Experiences of an interprofessional follow-up program in primary care practice.

BACKGROUND: An integrative cooperation of different healthcare professional is a key component for high quality health services. With an aging population and many with long-term conditions, more health tasks and follow-up care are being transferred to primary care and locally where people live. Interprofessional collaboration among providers of different professional designations will be of increasing importance to optimizing primary care capacity in years to come. There is a call for further exploration of models of interprofessional collaboration that might be applicable in Norwegian primary care. The aim of this study was to explore experiences of interprofessional collaboration between primary care physicians and nurses working in primary care by applying an intervention for people with type 2 diabetes. Specifically, this study was designed to strengthen and gain deeper insight into interprofessional collaboration between primary care physicians and nurses in primary care settings. METHODS: We applied Interpretive Description as a research strategy. The participants within this study were primary care physicians and nurses from four different primary care practices in the western and eastern parts of Norway. We used semi-structured telephone interviews for collecting the data between January and September 2021. RESULTS: The analysis revealed two key features of the primary care physicians and the nurses experience with interprofessional collaboration in primary care practices. The first involved managing the influence of discrepancies in their expectations of IPC and the second involved becoming aware of the competence they developed that allowed for better complementarity consultation. CONCLUSIONS: This study indicates that interprofessional collaboration in primary care practice requires that primary care physicians and nurses clarify their expectations and, in turn, determine how flexible they can become in changing their usual primary care practices. Moreover, findings reveal that nurses and primary care physicians had discrepancies in expectations of how interprofessional collaboration should be carried out in primary care practice. However, both the nurses and primary care physicians appreciated the blending of complementary competencies and skills that facilitated a more collaborative care practice. They experienced that this interprofessional collaboration represented an essential quality improvement in the primary care services. TRIAL REGISTRATION: The trial is registered 03/09/2019 in ClinicalTrials.gov (ID: NCT04076384).

The implementation of telemedicine in wound care: a qualitative study of nurses' and patients' experiences.

BACKGROUND: The increasing use of telemedicine (TM) represents a major shift for health workers and patients alike. Thus, there is a need for more knowledge on how these interventions work and are implemented. We conducted a qualitative process-evaluation alongside a larger randomized controlled trial designed to evaluate a telemedicine follow-up intervention for patients with a leg- or foot-ulcer, who either have or do not have diabetes. Accordingly, the aim of this study was to explore how both health care professionals and patients experienced the implementation of TM follow-up in primary care. METHODS: The intervention comprised an interactive TM platform facilitating guidance and counselling regarding wound care between nurses in primary care and nurses in specialist health care in Norway. Nurses and patients from seven clusters in the intervention arm were included in the study. We conducted 26 individual interviews (14 patients and 12 nurses) in primary care between December 2021 and March 2022. Thematic analyses were conducted. RESULTS: The analyses revealed the following themes: (1) enhancing professional self-efficacy for wound care, (2) a need to redesign the approach to implementing TM technology and (3) challenging to facilitate behavioral changes in relation to preventive care. As to patients' experiences with taking part in the intervention, we found the following three themes: (1) experience with TM promotes a feeling of security over time, (2) patients' preferences and individual needs on user participation in TM are not met, and (3) experiencing limited focus on prevention of re-ulceration. CONCLUSIONS: TM presents both opportunities and challenges. Future implementation should focus on providing nurses with improved technological equipment and work on how to facilitate the use of TM in regular practice in order to fully capitalize on this new technology. Future TM interventions need to tailor the level of information and integrate a more systematic approach for working with preventive strategies. CLINICAL TRIAL REGISTRATION: NCT01710774. Registration Date 2012-10-17.

Interprofessional follow-up for people at risk of type 2 diabetes in primary healthcare - a randomized controlled trial with embedded qualitative interviews.

