerable populations; healthcare workforce knowledge and burnout; patients' complex role in accepting and managing their conditions; collaboration within healthcare teams; and fragmentation of health information systems. Peer support and telemedicine were the only two potential solutions identified. Conclusions: This study offers a comprehensive evaluation of integrated care for hypertension and type 2 diabetes in Slovenia, featuring insights into facilitators and barriers. These findings have implications for policy and practice. Monitoring integrated care progress, refining strategies, and enhancing care quality for patients with these two diseases should be priorities in Slovenia.

Bottom-Up Analysis of Telemonitoring Costs: A Case Study in Slovenian Primary Care.

Introduction: Telemonitoring improves clinical outcomes in patients with arterial hypertension (AH) and type 2 diabetes (T2D), however, cost structure analyses are lacking. This study seeks to explore the cost structure of telemonitoring for the elderly with AH and T2D in primary care and identify factors influencing costs for potential future expansions. Methods: Infrastructure, operational, patient participation, and out-of-pocket costs were determined using a bottom-up approach. Infrastructure costs were determined by dividing equipment and telemonitoring platform expenses by the number of participants. Operational and patient participation costs were determined by considering patient training time, data measurement/review time, and teleconsultation time. The change in out-of-pocket costs was assessed in both groups using a structured questionnaire and 12-month expenditure data. Statistical analysis employed an unpaired sample t-test, Mann-Whitney U test, and chi-square test. Results: A total of 117 patients aged 71.4±4.7 years were included in the study. The telemonitoring intervention incurred an annual infrastructure costs of €489.4 and operational costs of €97.3 (95% CI 85.7-109.0) per patient. Patient annual participation costs were €215.6 (95% CI 190.9-241.1). Average annual out-of-pocket costs for both groups were €345 (95% CI 221-469). After 12 months the telemonitoring group reported significantly lower out-of-pocket costs (€132 vs. €545, p<0.001), driven by reduced spending on food, dietary supplements, medical equipment, and specialist check-ups compared to the standard care group. Conclusion: To optimise the cost structure of telemonitoring, strategies like shortening the telemonitoring period, developing a national telemonitoring platform, using patient devices, integrating artificial intelligence into platforms, and involving nurse practitioners as telemedicine centre coordinators should be explored.

Costs and Quality of Life in Patients With Systemic Arterial Hypertension in Slovenia.

OBJECTIVES: Systemic arterial hypertension (SAH) is one of the most critical risk factors for morbidity in chronic noncommunicable diseases. The aim of this study was to estimate the costs incurred by and the health-related quality of life (HRQoL) for a sample of patients with AH aged ≥ 65, in 2019. METHODS: A sample of 142 patients who were taking medicines for SAH was selected from the urban and rural areas. The patients consented to participate in the study. Patients also reported their out-of-pocket expenditures connected to SAH and their HRQoL. HRQoL was measured using generic 5-level version of EQ-5D (EQ-5D-5L) and the disease-specific MINICHAL questionnaires. Descriptive analysis was used to present the results. Calculations were made using R (v4.01) software. RESULTS: A sample of 141 patients filled out 17-item MINICHAL and 142 filled out the EQ-5D-5L questionnaire. Patients' MINICHAL mood and somatic domain scores were 5.5 and 3.5, respectively. EQ-5D-5L mean index utility score was 0.7 and the mean EQ VAS was 70.9. Pain/discomfort was the most affected health dimension as 60.6% of patients reported having problems. The 2 HRQoL questionnaires are moderately correlated (-0.215). The average annual costs of SAH treatment amounted to €274.3 per patient. The largest share of costs is represented by pharmacological treatment (30.5%) and out-of-pocket expenses (28.2%). CONCLUSIONS: Our study is the first study in Slovenia to assess the costs incurred by and HRQoL of patients with SAH using bottom-up approach and societal perspective. It offers important input in a decision-analytic model to assess cost-effectiveness of interventions to reduce the burden of SAH.

Peer Support as Part of Scaling-Up Integrated Care in Patients with Type 2 Diabetes and Arterial Hypertension at the Primary Healthcare Level: A Study Protocol.

Introduction: Type 2 diabetes (T2D) and arterial hypertension (AH) are among the greatest challenges facing health systems worldwide and require comprehensive patient-centred care. The key to successful management in chronic patients is self-management support, which was found to be only weakly implemented in Slovenia. The aim of the study is to develop an evidence-based model of peer support for people with T2D and AH at the primary healthcare level in Slovenia, which could represent a potential solution for upgrading integrated care for these patients. Methods: A prospective interventional, mixed-methods pilot study will begin by recruiting approximately 40 eligible people with T2D and AH through purposive sampling. The participants will receive structured training, led by a specialist nurse, to become trained peer supporters. Each will voluntarily share their knowledge and experience at monthly group meetings with up to 10 people with T2D and AH over a three-month period in the local community. Data will be collected through interviews and focus groups and questionnaires about socio-demographic and clinical data, knowledge about T2D and AH, participants' quality of life, level of empowerment and acceptability of the intervention. Expected results: The study will provide an evidence-based model for integrating peer support into the local community. It is expected that the intervention will prove feasible and acceptable with educational, psychosocial and behavioural benefits. Conclusion: Peer support through empowerment of people with T2D and AH, family members and other informal caregivers in the local community could scale-up the integrated care continuum and contribute to sustainability of the healthcare system.

Telemonitoring of Elderly with Hypertension and Type 2 Diabetes at the Primary Care Level: Protocol for a Multicentric Randomized Controlled Pilot Study.

Introduction: Arterial hypertension (AH) and type 2 diabetes (T2D) represent a significant burden for the public health system, with an exceptionally high prevalence in patients aged ≥65 years. This study aims to test the acceptability, clinical effectiveness, and cost-effectiveness of telemonitoring in elderly patients with AH and T2D at the primary care level. Methods: A m ulti-centre, prospective, randomized, controlled t rial w ill be conducted. Patients a ged ≥ 65 y ears with AH and T2D will be randomized in a 1:1 proportion to a mHealth intervention or standard care group. Patients in the intervention group will measure their blood pressure (BP) twice weekly and blood glucose (BG) once monthly. The readings will be synchronously transmitted via a mobile application to the telemonitoring platform, where they will be reviewed by a general practitioner who will indicate changes in measurement regimen or carry out a teleconsultation. The primary endpoint will be a change in systolic BP (SBP) and glycated haemoglobin (HbA1c) relative to standard care up to 12 months after inclusion. Secondary endpoints will be a change in other observed clinical variables, quality-of-life indexes, and costs. Expected results: Telemonitoring will be an acceptable method of care associated with significant reductions in SBP and HbA1c levels and an increase in quality-of-life indexes in the intervention group. However, the cost-effectiveness threshold (incremental cost-effectiveness ratio below €25,000/quality-adjusted life year) might not be reached. Conclusion: This study will provide new evidence for scaling up telemonitoring network at the primary care level and modifying telemonitoring protocols to achieve the best clinical and cost-effective outcomes.