National primary care research & development centre




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The National Health Service in England has invested substantially in recent years to improve the quality of primary care services for patients with chronic diseases such as diabetes. A key aim of this investment is to reduce associated complication rates and decrease consequent hospital admission rates. The goal of the study was to examine associations between the quality of primary care services and hospital admission rates for diabetes mellitus in England. An ecological cross-sectional study design was used. Three hundred three primary care trusts in England participated in the public reporting and performance-linked reimbursement of quality measures, including measures relevant to diabetes care. A total of 1,760,898 persons with diabetes registered with 8441 family practices in England. Hospital admission rates (total admissions for diabetes, admissions for ketoacidosis) were compared with quality of care scores, diabetes prevalence and neighborhood socio-economic status. We found a 10-fold variation across the country in total admissions for diabetes despite uniformly high scores on quality measures over the first year of the new family practitioner contract. Significant but weak inverse associations were found between primary care quality scores and hospital admission rates in patients aged 60 years and older, with a correlation coefficient of -0.21 (P < .001) between glycemic control and total admissions. Neighborhood socioeconomic status was more strongly correlated with total hospital admission rates than quality scores in patients aged 25-59 years (r = 0.58; P < .001) and 60 years and older (r = 0.45; P < .001). Quality of care scores and prevalence data were available only at the practice level rather than at the patient level. Improving the quality of primary care services may lead to modest reductions in demand for hospital services among older patients with diabetes. However, low neighborhood socioeconomic status is more strongly associated with hospital admission rates for diabetes




Borgermans LA,et al . Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework? International Journal of Integrated Care 2008 8:e07.

http://pmid.us/18493592


Objectives: To explore views on high quality diabetes care based on an analysis of existing diversity in diabetes care programmes and related quality indicators. Methods: A review of systematic reviews was performed. Four databases (MEDLINE database of the National Library of Medicine, COCHRANE database of Systematic Reviews, the Cumulative Index to Nursing and Allied Health Database-CINAHL and Pre-Cinahl) were searched for English review articles published between November 1989 and December 2006. Methodological quality of the articles was assessed. A standardized extraction form was used to assess features of diabetes care programmes and diabetes quality indicators with special reference to those aspects that hinder the conceptualization of high quality diabetes care. Based on these findings the relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care was further explored. Results: Twenty-one systematic reviews met the inclusion criteria representing a total of 185 diabetes care programmes. Six elements were identified to produce a picture of diversity in diabetes care programmes and hinder their standardization: 1) the variety and relative absence of conceptual backgrounds in diabetes care programmes, 2) confusion over what is considered a constituent of a diabetes care program and components of the implementation strategy, 3) large variety in type of diabetes care programmes, settings and related goals, 4) a large number and variety in interventions and quality indicators used, 5) no conclusive evidence on effectiveness, 6) no systematic results on costs. Conclusions: There is large diversity in diabetes care programmes and related quality indicators. From this review and our analysis on the mutual relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care, we conclude that no single conceptual framework used to date provides a comprehensive overview of attributes of high quality diabetes care linked to quality indicators at the structure, process and outcome level. There is a need for a concerted action to develop a standardized framework on high quality diabetes care that is complemented by a practical tool to provide guidance to the design, implementation and evaluation of diabetes care programmes

Boston A. Preventing and managing chronic disease through primary health organizations: the example of “Heartbeat Tararua” Primary Health Care Research & Development 2008 9: (3) 225-35.
http://dx.doi.org/10.1017/S1463423608000777

