RESUMO
To facilitate the development of leadership competencies in a multidisciplinary group of 18 emerging bone experts from 6 European Countries and Brazil, to face future scenarios in the evolving field of fragility fractures, and to support secondary fracture prevention and improve patient outcomes. Changes brought by the COVID-19 pandemic have further highlighted this need. A 2.5-year community of practice (CoP) programme was established with two senior bone experts acting as mentors. The content was adapted during the COVID-19 pandemic. The education impact of the programme was assessed using an ethics-approved mixed-method design consisting of multiple sources of qualitative and quantitative data collected longitudinally. Quantitative data were analysed descriptively. Qualitative data underwent a thematic analysis. After participating in the programme, participants reported increased interprofessional collaboration and communication skills, better understanding of health economics and negotiation, application of adult learning principles to their work setting, development of competencies to critically appraise guidelines, enhanced abilities to facilitate behaviour change in others, and improved confidence leading their team through crisis situations. Although time was required for some physicians to get accustomed to the CoP concept and develop trust with other members, it was described as a beneficial real-world learning experience. An educational real-world CoP programme was effective in enhancing leadership competencies among future leaders in the bone field to improve care of fragility fracture patients. The results presented could guide the development of other CoPs in fragility fracture care as leadership competencies are increasingly required in that field.
RESUMO
OBJECTIVE: To summarize currently available data about insulin therapy in patients with diabetes mellitus (DM), focusing on patients with type 2 DM (T2DM), in long term care (LTC) settings. DATA SOURCES: Ovid Medline, EMBASE, Cochrane Library databases, and United Kingdom National Health Service (NHS) Economic Evaluation Database, last accessed on November 12, 2012. STUDY ELIGIBILITY CRITERIA: We included studies that reported insulin use in patients with T2DM, and studies with combined samples of patients with type 1 DM or T2DM, that were conducted in LTC settings. Excluded were review articles and studies published before 2000. RESULTS: We identified 11 articles that met all inclusion and exclusion criteria. Insulin use in patients with DM in LTC settings varied widely, from 2.7% to 58.0%. It is difficult to draw conclusions from these proportions, as many studies did not define whether their populations were exclusively patients with T2DM. Despite recommendations against its use by the American Diabetes Association, the American Geriatrics Society, and the American Medical Directors Association, treatment with sliding-scale insulin (insulin injections adjusted to current blood glucose levels) was prevalent in the LTC setting. Although the recommended target hemoglobin A1c (A1C) for this patient population varies from ≤6.5% to ≤8.0%, higher A1C values (8.0%-8.9%) were associated with better patient outcomes in a study examining insulin treatment in community-dwelling elderly patients enrolled in an outpatient LTC setting. Insulin pen-devices seemed associated with a high incidence of needle-stick injuries in workers in LTC settings but, compared with insulin vials, showed cost advantages for use in very short-term (≤30 days) patients with DM in LTC settings. LIMITATIONS: Paucity of available data; only published studies for which full-text articles could be retrieved and which were identified by our search strategy were included; insufficient detail about patient samples were available in many included studies; and potential biases across studies might be introduced by funding sources or study designs. CONCLUSIONS: Available data about insulin therapy in patients with DM in LTC settings are very scarce and great treatment variability of this patient population seems to prevail in the current clinical practice. Additional, randomized, prospective clinical trials are needed to expand our knowledge and allow clinicians to make informed treatment decisions for patients with DM in LTC settings.