Evaluation of the Implementation of Integrated Primary Care for Patients with Type 2 Diabetes and Hypertension in Belgium, Cambodia, and Slovenia.

Introduction: Integrated care of chronic patients improves quality of their management, but there is scarce evidence of its implementation in different healthcare settings. With this article, we wanted to determine the level of integrated care implementation in the management of T2D (diabetes) and HT (hypertension) in three different settings: Belgium, Slovenia, and Cambodia. Methods: This was an observational study with integrated approach. It was conducted in primary health care organisations in three countries. In each primary health care organisation, we aimed to include primary care workers that worked with Type 2 Diabetes (T2D) and hypertension (HT) patients. Data was collected with the Integrated Care Package (ICP) grid (consisting of six elements: identification, treatment, health education, self-management, caregiver collaboration, and care organisation). Results: ICP is almost completely implemented without major differences within Slovenia. There is a considerable variability across practice types in Belgium. Implementation is constrained by health system resources in Cambodia. Some elements, especially identification, are better implemented then others, across health systems. Conclusion: Countries can enhance integrated care for chronic diseases by implementing central policies, standardized protocols, and local adaptation, addressing resource constraints, promoting systematic screening and health education, and providing training for healthcare workers, tailored to community needs, to improve patient outcomes and healthcare delivery.

Development of a Qualitative Data Analysis Codebook for Arterial Hypertension and Type-2-Diabetes Integrated Care Evaluation.

Introduction: Non-communicable diseases, such as arterial hypertension (HTN) and type-2 diabetes (T2D), pose a global public health problem. Integrated care with focus on person-centred principles aims to enhance healthcare quality and access. Previous qualitative research has identified facilitators and barriers for scaling-up integrated care, however the lack of standardized terms and measures hinder cross-country comparisons. This paper addresses these gaps by presenting a generic codebook for qualitative research on integrated care implementation for HTN and T2D. Description: The codebook serves as a tool for deductive or deductive-inductive qualitative analysis, organizing concepts and themes from qualitative data. It consists of nine first level and 39 second level themes. First level codes cover core issues; and second level codes provide detailed insights into facilitators and barriers. Discussion: This codebook is more widely applicable than previously developed tools because it includes a broader scope of stakeholders across micro, meso, and macro levels, and the themes being derived from highly diverse health systems across high- and low-income countries. Conclusion: The codebook is a useful tool for implementation research on integrated care for HTN and T2D at global scale. It facilitates cross-country learning, contributing to improved implementation, scale-up and outcomes.

Developing a competency framework for training with simulations in healthcare: a qualitative study.

BACKGROUND: Simulation is a technique used to create an experience without going through the real event. Competency-based medical education focuses on outcomes and ensures professionals have the necessary knowledge, skills, and attitudes. The purpose of this study was to develop a set of competencies for the instructors providing basic and advanced levels of simulation-based training in healthcare. METHODS: We conducted a qualitative study in three steps, with each next step building on and influenced by the previous one. First, we conducted a literature review, then a consensus development panel, and finally a three-step Delphi process. The participants were experts in the fields of healthcare, education, and simulations. RESULTS: The six main competencies identified for the instructor providing simulation-based training at the basic level in healthcare include knowledge of simulation training, education/training development, education/training performance, human factors, ethics in simulation, and assessment. An instructor providing simulation-based training at an advanced level in healthcare should also possess the following five competencies: policies and procedures, organisation and coordination, research, quality improvement, and crisis management. CONCLUSION: The identified competencies can serve as a valuable resource for simulation educators and organisations involved in simulation education, to plan curriculum and implement a continuous train-the-trainers programme.

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.

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.

Process evaluation of the scale-up of integrated diabetes and hypertension care in Belgium, Cambodia and Slovenia (the SCUBY Project): a study protocol.

INTRODUCTION: Integrated care interventions for type 2 diabetes (T2D) and hypertension (HT) are effective, yet challenges exist with regard to their implementation and scale-up. The 'SCale-Up diaBetes and hYpertension care' (SCUBY) Project aims to facilitate the scale-up of integrated care for T2D and HT through the co-creation and implementation of contextualised scale-up roadmaps in Belgium, Cambodia and Slovenia. We hereby describe the plan for the process and scale-up evaluation of the SCUBY Project. The specific goals of the process and scale-up evaluation are to (1) analyse how, and to what extent, the roadmap has been implemented, (2) assess how the differing contexts can influence the implementation process of the scale-up strategies and (3) assess the progress of the scale-up. METHODS AND ANALYSIS: A comprehensive framework was developed to include process and scale-up evaluation embedded in implementation science theory. Key implementation outcomes include acceptability, feasibility, relevance, adaptation, adoption and cost of roadmap activities. A diverse range of predominantly qualitative tools-including a policy dialogue reporting form, a stakeholder follow-up interview and survey, project diaries and policy mapping-were developed to assess how stakeholders perceive the scale-up implementation process and adaptations to the roadmap. The role of context is considered relevant, and barriers and facilitators to scale-up will be continuously assessed. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the Institutional Review Board (ref. 1323/19) at the Institute of Tropical Medicine (Antwerp, Belgium). The SCUBY Project presents a comprehensive framework to guide the process and scale-up evaluation of complex interventions in different health systems. We describe how implementation outcomes, mechanisms of impact and scale-up outcomes can be a basis to monitor adaptations through a co-creation process and to guide other scale-up interventions making use of knowledge translation and co-creation activities.

