Evaluating the effect of Conversation Cards on agenda-setting in annual diabetes status visits: A multi-method study.

OBJECTIVE: To evaluate Conversation Cards for shared agenda-setting between patients and nurses in status visits for type 2 diabetes. METHODS: Non-randomized comparison of survey responses between intervention and control groups. Content analysis of interview data of patient experiences from a purposive sample of the intervention group. RESULTS: The survey included 52 patients in the intervention and 55 in the control group. Survey data showed no significant differences between the groups. Regardless of the intervention, patients experienced that topics relevant to them were addressed. One in four patients rated the Conversation Cards as very supportive. Interview data indicated that the Conversation Cards added structure, commitment to the conversation, and support to raise topics not previously considered diabetes related. CONCLUSION: Topics of concern were addressed in both intervention and control groups. The Conversation Cards for agenda-setting clarified a mutually agreed structure of the conversation, eased raising hitherto ignored topics, and increased engagement. PRACTICE IMPLICATIONS: The Conversation Cards have potential to improve shared agenda-setting, but implementation requires efforts from both parties. Patients are expected to consider their concerns and take an active part in agenda-setting. Nurses are expected to collaborate with the patient in the agenda-setting, which might challenge the nurses' habitual practice.

"Less is more": A design thinking approach to the development of the agenda-setting conversation cards for people with type 2 diabetes.

Objectives: To report a design-thinking approach to a user-centred agenda-setting tool for use in type 2 diabetes clinics. Methods: The study followed design-thinking phases: emphasizing, defining, and ideating an intervention, followed by iterative user-testing of prototypes. It was conducted at a Danish diabetes center using observations, interviews, workshops, focus groups, and questionnaires. Results: Nurses wanted to put more emphasis on agenda-setting in status visits. During brainstorms the idea of using illustrated cards that listed key agenda topics was proposed and became the goal of this research. Adopting a design-thinking approach provided the basis for developing prototypes for iterative user-testing that led to a version that was acceptable to stakeholders. The resulting tool, Conversation Cards, was a set of cards that listed and illustrated seven key topics that were considered important to consider during diabetes status visits. Conclusion: The goal of the Conversation Card intervention is to support collaborative agenda-setting in diabetes status visits. Further evaluation is needed to determine the utility and acceptability of the tool to nurses and to people with diabetes in routine settings. Innovation: This novel tool is designed to trigger agenda-setting conversations and thereby prioritize individuals' choice of topics to talk about during diabetes status visits.

Experience of family function, family involvement, and self-management in adult patients with type 2 diabetes: A thematic analysis.

AIM: To describe the patient's experience of family function and its importance in diabetes-related self-management. BACKGROUND: Many patients fail to reach the targeted glycemic level due to low self-management adherence. Knowledge is needed regarding the impact of family function on diabetes self-management. DESIGN: A qualitative descriptive design. METHODS: A purposive sample of 20 patients with type 2 diabetes. Data were collected in March-June 2017 via audio-recorded semi-structured interviews, field notes and Eco-maps. Analysed using thematic framework matrix and thematic analysis. RESULTS: Four themes were identified: (1) Downplaying disease. The disease was trivialized creating a barrier to family involvement; (2) Second guessing. When diabetes was not discussed, patient and family made their own assumptions; (3) Going it alone. The participants preferred sole disease responsibility to maintain usual family life; (4) No regrets. The participants managed their disease with medications only to maintain family cohesion and 'the good life'. CONCLUSION: The participants in our study downplayed the consequences of type 2 diabetes and chose to control their disease medically rather than by lifestyle changes. They renounced family involvement to maintain their lifestyle and promote family cohesion. IMPACT: During clinical check-ups, patients should be encouraged to involve their family in lifestyle changes. Healthcare professionals need to recognize illness- and treatment beliefs and the impact of family function in disease management.

Patient Assessment of Family Function, Glycemic Control and Quality of Life in Adult Patients With Type 2 Diabetes and Incipient Complications.

OBJECTIVES: Family affects the perception of diabetes self-management in patients with diabetes. Family-related questionnaires have been used to assess family function, but the Brief Family Assessment Measure (Brief FAM-III) has not been used previously in a diabetes population. We aimed to determine whether the family function is associated with glycated hemoglobin levels and quality of life as potential predictors of diabetes self-management. METHODS: An exploratory study of patients with type 2 diabetes and incipient complications and their relatives using the Brief FAM-III, a self-report questionnaire comprising 3 scales assessing family function according to different perspectives: a general score, a dyadic relationship score and a self-rating score. RESULTS: We included 127 patients: 72.4% males, mean age 65.23 (SD=10.26) years; glycated hemoglobin levels, 6.9% (SD=0.9%); diabetes duration, 9.1 (SD=0.6) years; and body mass index, 30.8 (SD=0.5) kg/m2. Mean FAM-III scores for the 3 scales were 41.7 (SD=1.0), 41.5 (SD=0.9) and 38.5 (SD=1.1), respectively. Correlation coefficients were -0.06 (p=0.37), -0.09 (p=0.18) and -0.12 (p=0.06), showing no significant correlation between scales and glycated hemoglobin levels levels in the 3 perspectives before and after adjustment for confounders. Family function correlated with burden of diabetes at 0.14 (p=0.02), 0.24 (p=0.0003) and 0.16 (p=0.01), respectively, and mental health at -0.21 (p=0.0007), -0.23 (p=0.0005) and -0.25 (p<0.0001), respectively. CONCLUSION: The results of our study suggest that in patients with type 2 diabetes, family function does not predict the level of glycemic control. However, we found an association among healthy family function, low burden of diabetes and strong mental health, issues that are important for the patients' quality of life, compliance with lifestyle factors and diabetes self-management.