OBJECTIVE: To examine the effects of an empowerment-based interprofessional lifestyle intervention program among people at risk of type 2 diabetes on knowledge, skills, and confidence in self-management, health, psychological well-being, and lifestyle characteristics, and to explore the participants' perceptions of participating in the intervention. DESIGN AND METHODS: In line with the Medical Research Council complex interventions research methods framework, we conducted a randomized controlled trial with embedded qualitative interviews in primary healthcare clinics in Norway between 2019-2021. Of the patients at risk (The Finnish Diabetes Risk Score Calculator (FINDRISC) ≥15 or Body Mass Index (BMI) ≥30) 142 accepted the invitation, and 14 participants from the intervention group participated in individual interviews after the 12-month follow-up. Our primary outcome was the Patient Activation Measure (PAM-13). Secondary outcomes were EQ-5D-5L, EQ-VAS, WHO-Overall health, WHO-Overall QOL, weight, height, waist circumference, and regularity of physical activity. We used thematic analysis to analyse the qualitative data. RESULTS: There was no clinically relevant differences of neither the primary nor the secondary endpoints between intervention and control group. As to the qualitative data, we identified two distinct features: 'Meaningful perspectives on lifestyle changes' and 'Lifestyle change is not a linear process due to challenges faced along the way' putting ownership of their choices in life into picture. CONCLUSION: The negative results of the RCT stand in contrast to the findings given by the participants voices, perceiving the intervention as a key eye opener placing their health challenges in perspective. How to interpret these seemingly conflicting findings of participants being seen, heard, and understood, helping them to take more conscious ownership of their choices in life, and at the same time demonstrating no improvements in symptoms or measures, is a dilemma that needs further exploration. We should be careful to implement interventions that do not demonstrate any effects on the quantitative outcomes.

High number of hypoglycaemic episodes identified by CGM among home-dwelling older people with diabetes: an observational study in Norway.

BACKGROUND: A scoping review from 2021 identified a lack of studies on the incidence, prevention and management of hypoglycaemia in home-dwelling older people with diabetes. The aim of this study was to investigate the frequency and duration of hypoglycaemic episodes measured by continuous glucose monitoring (CGM) in older people with diabetes who received home care and who were treated with glucose-lowering medications, and to compare the frequency and duration of hypoglycaemic episodes between subgroups of the study population according to demographic and clinical variables. METHODS: This was an observational study investigating the occurrence of hypoglycaemia in people with diabetes aged ≥ 65 years. Data were collected using blinded continuous glucose monitoring (CGM, iPro2) for 5 consecutive days. Frequency and duration of hypoglycaemic episodes were assessed using a sensor glucose cut-off value of 3.9 mmol/L. A blood sample for measurement of HbA1c and creatinine-based eGFR (CKD-EPI) was obtained during the monitoring period. Demographic and clinical data were collected from electronic patient records. RESULTS: Fifty-six individuals were enrolled (median age 82 years and 52% were men). Of the 36 participants who were treated with insulin, 33% had at least one hypoglycaemic episode during the five-day period. Among 18 participants who neither used insulin nor sulfonylurea, but other glucose-lowering medications, 44% had at least one hypoglycaemicepisode. Of those with hypoglycaemic episodes, 86% lived alone. The median duration of the hypoglycaemia was 1 h and 25 min, ranging from 15 min to 8 h and 50 min. CONCLUSION: This study identified an unacceptably high number of unknown hypoglycaemic episodes among older home-dwelling people with diabetes receiving home care, even among those not using insulin or sulfonylurea. The study provides essential knowledge that can serve as a foundation to improve the treatment and care for this vulnerable patient group. The routines for glucose monitoring and other prevention tasks need to be considered more comprehensively, also, among those treated with glucose-lowering medications other than insulin.

Using HbA1c measurements and the Finnish Diabetes Risk Score to identify undiagnosed individuals and those at risk of diabetes in primary care.

BACKGROUND: Prevalence of prediabetes and type 2 diabetes mellitus (T2DM) is increasing worldwide. The objective of this study was to determine the proportion of people in Northern Iceland with prediabetes, at risk of developing T2DM or with manifest undiagnosed T2DM, as this information is lacking in Iceland. METHODS: A cross-sectional study. Clients of the three largest primary health care centres in the Health Care Institution of North Iceland (HSN) were invited to participate if fulfilling the following inclusion criteria: a) aged between 18 and 75 years, b) not diagnosed with diabetes, c) speaking and understanding Icelandic or English fluently and d) living in the included service area. Data collection took place via face-to-face interviews between 1 March 2020 and 15 May 2021. Participation included answering the Finnish Diabetes Risk Score (FINDRISC), measuring the HbA1c levels and background information. RESULTS: Of the 220 participants, 65.9% were women. The mean age was 52.1 years (SD ± 14.1) and FINDRISC scores were as follows: 47.3% scored ≤8 points, 37.2% scored between 9 and 14 points, and 15.5% scored between 15 and 26 points. The mean HbA1c levels in mmol/mol, were 35.5 (SD ± 3.9) for men and 34.4 (SD ± 3.4) for women, ranging from 24 to 47. Body mass index ≥30 kg/m2 was found in 32% of men and 35.9% of women. Prevalence of prediabetes in this cohort was 13.2%. None of the participants had undiagnosed T2DM. Best sensitivity and specificity for finding prediabetes was by using cut-off points of ≥11 on FINDRISC, which gave a ROC curve of 0.814. CONCLUSIONS: The FINDRISC is a non-invasive and easily applied screening instrument for prediabetes. Used in advance of other more expensive and invasive testing, it can enable earlier intervention by assisting decision making, health promotion actions and prevention of the disease burden within primary health care. TRIAL REGISTRATION: This study is a pre-phase of the registered study "Effectiveness of Nurse-coordinated Follow up Program in Primary Care for People at risk of T2DM" at www. CLINICALTRIALS: gov (NCT01688359). Registered 30 December 2020.

