Improving the structure of diabetes care in primary care: A pilot study
Primary Care Diabetes

Nouha Saleh Stattina,b,∗, Kimberly Kanea,c, Marina Stenbäcka,Alexandre Wajngota, Kaija SeijboldtaaAcademic Primary Healthcare Centre, Stockholm County Council, Solnavägen 1E (Torsplan), 113 65, Stockholm,SwedenbDivision of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, KarolinskaInstitutet, Alfred Nobels Allé 23 D2, 141 83 Huddinge, SwedencAging Research Center, Karolinska Institutet and Stockholm University, Tomtebodavägen 18 A, SE-171 77Stockholm, Sweden

a b s t r a c t

Aim: The aim of this pilot study was to determine whether glycemic control can be improvedin patients with type 2 diabetes by implementing a workshop model to improve the structureof diabetes care at primary health care centers (PHCCs).

Methods: The intervention consisted of 4 workshops at 12 PHCCs with HbA1c >70 mmol/mol(high HbA1c).

Each PHCC could choose how many workshops they wished to attend andwas to be represented by the manager, a diabetes nurse, and a GP. Participants analyzedthe structure of diabetes care at their PHCC and developed an action plan to improve it.The percentage of patients with high HbA1c at baseline, 12, and 24 months was collected.Qualitative content analysis was also conducted.

Results: All PHCCs reduced the percentage of patients with high HbA1c 12 months after theintervention, but not all maintained the reduction at 24 months. Participants experiencedstructuring diabetes care as central to reducing the percentage of patients with high HbA1c.Pillars of structured diabetes care included establishing routines, working in teams, andhaving and implementing an action plan.

Conclusions: Working with the structure of diabetes care improved care structure and had apositive impact on HbA1c. To sustain the positive impact, PHCCs had to set long-term goalsand regularly evaluate performance.

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ammanfattning av studien

Diabetes care processes are frequently suboptimal, a prob-lem that can lead to inequities in care access and delivery[1,2]. Such inequities exist even in countries like Sweden thatmandate equity by law and have good resources, universalprimary healthcare, and good quality of care [3]. In Sweden,the percentage of patients with high glycated hemoglobin(HbA1c) > 70 mmol/mol (high HbA1c) at primary healthcarecenters (PHCCs) [4] is associated with high scores on a neigh-borhood social deprivation index (Care Need Index or CNI) [5].Care equity can only be achieved when access to and deliv-ery of diabetes care are structured in a way that accounts forindividuals’ differing needs and circumstances [6].

A 2011 survey by the Swedish National Board of Health andWelfare showed that diabetes care structure, processes, andresults were good but not optimal [7]. The survey found thatthe percentage of people with high HbA1c had risen between2007 and 2011 and that the quality of diabetes care and patientoutcomes varied by PHCC. In 2013, the Swedish Associationof Local Authorities and Regions published a report on factorsthat might contribute to these variations [8,9]. The researchersfound seven factors that contributed to good results at high-performing PHCCs.

All were organizational: discussing thePHCCs’ results from the National Diabetes Register (NDR), set-ting treatment targets, using targeted initiatives with patientswho have poor metabolic control, frequently following uppatients with extremely high HbA1c, setting clear expecta-tions and providing continuing education for staff, providingongoing follow-up and feedback from management to staff,and taking long-term initiatives to improve diabetes care.Additionally, a nationwide cross-sectional study of the orga-nization of primary healthcare (PHC) for patients with type 2diabetes (T2DM) found that several factors were crucial to thequality of care and patient outcomes [10]. These included thepresence of a diabetes team, follow-up call-recall to minimizethe risk of losing track of patients with high HbA1c, and reg-ular discussions of patients’ metabolic results extracted fromthe NDR [10].Ninety-eight percent of patients with diabetes are regis-tered in the NDR. PHCCs update data in the register at leastonce a year.

Each PHCC has on-demand access to results aboutHbA1c, blood pressure, and other parameters. PHCCs can thusplan and implement interventions in accordance with infor-mation they extract from the register [11].In 2013, the Stockholm County Council (SCC) and Karolin-ska Institutet started a project called 4-D to improvehealthcare for people with four common diagnoses, includingT2DM.

The 4-D project aimed to create tools (e.g. models, inter-ventions, and apps) that would facilitate the application ofresearch findings in clinical practice [12]. One of several resultsof the 4-D Diabetes subproject was a standardized health-care process for T2DM based on national and internationalguidelines [1,7,8] and on analyses of interviews with PHC pro-fessionals and patients [13]. Other results to date include anapp and several ongoing screening interventions [13].

One ofthe aims of the 4-D Diabetes subproject was to establish aframework for certifying diabetes clinics at PHCCs. Because ofthis, several of the results of 4-D Diabetes subproject have beencalled “DiaCert,” which stands for “diabetes certification.” Anexample is the “DiaCert smartphone-app” [14].The 4-D Diabetes subproject identified a gap in guideline-based care at PHCCs. The researchers found that PHCCsfollowed guidelines to varying degrees [13]. The care the PHCCsprovided was thus of differing quality, a finding consistentwith the findings of previous studies [7–10].