Background Primary health care service delivery in New Zealand is in an exploratory phase as primary health organizations determine new models of service delivery to reduce the incidence and impact of chronic disease. As organizations have restructured from predominantly primary care providers, the incorporation of a population approach to practice is welcomed but has provided some challenges for providers and funders alike as they reorient and extend practice parameters and determine the most effective methods of service delivery. Aim To describe and critically examine the underpinning assumptions of a new service delivered through a primary health organization to reduce the impact and burden of chronic disease with a focus on lifestyle risk factors, acting on obesity, nutrition, physical activity and smoking. Approach is a community-based lifestyle change programme focusing on the issues of obesity, nutrition, exercise and smoking and provides both clinical care for high-risk clients as well as operating a community-based prevention programme. The simplistic health education psychological and ecological models with participatory and empowerment approaches. The work demonstrates a skilled practice team well able to reflect on practice, willing to seek advice and work towards establishing new models of primary health care service delivery

Campbell SM, et al. Quality indicators for the prevention and management of cardiovascular disease in primary care in nine European countries. European Journal of Cardiovascular Prevention and Rehabilitation 8th August 2008.

http://dx.doi.org/10.1097/HJR.0b013e328302f44d

http://pmid.us/18695594


Background: With free movement of labour in Europe, European guidelines on cardiovascular care and the enlargement of the European Union to include countries with disparate health care systems, it is important to develop common quality standards for cardiovascular prevention and risk management across Europe. Methods: Panels from nine European countries (Austria, Belgium, Finland, France, Germany, Netherlands, Slovenia, United Kingdom and Switzerland) developed quality indicators for the prevention and management of cardiovascular disease in primary care. A two-stage modified Delphi process was used to identify indicators that were judged valid for necessary care. Results: Forty-four out of 202 indicators (22%) were rated as valid. These focused predominantly on secondary prevention and management of established cardiovascular disease and diabetes. Less agreement on indicators of preventive care or on indicators for the management of hypertension and hypercholesterolaemia in patients without established disease was observed. Although 85% of the 202 potential indicators assessed were rated valid by at least one panel, lack of consensus among panels meant that the set that could be agreed upon among all panels was much smaller. Conclusion: Indicators for the management of established cardiovascular disease have been developed, which can be used to measure the quality of cardiovascular care across a wide range of countries. Less agreement on how the quality of preventive care should be assessed was observed, probably caused by differences in health systems, culture and attitudes to prevention

Dennis SM, et al. Chronic disease management in primary care: from evidence to policy. Medical Journal of Australia 2008 188 8 Suppl S53-S56.

http://pmid.us/18429737


Objectives: To review the effectiveness of chronic disease management interventions for physical health problems in the primary care setting, and to identify policy options for implementing successful interventions in Australian primary care. Methods: We conducted a systematic review with qualitative data synthesis, using the Chronic Care Model as a framework for analysis between January 1990 and February 2006. Interventions were classified according to which elements were addressed: community resources, health care organisation, self-management support, delivery system design, decision support and/or clinical information systems. Our major findings were discussed with policymakers and key stakeholders in relation to current and emerging health policy in Australia. Results: The interventions most likely to be effective in the context of Australian primary care were engaging primary care in self-management support through education and training for general practitioners and practice nurses, and including self-management support in care plans linked to multidisciplinary team support. The current Practice Incentives Payment and Service Incentives Payment programs could be improved and simplified to encourage guideline-based chronic disease management, integrating incentives so that individual patients are not managed as if they had a series of separate chronic diseases. The use of chronic disease registers should be extended across a range of chronic illnesses and used to facilitate audit for quality improvement. Training should focus on clear roles and responsibilities of the team members. Conclusion: The Chronic Care Model provides a useful framework for understanding the impact of chronic disease management interventions and highlights the gaps in evidence. Consultation with stakeholders and policymakers is valuable in shaping policy options to support the implementation of the National Chronic Disease Strategy in primary care

Gately C, et al Integration of devices into long-term condition management: a synthesis of qualitative studies. Chronic Illness 2008 4 135-48.