[Cross-sectoral collaboration in type 2 diabetes management in Denmark].

To optimize medical care, Danish guidelines for type 2 diabetes emphasize cross-sectoral collaboration. Risk stratification is recommended as a model of organizing care in terms of distributing tasks and responsibilities between primary and secondary healthcare sectors. Collaboration between the sectors is expected to be beneficial for patients and ensure rational utilization of resources. Challenges such as inter-sectoral communication, sharing of data and unambiguous responsibility underline the need for continuous optimization of the organization of cross-sectorial diabetes management.

Supportive and non-supportive interactions in families with a type 2 diabetes patient: an integrative review.

BACKGROUND: Type 2 diabetes and its management affect the patient and the close family potentially causing either psychological distress or increased sense of responsibility and collaboration in these families. Interactions between patient and family play an important role in maintaining lifestyle changes and diabetes self-management. The purpose of this integrative review was to summarise and assess published studies on the intra-family perspective of supportive and non-supportive interactions in families with a type 2 diabetes patient. METHODS: Included in the review were published qualitative and quantitative studies that examined the intra-family perspective on supportive and non-supportive interactions. We searched the literature from 2000 to 2016 and the search strategy comprised the following databases: Cochrane, PubMed, CINAHL, Web of Science, PsycINFO and Psyc-ARTICLES as well as hand searching of reference lists. Quality assessment, data extraction and analysis were undertaken on all included studies. RESULTS: We identified five eligible research papers. Employing content analysis three categories describing interactions were refined: Impact of practical action, impact of emotional involvement, and impact of communication content. Supportive interactions included encouraging communication and family collaboration in managing diet, medications, and blood glucose checking. Non-supportive interactions were visible irritation, nagging behaviour and refusing to share the burden of living with diabetes. CONCLUSION: The findings stress the importance of including both patient and family in clinical practice to target diabetes self-management adherence and well-being of the whole family. The majority of self-management occurs within the family environment. Therefore, the intra-family perspective of supportive and non-supportive interactions should be understood and addressed as the family members are interdependent and affected by each other. Future research assessing the impact of professional support and the family function will have the potential to improve the daily life and well-being of patients with type 2 diabetes as well as the whole family.

Constipation is casting a shadow over everyday life - a systematic review on older people's experience of living with constipation.

AIMS AND OBJECTIVES: To explore and summarise best evidence of how constipation affects the daily living of older people from their own perspective. Furthermore, to assess how interventions aimed at treating constipation in older people affect patient-reported outcome such as quality of life. BACKGROUND: Constipation is a common and overlooked problem with an impact on everyday life, especially among older people. Older people seem to have individual preconceptions on constipation which can influence the strategies used to prevent and treat constipation. DESIGN: A systematic review, integrating findings from both qualitative and quantitative studies. METHOD: Systematic searches were carried out in PubMed, CINAHL, PsycINFO and EMBASE on the 31st of July 2014. A search strategy was constructed with key concepts identified using PICO to identify quantitative studies and PIC(o) to identify qualitative studies. Search terms included constipation, elderly, aged, elderly people, aged people, quality of life, patient experience, patient perspective, meaning, emotion, psychological. Reference lists were searched manually. RESULTS: A total of nine studies were included in the review, five quantitative and four qualitative. Three main themes crystallised from the results of the included studies: bodily experiences, everyday life shadowed by constipation and adverse psychological effects. CONCLUSION: Constipation among older people was connected to subjective and comprehensive experiences. It had a negative impact on physical and mental well-being as well as the social life of older people. The review also showed that older people had individual and personal strategies, based on their own beliefs. RELEVANCE TO CLINICAL PRACTICE: Healthcare professionals need to be aware of the experiences of living with constipation as well as the range of strategies used by patients to prevent and treat constipation. The patient perspective on constipation needs to be integrated in the strategies and actions carried out by healthcare professionals.

Shared care management of patients with type 2 diabetes across the primary and secondary healthcare sectors: study protocol for a randomised controlled trial.