Implementation of Integrated Primary Care for Patients with Diabetes and Hypertension: A Case from Slovenia.

INTRODUCTION: Research on models of integrated health care for hypertension and diabetes is one of the priority issues in the world. There is a lack of knowledge about how integrated care is implemented in practice. Our study assessed its implementation in six areas: identification of patients, treatment, health education, self-management support, structured collaboration and organisation of care. METHODS: This was a mixed methods study based on a triangulation method using quantitative and qualitative data. It took place in different types of primary health care organisations, in one urban and two rural regions of Slovenia. The main instrument for data collection was the Integrated Care Package (ICP) Grid, assessed through four methods: 1) a document analysis (of a current health policy and available protocols; 2) observation of the infrastructure of health centres, organisation of work, patient flow, interaction of patients with health professionals; 3) interview with key informants and 4) review of medical documentation of selected patients. RESULTS: The implementation of the integrated care in Slovenia was assessed with the overall ICP score of 3.7 points (out of 5 possible points). The element Identification was almost fully implemented, while the element Self-management support was weakly implemented. DISCUSSION: The implementation of the integrated care of patients with diabetes and/or hypertension in Slovenian primary health care organisations achieved high levels of implementation. However, some week points were identified. CONCLUSION: Integrated care of the chronic patients in Slovenia is already provided at high levels, but the area of self-management support could be improved.

Scaling-up an Integrated Care for Patients with Non-communicable Diseases: An Analysis of Healthcare Barriers and Facilitators in Slovenia and Belgium.

INTRODUCTION: Although the concept of integrated care for non-communicable diseases was introduced at the primary level to move from disease-centered to patient-centered care, it has only been partially implemented in European countries. The aim of this study was to identify and compare identified facilitators and barriers to scale-up this concept between Slovenia and Belgium. METHODS: This was a qualitative study. Fifteen focus groups and fifty-one semi-structured interviews were conducted with stakeholders at the micro, meso and macro levels. In addition, data from two previously published studies were used for the analysis. Data collection and analysis was initially conducted at country level. Finally, the data was evaluated by a cross-country team to assess similarities and differences between countries. RESULTS: Four topics were identified in the study: patient-centered care, teamwork, coordination of care and task delegation. Despite the different contexts, true teamwork and patient-centered care are limited in both countries by hierarchies and a very heavily skewed medical approach. The organization of primary healthcare in Slovenia probably facilitates the coordination of care, which is not the case in Belgium. The financing and organization of primary practices in Belgium was identified as a barrier to the implementation of task delegation between health professionals. CONCLUSIONS: This study allowed formulating some important concepts for future healthcare for non-communicable diseases at the level of primary healthcare. The results could provide useful insights for other countries with similar health systems.

Scale-up integrated care for diabetes and hypertension in Cambodia, Slovenia and Belgium (SCUBY): a study design for a quasi-experimental multiple case study.

Health systems worldwide struggle to manage the growing burden of type 2 diabetes and hypertension. Many patients receive suboptimal care, especially those most vulnerable. An evidence-based Integrated Care Package (ICP) with primary care-based diagnosis, treatment, education and self-management support and collaboration, leads to better health outcomes, but there is little knowledge of how to scale-up. The Scale-up integrated care for diabetes and hypertension project (SCUBY) aims to address this problem by roadmaps for scaling-up ICP in different types of health systems: a developing health system in a lower middle-income country (Cambodia); a centrally steered health system in a high-income country (Slovenia); and a publicly funded highly privatised health-care health system in a high-income country (Belgium). In a quasi-experimental multi-case design, country-specific scale-up strategies are developed, implemented and evaluated. A three-dimensional framework assesses scale-up along three axes: (1) increase in population coverage; (2) expansion of the ICP package; and (3) integration into the health system. The study includes a formative, intervention and evaluation phase. The intervention entails the development and implementation of an improved scale-up strategy through a roadmap with a minimum dataset to monitor proximal and distal outcomes. The SCUBY project is expected to result in three different roadmaps, tailored to the specific health system and country context, to progress scale-up of the ICP along three dimensions. These roadmaps can be adapted to other health systems with similar typology. Implementation is expected to increase the number of well-controlled patients with type 2 diabetes and hypertension in Cambodia, to reduce inequities in care and increase patient empowerment in Belgium and Slovenia.

Cystic fibrosis related diabetes in Europe: Prevalence, risk factors and outcome; Olesen et al.