Person-specific evidence has the ability to mobilize relational capacity: A four-step grounded theory developed in people with long-term health conditions.

Person-specific evidence was developed as a grounded theory by analyzing 20 selected case descriptions from interventions using the guided self-determination method with people with various long-term health conditions. It explains the mechanisms of mobilizing relational capacity by including person-specific evidence in shared decision-making. Person-specific self-insight was the first step, achieved as individuals completed reflection sheets enabling them to clarify their personal values and identify actions or omissions related to self-management challenges. This step paved the way for sharing these insights and challenges in a relationship with a supportive health professional, who could then rely on person-specific evidence instead of assumptions or a narrow disease perspective for shared decision-making. Trust in the evidence encouraged the supportive health professional to transfer it to the interdisciplinary team. Person-specific evidence then enhanced the ability of team members to apply general evidence in a meaningful way. The increased openness achieved by individuals through these steps enabled them to eventually share their new self-insights in daily life with other people, decreasing loneliness they experienced in self-management. Relational capacity, the core of the theory, is mobilized in both people with long-term health conditions and healthcare professionals. Further research on person-specific evidence and relational capacity in healthcare is recommended.

The prevalence and incidence of pharmacologically treated diabetes among older people receiving home care services in Norway 2009-2014: a nationwide longitudinal study.

BACKGROUND: A substantial proportion of older people who receive home care services (HCS) has diabetes and requires diabetes specific monitoring, treatment and self-care assistance. However, the prevalence and incidence rates of diabetes among older people in HCS are poorly described. The aim of the study is to estimate prevalence, incidence and time trends of pharmacologically treated diabetes among older people receiving HCS in Norway 2009-2014. METHODS: This nationwide observational cohort study is based on data from two population registries. The study population consisted of persons registered in the Norwegian Information System for the Nursing and Care Sector aged ≥ 65 years receiving HCS during at least one of the years 2009-2014. The Norwegian Prescription Database was utilized to identify participants' prescriptions for glucose lowering drugs (GLD). The period prevalence was calculated each year as persons with one or more prescriptions of GLD in the current or previous year. Incident cases were defined as subjects receiving prescriptions of GLD for the first time in the given calendar year if there were no prescriptions of any GLD for that person during the previous two years. RESULTS: From 2009 to 2014, the number of older people receiving HCS increased from 112,487 to 125,593. The proportion of these who received GLD increased from 14.2% to 15.7% (p < 0.001) and was significantly higher among men than women. The annual incidence rate of diabetes among those receiving HCS showed a decreasing trend from 95.4 to 87.5 cases per 10,000 person-years from 2011 to 2014, but when stratifying on age group and gender, was significant only among the oldest women (age groups 85-89 years and 90 +). CONCLUSIONS: The increasing prevalence of older people with diabetes who receive HCS highlights the importance of attention to treatment and care related to diabetes in the HCS.

Young adults with type 1 diabetes and their experiences with diabetes follow-up and participation in the DiaPROM pilot trial: A qualitative study.