http://dx.doi.org/10.1177/1742395308092484


http://pmid.us/18583451

Background: Understanding peoples' responses to and ability to incorporate technology for managing long-term conditions into their everyday lives is relevant for informing the development and implementation of new technologies as part of future long-term condition management in domestic environments. Future research and theory building can be facilitated by the synthesis of existing qualitative studies. Methods: A systematic search for qualitative studies of health technologies at home was undertaken on OVID CINAHL, OVID Medline and CSA databases for the period 1996-2006. Studies (n = 12) that met the inclusion criteria were synthesized and their analyses subjected to qualitative meta-synthesis .Findings: Analyses clustered into five themes: (1) managing multiple uncertainties; (2) the reconstruction of identity; (3) the struggle to remain autonomous while allowing dependence; (4) coming to terms with living a technology-assisted life; and (5) the usability of devices. These translated into a line of argument synthesis in which technology takes on the status of a personified ;other' around which a set of personal and relational attributions are subsequently constructed. These allow the extension of existing illness work to incorporate new technologies. Conclusions: Ambivalence about the value of technologies that are designed to assist with the management of a long-term condition reflects experiences of the disruptive effects of health technologies on personal identities and strategies of managing illness. At the same time, they are highly valued because they provided new opportunities to complete aspects of illness work that were previously impossible

. Glynn L G, et al. Multimorbidity and risk among patients with extablished cardiovascular disease: a cohort study. British Journal of General Practice 2008 58 (552) 488-94.

http://dx.doi.org/10.3399/bjgp08X319459

http://pmid.us/18611315


Background Most patients managed in primary care have more than one condition. Multimorbidity presents challenges for the patient and the clinician, not only in terms of the process of care, but also in terms of management and risk assessment. Aim To examine the effect of the presence of chronic kidney disease and diabetes on mortality and morbidity among patients with established cardiovascular disease. Design of study Retrospective cohort study. Setting Random selection of 35 general practices in the west of Ireland. Method A practice-based sample of 1609 patients with established cardiovascular disease was generated in 2000-2001 and followed for 5 years. The primary endpoint was death from any cause and the secondary endpoint was a cardiovascular composite endpoint that included death from a cardiovascular cause or any of the following cardiovascular events: myocardial infarction, heart failure, peripheral vascular disease, or stroke. Results Risk of death from any cause was significantly increased in patients with increased multimorbidity (P<0.001), as was the risk of the cardiovascular composite endpoint (P<0.001). Patients with cardiovascular disease and diabetes had a similar survival pattern to those with cardiovascular disease and chronic kidney disease, but experienced more cardiovascular events. Conclusion Level of multimorbidity is an independent predictor of prognosis among patients with established cardiovascular disease. In such patients, the presence of chronic kidney disease carries a similar mortality risk to diabetes. Multimorbidity may be a useful factor in prioritising management of patients in the community with significant cardiovascular risk.

Gorawara-Bhat R, Huang ES, Chin MH. Communicating with older diabetes patients: self-management and social comparison. Patient Education and Counseling Online 18th July 2008 2008


http://dx.doi.org/10.1016/j.pec.2008.05.011

http://pmid.us/18639997

Objective The health status and life experiences of older diabetes patients may be highly heterogeneous, thus making their perspectives particularly relevant for developing individualized self-management plans for this population. Our earlier research showed older diabetes patients' healthcare goals and self-management behaviors are frequently shaped through social comparisons with peers/family members. The present paper explores this role of social comparison in their self-management practices and develops a conceptual model depicting the process.Methods Data were collected using open-ended, semi-structured interviews to elicit 28 older, type 2 diabetes patients' healthcare goals and self-management practices. Qualitative techniques were used to extract salient themes.Results Social comparison plays a salient role in routinizing older patients' self-management practices. Almost all patients assess their self-management by making "downward" comparisons with individuals doing worse than them; "upward" comparisons are rarely invoked. Occasionally patients' social comparisons lead them to adopt "normalizing" behaviors resulting in deviations from medically recommended self-care.Conclusion The findings formed the basis for developing a conceptual model delineating the role of social comparison in self-management that can be beneficial for providers in tailoring educational interventions for self-management.Practice implications Fostering these comparisons can help providers enhance communication on initiating and sustaining self-management practices