To help PHCCsreduce the gap between the guidelines and everyday prac-tice, the 4-D Diabetes working group developed the DiaCertworkshop model [13,15].The aim of this pilot study was to determine whetherglycemic control can be improved in patients with type 2diabetes by implementing a workshop model to improve thestructure of diabetes care at primary health care centers(PHCCs).

All PHCCs in this pilot study reduced the percentage ofpatients with high HbA1c 12 months after the intervention,but not all maintained the reduction after 24 months. Par-ticipants experienced structuring diabetes care as central toreducing the percentage of patients with high HbA1c. Thepillars of structured care included establishing diabetes careroutines, working in teams, and having and implementing anaction plan.The current intervention was an effort to improve thestructure of PHC for patients with a chronic illness. Assuch, it addressed components of the healthcare system inthe Chronic Care Model (CCM) [21]. Systematic reviews ofthe effectiveness of implementing the CCM in primary care[22,23] indicate that multiple factors contribute to improv-ing healthcare practices and outcomes. Some of these factorsare congruent with those found in a Swedish study [9] andin our qualitative findings, including support from managersin implementing and sustaining interventions and reflectivehealthcare practice.Another systematic review and meta-analysis found thatstrategies that included both healthcare professionals andpatients improved care [24]. Unlike that study, our inter-vention directly targeted the diabetes care delivery system.Nevertheless, the quantitative results showed a modestimprovement in HbA1c.The DiaCert workshop model incorporates organizationalfactors that the Swedish Association of Local Authorities

5and Regions described as important in diabetes care [8]; forexample, discussing NDR results, setting treatment targets forpatients, and using targeted initiatives with patients who havepoor metabolic control. Our results underline the importanceof these factors.Previous research has found that “owning” patients’ results– examining and understanding them – is a crucial prerequi-site for quality care for PHC patients with T2DM [9]. Congruentwith those findings, participants in this pilot study experi-enced extracting patient results from the NDR and discussingthem as crucial to structured care.Some participants indicated that certain routines need tobe established to attain the goals agreed on with patients. Onesuch routine was the call-recall system, which Husdal et al.also found contributed to attaining such goals [10].Awareness of team members’ differing and complemen-tary knowledge and competence played an important rolein clarifying role descriptions and allocating responsibility,which facilitated working in teams.

Previous studies show thatcare provided by teams helps patients improve their HbA1clevels and quality of life [5,25–29]. Facilitators in this studyobserved that PHCCs that had teams improved their NDRresults and maintained improvements better than those thatdid not have teams.Our qualitative findings support previous research showingthat internal (managerial) support is needed to sustain QI inPHC [9]. However, they add to previous findings on the impor-tance of external support. An earlier study found that externalsupport may be needed to initiate improvement [30], and wefound that such support (e.g. from facilitators) may also behelpful in sustaining it.It is important for all PHCC personnel to actively participatein the process of change [31–34]. In this study, the majority ofparticipants emphasized that for changes to take place, bothmanagers and teams had to be engaged.Implementing QI is a complex and challenging process.Difficulties achieving QI can stem from internal factors thatPHCCs can influence, such as managers’ involvement. Theycan also stem from external factors over which PHCCs havelittle or no control [35], such as health policy issues. In thecurrent study, we observed that PHCCs that dropped out earlytended to have high personnel turnover, which could be dueto internal and/or external factors.4.1. Strengths and limitationsA main strength of this study was that the DiaCert workshopmodel was based on a standardized PHC process developedusing international and national guidelines.

In this pilotproject, participants found the model easy to use. A furtherstrength was the continuous accessibility of facilitator supportduring and after the workshops.The study had some limitations. Only 12 of the 23 centersinvited to participate accepted, and two dropped out early.Possible reasons include lack of time, high staff turnover, andconcern about losing income if staff left work to attend theworkshops. Another limitation was the unvalidated analy-sis tool. At least two validated tools have been developedto help healthcare providers assess and improve their workwith chronically ill people: the System Assessment Tool (SAT)[36,37] and Assessment of Chronic Illness Care survey (ACIC)[14]. Neither is available in Swedish or specific to diabetes care.Because this was a pilot study, it is not possible to gener-alize the results outside Stockholm County. Some aspects ofthe model are probably transferrable to contexts that have adiabetes care process, or at least diabetes care guidelines (e.g.,using post-it notes to reflect on strengths and weaknesses ofdiabetes care). Other aspects of the model would have to beadjusted for differences in health care systems and cultures(e.g., the analysis tool).4.2.

Impact of this pilot study
The pilot study led to a number of changes to the DiaCertworkshop model. In response to participant feedback, thequestionnaire was adjusted for clarity. We are also develop-ing a questionnaire to evaluate the workshops. Finally, wenow offer workshops to all PHCCs interested in improving carequality, regardless of patients’ HbA1c levels.

Conclusions and implications for practice
Working with the structure of diabetes care via the pilotproject had a positive impact on patient outcomes (HbA1c).Results indicate that the workshops were a good way to startthe QI process. However, to sustain the positive impact, PHCCshad to regularly evaluate their performance, reanalyze the waythey structured diabetes care, and update their action plan.The findings underscore the value of working in teams in PHC.In future studies, we plan to evaluate a larger-scale imple-mentation of the DiaCert workshop model in StockholmCounty PHCCs regardless of patients’ HbA1c levels. Thesestudies will address short- and long-term effects on bothHbA1C and patients’ experiences.

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