AIM: To explore young adults' experiences of outpatient follow-up appointments, completing electronic Patient-Reported Outcome Measures (PROMs), and using the Problem Areas In Diabetes (PAID) scale during the Diabetes Patient-Reported Outcome Measures (DiaPROM) pilot trial. METHODS: We performed a qualitative study among 19 young adults (aged 22-39 years) with type 1 diabetes who participated in the pilot trial. Between February and June 2019, we conducted individual, semi-structured telephone interviews with participants from the intervention and control arms. We analysed the data using thematic analysis. RESULTS: Our analyses generated three themes, each with two subthemes: (1) Follow-up with limitations; (i) Marginal dialogue about everyday challenges, (ii) Value of supportive relationships and continuity, indicate that previous follow-up had been experienced as challenging and insufficient. (2) New insights and raised awareness; (i) More life-oriented insights, (ii) Moving out of the comfort zone, suggest mostly positive experiences with completing questionnaires and discussing the PAID scores. (3) Addressing problem areas with an open mind; (i) Need for elaboration, (ii) Preparedness for dialogue, indicate that both openness and explanations were vital in the follow-up. CONCLUSIONS: Participants characterised the previous follow-up as challenging and insufficient. They described completing and using the PAID as somewhat uncomfortable yet worthwhile. Our findings also suggest that by utilising diabetes distress data alongside health and biomedical outcomes, consultations became more attuned to the young adults' wishes and needs, mainly because the dialogue was more focused and direct. Hence, the PAID has the potential to facilitate person-centredness and improve patient-provider relationships.

Documented diabetes care among older people receiving home care services: a cross-sectional study.

BACKGROUND: Home care services plays an important role in diabetes management, and to enable older adults remain home-dwellers. Adequate follow-up and systematic nursing documentation are necessary elements in high quality diabetes care. Therefore, the purpose of this study was to examine the diabetes treatment and management for older persons with diabetes receiving home care services. METHODS: A cross-sectional study was used to assess the diabetes treatment and management in a Norwegian municipality. Demographic (age, sex, living situation) and clinical data (diabetes diagnose, type of glucose lowering treatment, diabetes-related comorbidities, functional status) were collected from electronic home care records. Also, information on diabetes management; i.e. follow-up routines on glycated haemoglobin (HbA1c), self-monitoring of blood glucose, insulin administration and risk factors (blood pressure, body mass index and nutritional status) were registered. HbA1c was measured upon inclusion. Descriptive and inferential statistics were applied in the data analysis. RESULTS: A total of 92 home care records from older home-dwelling persons with diabetes, aged 66-99 years were assessed. Only 52 (57 %) of the individuals had the diabetes diagnosis documented in the home care record. A routine for self-monitoring of blood glucose was documented for 27 (29 %) of the individuals. Only 2 (2 %) had individual target for HbA1c documented and only 3 (3 %) had a documented routine for measuring HbA1c as recommended in international guidelines. Among 30 insulin treated older individuals, a description of the insulin regimen lacked in 4 (13 %) of the home care records. Also, documentation on who performed self-monitoring of blood glucose was unclear or lacking for 5 (17 %) individuals. CONCLUSIONS: The study demonstrates lack of documentation in home care records with respect to diagnosis, treatment goals and routines for monitoring of blood glucose, as well as insufficient documentation on responsibilities of diabetes management among older home-dwelling adults living with diabetes. This indicates that home care services may be suboptimal and a potential threat to patient safety.

Hypoglycaemia in older home-dwelling people with diabetes- a scoping review.

BACKGROUND: Hypoglycaemia is associated with cognitive and functional decline in older people with diabetes. Identification of individuals at risk and prevention of hypoglycaemia is therefore an important task in the management of diabetes in older home-dwelling individuals. The purpose of this scoping review was to map the literature on hypoglycaemia in home-dwelling older people with diabetes. METHODS: This scoping review included original research articles on hypoglycaemia in older (≥ 65 years) individuals with diabetes from developed countries. A broad search of the databases Cinahl, Embase and Medline was performed in July 2018. The report of the scoping review was conducted in accordance with the PRISMA Extension for Scoping Reviews. RESULTS: Our database search identified 577 articles of which 23 were eligible for inclusion. The identified literature was within four areas: 1) incidence of hypoglycaemia in older home-dwelling people with diabetes (11/23 articles), 2) risk factors of hypoglycaemia (9/23), 3) diabetes knowledge and self-management (6/23) and 4) consequences of hypoglycaemia for health care use (6/23). The majority of the literature focused on severe hypoglycaemia and the emergency situation. The literature on diabetes knowledge and management related to preventing adverse events relevant to older home-dwellers, was limited. We found no literature on long-term consequences of hypoglycaemia for the use of home health care services and the older persons' ability to remain home-dwelling. CONCLUSIONS: We identified a lack of studies on prevention and management of hypoglycaemia in the older individuals' homes. Such knowledge is of utmost importance in the current situation where most western countries' governmental policies aim to treat and manage complex health conditions in the patient's home. Future studies addressing hypoglycaemia in older individuals with diabetes are needed in order to tailor interventions aiming to enable them to remain home-dwelling as long as possible.