Lanting LC, et al Ethnic differences in outcomes of diabetes care and the role of self-management behavior. Patient Education and Counseling 2008 72 (1) 146-54.

http://dx.doi.org/10.1016/j.pec.2008.03.008

http://pmid.us/18455354

Objective Ethnic differences in outcomes of outpatient diabetic care and the role of self-management behavior and its determinants in explaining observed differences.Methods Face-to-face interviews were held with 102 Turkish or Moroccan, and 102 native Dutch diabetic patients to measure self-management behavior and determinants of self-management (as derived from the Attitudes-Social support self-Efficacy model, and Personal Models and Barriers). A medical record review was conducted to measure ethnic differences in outcomes of diabetes care. Data were analyzed using multiple linear regression.Results Outcomes differed significantly with ethnic minorities having higher levels of lipids (risk differenceá=áRDá=á0.7%; CI: 0.3-1.2) and HbA1c (RDá=á0.9%; CI: 0.4-1.4) than native Dutch patients. Differences in self-management could not explain the ethnic differences in outcomes. Self-efficacy explained 18% of the ethnic differences in HbA1c. Beliefs about seriousness of diabetes and social support regarding diabetes management together explained 47% of the ethnic differences in lipids.Conclusion This study provides evidence for ethnic differences in outcomes of diabetes care. Self-efficacy is the most important determinant in explaining the differences in HbA1c.Practice implications For diabetes practice this suggests that strengthening patients' self-efficacy may improve the control of HbA1c and may result in a decrease of ethnic differences. The relationship between behavioral determinants like seriousness and social support and outcomes of diabetes care was differential by ethnic group, implying that caution is required when applying behavioral models to different ethnic groups


McDonald R, Rogers A, Macdonald W. Dependence and identity: nurses and chronic conditions in a primary care setting. Journal of Health Organization and Management 2008 22 (2) 294-308.


http://dx.doi.org/10.1108/14777260810883558

http://pmid.us/18700586


Purpose - This paper aims to explore the ways in which practice nurses engage in identity work in the context of chronic disease management in primary care and assess the extent to which this is compatible with the identities promoted in government policy. Design/methodology/approach - The paper draws on qualitative interviews with nurses applying the concepts of "identity threat" and Hegel's Master-Slave dialectic to explore the implications of nurse-patient interdependence for identity in a policy context which aims to promote self-management and patient empowerment. Findings - The nurses in the study showed little sign of adapting their identities in line with government policies intended to empower health care "consumers". Instead, various aspects of identity work were identified which can be seen as helping to defend against identity threat and maintain and reproduce the traditional order. Practical implications - The paper provides information on barriers to self-management that are likely to inhibit the implementation of government policy. Originality/value - Whilst much has been written on the extent to which patients are dependent on health professionals, the issue of professional dependence on patients has received much less attention. The paper hightlights how viewing the nurse-patient relationship in the context of a struggle for mastery related to identity represents a departure from traditional approaches and sheds light on hitherto unexplored barriers to self-management.

Maier M, et al. Diabetes in Europe: role and contribution of primary care: position paper of the European Forum for Primary Care. Quality in Primary Care 2008 16 (3) :197-208.


Diabetes is a chronic condition associated with multiple late complications, reduced life expectancy,1 and a marked limitation in the quality of life.2 Mortality among people with diabetes is about twice that in the normal population, and life expectancy is about 5–10

years shorter. The disease, its complications and late onset systems.3–5 This position paper focuses on the pivotal role of primary care in the management of people with diabetes mellitus, and targets policymakers in the European Union and its member states. We argue the need for a concerted approach to define how programmes to manage diabetes mellitus should be designed, developed, implemented and evaluated to ensure the highest level of quality care delivery across the different European healthcare systems.