BACKGROUND: Cystic fibrosis related diabetes (CFRD) has implications for morbidity and mortality with several risk factors identified. We studied the epidemiology of CFRD in the large dataset of the European Cystic Fibrosis Society Patient registry. METHODS: Data on CF patients were investigated for the prevalence of CFRD as well as for any association with suggested risk factors and effects. RESULTS: CFRD increased by approximately ten percentage points every decade from ten years of age. Prevalence was higher in females in the younger age groups. CFRD was associated with severe CF genotypes (OR = 3.11, 95%CI: 2.77-3.48), pancreatic insufficiency (OR = 1.46, 95%CI: 1.39-1.53) and female gender (OR = 1.28, 95%CI: 1.21-1.34). Patients with CFRD had higher odds of being chronically infected with Pseudomonas aeruginosa, Burkholderia cepacia complex and Stenotrophomonas maltophilia than patients without CFRD, higher odds of having FEV1% of predicted <40% (OR = 1.82, 95%CI: 1.70-1.94) and higher odds of having BMI SDS ≤-2 than patients without CFRD (OR = 1.24, 95%CI: 1.15-1.34). CONCLUSIONS: Severe genotype, pancreatic insufficiency and female gender remain considerable intrinsic risk factors for early acquisition of CFRD. CFRD is associated with infections, lower lung function and poor nutritional status. Early diagnosis and aggressive treatment of CFRD are more important than ever with increasing life span.

Chronic necrotizing pulmonary aspergillosis in an immunocompetent, obese 10-year-old boy.

Chronic necrotizing pulmonary aspergillosis is a rare form of pulmonary aspergillosis. It is usually seen in middle-aged or elderly patients with underlying chronic lung disease or mild immunodeficiency, and has been only rarely encountered in children. Clinical presentation is variable and usually involves constitutional symptoms of several months' duration as well as respiratory symptoms. We present a previously well, immunocompetent, obese 10-year-old boy with cough and mild hemoptysis lasting for a couple of days and a round pulmonary infiltrate on chest radiograph. Further diagnostic investigations revealed the histopathological features of chronic necrotizing pulmonary aspergillosis in excised lung tissue, and Aspergillus fumigatus was isolated in lung tissue culture. This is one of the youngest described patients with this semi-invasive form of aspergillosis.

Potassium channel opener pinacidil induces relaxation of the isolated human radial artery.

Taking into consideration that the search for drugs capable of modifying blood flow through human radial artery (RA) is warranted, the present study was designed to examine the vasodilatatory effects of the potassium channel opener, pinacidil on the RA and to define the contribution of different K+ -channel subtypes in the endothelium-independent pinacidil action on this blood vessel. Pinacidil relaxed the RA rings with endothelium and without endothelium with comparable potency. N-nitro-L-arginine methyl ester (L-NAME) and methylene blue did not affect the pinacidil-induced vasorelaxation in rings with endothelium. In the rings without endothelium, the K+ -channel blockers glibenclamide and tetraethylammonium (TEA) moderately antagonized the pinacidil-induced relaxation, while charybdotoxin and 4-aminopiridine did not. In endothelium-denuded rings, precontracted with 100 mM K+, the relaxant responses to pinacidil were highly significantly shifted to the right compared to those obtained in RA precontracted with phenylephrine, but pinacidil-induced maximal relaxation was not affected. Addition of nifedipine did not but addition of nifedipine and nickel (Na+ -Ca2+ exchanger inhibitor) did cause a statistically significant rightward shift of the pinacidil concentration-relaxation curve, although the effect 0.1 mM pinacidil was preserved. Thus, pinacidil induces relaxation of the human RA in endothelium-independent manner, and glibenclamide- and TEA-sensitive vascular smooth muscle K+ channels are probably involved. Its ability to completely relax the RA precontracted with K+ -rich solution suggests that pinacidil has additional K+ channel-independent mechanism(s) of action. It seems that stimulation of the forward mode of the Na+ -Ca2+ exchanger plays a part in this K+ channel-independent effect of pinacidil.

Analysis of vasoreactivity of isolated human radial artery.

Radial artery (RA) is increasingly used as graft for coronary artery bypass grafting due to its good long-term patency. However, the mechanism of peri- and post-operative spasm is still unclear. Because of that, the aim of our study is to analyze the contractility of RA and to determine whether the presence of functional endothelium alters its contractile properties. Contractions of isolated RA rings were provoked by exogenously applied vasoconstrictors or by electrical field stimulation (EFS, 20 Hz). The order of vasoconstrictors potency based on their EC50 values was as follows: angiotensin II > phenylephrine > 5-hydroxytriptamine. Presence of endothelium increased both EC50 and maximal contraction to phenylephrine and angiotensin II, but inhibited reactivity of RA to 5-hydroxytriptamine. Spontaneous rhythmic contractions (SRC, <4 mHz) and EFS-induced contractions of RA are endothelium-independent and weaker than contractions induced by exogenously applied vasoconstrictors. Our study concludes that RA shows marked sensitivity and reactivity to angiotensin II, phenylephrine, and 5-hydroxytriptamine. Further investigations are necessary to answer why angiotensin II and phenylepehrine induce stronger contractions in the presence of endothelium. In addition, SRC as well as contractions of neurogenic origin may take part in developing vascular spasm of RA.