BACKGROUND: The prevalence of type 2 diabetes (T2D) is growing globally and hospital-based outpatient clinics are burdened with increasing numbers of patients. To ensure high quality treatment and care, it is necessary to structurally reorganise the management of patients with T2D. The objective of this study is to test if T2D patients (who are at intermediate risk of or are already having incipient diabetic complications) jointly managed by a hospital-based outpatient clinic and general practitioners (shared care programme) have a non-inferior outcome compared to an established programme in a specialised (hospital based) outpatient diabetes clinic. METHODS: The study is designed as a randomised controlled trial. The shared care model will be tested during a period of 3 years, with data collection at baseline and at 12, 24 and 36 months. All patients will be offered four medical visits a year; the shared care intervention consists of one annual comprehensive check-up at the outpatient clinic and three quarterly visits at the general practitioners' office. The control group will be followed with four quarterly visits at the outpatient clinic, including an annual comprehensive check-up. In the outpatient clinic, the patients will be treated by a specialised diabetes team, including an endocrinologist. On the basis of a predefined stratification model, we will recruit patients stratified to be at intermediate risk of or already having incipient diabetic complications. We plan to include 140 patients. The primary outcome is glycated haemoglobin. Other outcome measures include (1) the proportion of patients who meet the Danish standard indicators reflecting quality of care; (2) quality of life measured by Short Form 36; and (3) the functionality of the patients' families measured by Family Assessment Measure III. The experiences of the patients and families when participating in the shared care program will be explored by collecting dyadic interviews. DISCUSSION: This study will evaluate the quality of a shared care programme for patients with T2D, and provide evidence about advantages and disadvantages compared with a programme in a specialised outpatient clinic. The results may provide important information on how to organise the care for patients with T2D in the future. TRIAL REGISTRATION: This trial was registered with Clinicaltrials.gov on 21 October 2015, registration number: NCT02586545 .

Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: a cross-sectional study.

BACKGROUND: To target optimised medical care the Danish guidelines for diabetes recommend stratification of patients with type 2 diabetes (T2D) into three levels according to risk and complexity of treatment. The aim was to describe the T2D population in an outpatient clinic, measure the compliance of the endocrinologists' to perform risk stratification, and investigate the level of concordance between stratification performed by the endocrinologists and objective assessments. METHODS: A cross-sectional study with data collected from medical records and laboratory databases. The Danish risk stratification model contained the following criteria: HbA1c, blood pressure, metabolic complications, microvascular and macrovascular complications. Stratification levels encompassed: level 1 (uncomplicated), level 2 (intermediate risk) and level 3 (high risk). Objective assessments were conducted independently by two health professionals, and compared with the endocrinologists' assessments. In order to test the degree of concordance, we conducted Cohen's kappa, McNemar's test for marginal homogeneity, and Bowker's test for symmetry. RESULTS: Of 245 newly referred patients, 209 (85%) were stratified by the endocrinologists to level 1 (16%), level 2 (55%) and level 3 (29%). By objective assessments, 4% were stratified to level 1, 51% to level 2 and 45% to level 3. Of 419 long-term follow-up patients, 380 (91%) were stratified by the endocrinologists to level 1 (5%), level 2 (57%), level 3 (38%). By objective assessments, 3% were stratified to level 1, 58% to level 2 and 39% to level 3. The concordance rate between endocrinologists' and objective assessments was 63% among newly referred (kappa 0.39; fair agreement) and 67% for long-term follow-up (kappa 0.45; moderate agreement). Among newly referred patients, the endocrinologists stratified less patients at level 3 compared to objective assessments (p < 0.0001). There were no significant differences in marginal distribution within long-term follow-up patients. CONCLUSION: Type 2 diabetes patients, newly referred to or allocated for long-term follow-up in the out-patient clinic, were mainly intermediate and high-risk, complicated patients (96% and 95 %, respectively). Compliance of stratification by endocrinologists was high. The concordance between endocrinologists' and objective assessments was not strong. Our data suggest that clinician-support for stratification level categorisation might be needed.

Living with constipation--older people's experiences and strategies with constipation before and during hospitalization.

BACKGROUND: Constipation is a common problem among older people. This study aimed to explore how older patients experience constipation and which strategies they used in handling the condition before and during hospitalization. METHODS: A qualitative exploratory research design was used. Fourteen semi-structured interviews were conducted with patients (61-91 years of age) during hospitalization. Data were analyzed by using content analysis. RESULTS: Themes concerning experiences were Bodily signs and symptoms of constipation; the participants described severe pain during constipation, as well as pronounced relief after bowel movements, Impact on well-being and social activities; being constipated negatively impacted their mood and limited social activities, Striving for bowel balance; the participants experienced an ongoing strive for balancing between constipation and diarrhea. Themes related to strategies were Struggling to find a solution; they were aware of different strategies to prevent and treat constipation, though the most common solution described was the use of laxatives, Wait and see; the participants were awaiting to take action until they experienced constipation symptoms, Constipation is a private problem being challenged during hospitalization; constipation was considered a private issue rarely discussed with health-care professionals. CONCLUSION: This study illuminates the need for health-care professionals to be attentive to this issue and initiate the conversation with patients in order to advise on the management of constipation.