Morrow AS, et al Integrating diabetes self-management with the health goals of older adults: A qualitative exploration. Patient Education and Counseling 2008;

http://dx.doi.org/10.1016/j.pec.2008.05.017

http://pmid.us/18621501

Objective This study investigates the life and health goals of older adults with diabetes, and explores the factors that influence their diabetes self-management.Methods Qualitative in-depth interviews were conducted with 24 older adults with diabetes and other morbid conditions and/or their caregivers, when appropriate.Results Participants' provided a consistent set of responses when describing life and health goals. Participants described goals for longevity, better physical functioning, spending time with family, or maintaining independence. Diabetes discordant conditions, but not diabetes, were seen as barriers to life goals for participants with functional impairments. Functionally independent participants described additional health goals that related to diabetes self-management as diabetes was seen often a barrier to life goals. Caregivers, co-morbid conditions, denial and retirement were among the factors that influenced initiation of diabetes self-management.Conclusion Participants endorsed health goals and diabetes self-management practices that they believed would help them accomplish their life goals. Functional capabilities and social support were key factors in the relationship between diabetes self-management and their broader goals.Practice implications When planning diabetes treatments, clinicians, patients and caregivers should discuss the relationship between diabetes self-management and health and life goals as well as the affects of functional limitations and caregiver support


Rahman M, et al A simple risk score identifies individuals at high risk of developing Type 2 diabetes: a prospective cohort study. Family Practice 2008 25 (3) 191-6.

http://dx.doi.org/10.1093/fampra/cmn024

http://pmid.us/18515811


Background. Randomized trials have demonstrated that Type 2 diabetes is preventable among high-risk individuals. To date, such individuals have been identified through population screening using the oral glucose tolerance test. Objective. To assess whether a risk score comprising only routinely collected non-biochemical parameters was effective in identifying those at risk of developing Type 2 diabetes. Methods. Population-based prospective cohort (European Prospective Investigation of Cancer-Norfolk). Participants aged 40-79 recruited from UK general practices attended a health check between 1993 and 1998 (n = 25 639) and were followed for a mean of 5 years for diabetes incidence. The Cambridge Diabetes Risk Score was computed for 24 495 individuals with baseline data on age, sex, prescription of steroids and anti-hypertensive medication, family history of diabetes, body mass index and smoking status. We examined the incidence of diabetes across quintiles of the risk score and plotted a receiver operating characteristic (ROC) curve to assess discrimination. Results. There were 323 new cases of diabetes, a cumulative incidence of 2.76/1000 person-years. Those in the top quintile of risk were 22 times more likely to develop diabetes than those in the bottom quintile (odds ratio 22.3; 95% CI: 11.0-45.4). In all, 54% of all clinically incident cases occurred in individuals in the top quintile of risk (risk score > 0.37). The area under the ROC was 74.5%. Conclusion. The risk score is a simple, effective tool for the identification of those at risk of developing Type 2 diabetes. Such methods may be more feasible than mass population screening with biochemical tests in defining target populations for prevention programmes

.

Rosenberg M, et al. Management of chronic kidney disease in primary health care: position paper of the European Forum for Primary Care. Quality in Primary Care 2008 16 (4) :279-94.


Chronic kidney disease (CKD) is a worldwide public health problem that is often underdiagnosed andundertreated. CKD is a 'silent' disease and goes unnoticed
because it may not be 'felt'. Yet it affects many more people than we might imagine: 1 out of 10 adults in the world has some form of kidney damage. However, as many as 90% of those who have CKD remain unidentified. High blood pressure and diabetes are the main causes of CKD. It is projected that diabetes will increase by 70% by 2025. Therefore, early detection and prevention of the progression of CKD for people who also have a very high cardiovascular risk are extremely important challenges and goals for general practitioners/family doctors (GPs/FDs). CKD represents a progressive, irreversible decline in glomerular filtration rate (GFR). Most chronic nephropathies unfortunately lack a specific treatment and progress relentlessly to end-stage renal disease (ESRD). Progressive renal function loss is a common phenomenon in renal failure, irrespective of the underlying cause of the kidney disease.3 The kidney is able to adapt to damage by adaptive hyperfiltration - increasing the filtration in the remaining normal nephrons. As a result, a patient with mild renal insufficiency often has a normal or near-normal serum creatinine concentration. Adaptive hyperfiltration, although initially beneficial, appears to result in long-term damage to the glomeruli of the remaining nephrons, which is manifest by proteinuria and progressive renal insufficiency. This process appears to be responsible for the development of renal failure among those in whom the original illness is either inactive or cured The cost of the advanced renal failure and renal replacement therapy is enormous.5,6 Therefore, early diagnosis andoptimal management ofCKDaffords many challengesfor primary health care in helping to maintain healthand quality of life among the population at risk. This position paper is based on published reviews about CKD management in different stages, and focuses on key references published since the year 2000. This position statement also provides evidence-based screening recommendations and interventions for shared care between GPs/FDs and specialists.

Tahrani AA, et al. Impact of practice size on delivery of diabetes care before and after the Quality and Outcomes Framework implementation. British Journal of General Practice 2008 58 (553) 576-9.

http://dx.doi.org/10.3399/bjgp08X319729

http://pmid.us/18682020

General practice characteristics are important for healthcare providers to maximise outcomes. Although different aspects of general practice characteristics have been studied previously, the impact of practice size on the delivery of care has been sparsely studied, particularly in relation to diabetes care. This brief report presents a longitudinal study in Shropshire (66 practices, 16,858 patients with diabetes) to assess the impact of practice size on diabetes care before and after implementation of the Quality and Outcomes Framework (QOF). Achievement of glycaemic control targets was better before the QOF for larger as compared to smaller practices (P=0.02 and P=0.003 for haemoglobin A1c [HbA1c]<or=7.4% and 10% respectively). This difference disappeared following QOF implementation. Repeated measures analysis showed significant improvement in achieving glycaemic control targets following QOF implementation in both large and small practices (P<0.001 for HbA1c<or=7.4% and 10%). The study failed to reveal an impact of practice size on achieving the HbA1c target (or=7.4% (P=0.1) by this analysis. However, it did show an impact on reaching the target of HbA1c<10% (P=0.04) in favour of smaller practices. There was a significant difference in favour of smaller practices for achievement of prescription of angiotensin-converting enzyme inhibitors (P=0.001)

Townsend A, Wyke S, Hunt K. Frequent consulting and multiple morbidity: a qualitative comparison of 'high' and 'low' consulters of GPs. Family Practice 2008 25:168-75.

http://dx.doi.org/10.1093/fampra/cmn017

http://pmid.us/18448858

Background. Frequent consulting is associated with multiple and complex social and health conditions. It is not known how the impact of multiple conditions, the ability to self-manage and patient perception of the GP consultation combines to influence consulting frequency. Objective. To investigate reasons for frequent consultation among people with multiple morbidity but contrasting consulting rates. Methods. Qualitative study with in-depth interviews in the west of Scotland. Participants were 23 men and women aged about 50 years with four or more chronic illnesses; 11 reported consulting seven or more times in the last year [the frequent consulters (FCs)] and 12, three or fewer times [the less frequent consulters (LFCs)]. The main outcome measures were the participants' accounts of their symptoms, self-management strategies and reasons for consulting a GP. Results. All participants used multiple self-management strategies. FCs described: more disruptive symptoms, which were resistant to self-management strategies; less access to fewer treatments and resources and more medical monitoring, for unstable conditions and drug regimens. The LFCs reported: less severe and more containable symptoms; accessing more efficacious self-management strategies and infrequent GP monitoring for stable conditions and routine drug regimens. All participants conveyed consulting as a last resort'. However, the GP was seen as ally', for the FCs, and as innocent bystander', for the LFCs. Conclusions. This qualitative investigation into the combined significance of multiple morbidities and self-management on the GP consultation suggests that current models of self-management might have limited potential to reduce utilization rates among this vulnerable group. Severity of symptoms, stability of condition and complexity of drug regimens combine to influence the availability of effective resources and influence frequency of GP consultations
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