PA3 New Primary Care Incentive Scheme for Type 2 Diabetes in Denmark

Abstract Background The most efficient procedures to engage and guide healthcare professionals in collaborative processes that seek to optimize practice are unknown. The PREDIAPS project aims to assess the effectiveness and feasibility of different procedures to perform a facilitated interprofessional collaborative process to optimize type 2 diabetes prevention in routine primary care. Methods A type II hybrid cluster randomized implementation trial was conducted in nine primary care centers of the Basque Health Service. All centers received training on effective healthy lifestyle promotion. Headed by a local leader and an external facilitator, centers conducted a collaborative structured process—the PVS-PREDIAPS implementation strategy—to adapt the intervention and its implementation to their specific context. The centers were randomly allocated to one of two groups: one group applied the implementation strategy globally, promoting the cooperation of all health professionals from the beginning, and the other performed it sequentially, centered first on nurses, who later sought the pragmatic cooperation of physicians. The following patients were eligible for inclusion: all those aged ≥ 30 years old with at least one known cardiovascular risk factor and an impaired fasting glucose level (≥ 110-125 mg/dl) but without diabetes who attended centers during the study period. The main outcome measures concerned changes in type 2 diabetes prevention practice indicators after 12 months. Results After 12 months, 3273 eligible patients at risk of type 2 diabetes had attended their family physician at least once, and of these, 490 (15%) have been addressed by assessing their healthy lifestyles in both comparison groups. The proportion of at-risk patients receiving a personalized prescription of lifestyle change was slightly higher (8.6%; range 13.5-5.9% vs 6.8%; range 7.2-5.8%) and 2.3 times more likely (95% CI for adjusted hazard ratio, 1.38-3.94) in the sequential than in the global centers, after 8 months of the intervention program implementation period. The probability of meeting the recommended levels of physical activity and fruit and vegetable intake were four- and threefold higher after the prescription of lifestyle change than only assessment and provision of advice. The procedure of engagement in and execution of the implementation strategy does not modify the effect of prescribing healthy habits (p interaction component of intervention by group, p > 0.05). Discussion Our results show that the PVS-PREDIAPS implementation strategy manages to integrate interventions with proven efficacy in the prevention of type 2 diabetes in clinical practice in primary care. Further, they suggest that implementation outcomes were somewhat better with a sequential facilitated collaborative process focused on enhancing the autonomy and responsibility of nurses who subsequently seek a pragmatic cooperation of GPs. Trial registration Clinicaltrials.gov identifier: NCT03254979. Registered 16 August 2017—retrospectively registered.

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Optimal cut-off points for adherence measure among patients with type 2 diabetes in primary care clinics: a retrospective analysis

Therapeutic Advances in Chronic Disease ◽

10.1177/2040622321990264 ◽

2021 ◽

Vol 12 ◽

pp. 204062232199026

Author(s):

Ming Tsuey Lim ◽

Norazida Ab Rahman ◽

Xin Rou Teh ◽

Chee Lee Chan ◽

Shantini Thevendran ◽

...

Keyword(s):

Type 2 Diabetes ◽

Primary Care ◽

Medication Adherence ◽

Poor Adherence ◽

Adherence Measure ◽

Primary Care Clinics ◽

Assessment Period ◽

Hba1c Target ◽

Optimal Adherence

Background: Medication adherence measures are often dichotomized to classify patients into those with good or poor adherence using a cut-off value ⩾80%, but this cut-off may not be universal across diseases or medication classes. This study aimed to examine the cut-off value that optimally distinguish good and poor adherence by using the medication possession ratio (MPR) and proportion of days covered (PDC) as adherence measures and glycated hemoglobin (HbA1c) as outcome measure among type 2 diabetes mellitus (T2DM) patients. Method: We used pharmacy dispensing data of 1461 eligible T2DM patients from public primary care clinics in Malaysia treated with oral antidiabetic drugs between January 2018 and May 2019. Adherence rates were calculated during the period preceding the HbA1c measurement. Adherence cut-off values for the following conditions were compared: adherence measure (MPR versus PDC), assessment period (90-day versus 180-day), and HbA1c target (⩽7.0% versus ⩽8.0%). Results: The optimal adherence cut-offs for MPR and PDC in predicting HbA1c ⩽7.0% ranged between 86.1% and 98.3% across the two assessment periods. In predicting HbA1c ⩽8.0%, the optimal adherence cut-offs ranged from 86.1% to 92.8%. The cut-off value was notably higher with PDC as the adherence measure, shorter assessment period, and a stricter HbA1c target (⩽7.0%) as outcome. Conclusion: We found that optimal adherence cut-off appeared to be slightly higher than the conventional value of 80%. The adherence thresholds may vary depending on the length of assessment period and outcome definition but a reasonably wise cut-off to distinguish good versus poor medication adherence to be clinically meaningful should be at 90%.

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Improving the management of type 2 diabetes through large-scale general practice: the role of a data-driven and technology-enabled education programme

BMJ Open Quality ◽

10.1136/bmjoq-2020-001087 ◽

2021 ◽

Vol 10 (1) ◽

pp. e001087

Author(s):

Tarek F Radwan ◽

Yvette Agyako ◽

Alireza Ettefaghian ◽

Tahira Kamran ◽

Omar Din ◽

...

Keyword(s):

Type 2 Diabetes ◽

Primary Care ◽

Large Scale ◽

Education Programme ◽

Educational Programme ◽

Data Driven ◽

Treatment Targets ◽

Care Processes ◽

Data Driven Approach

A quality improvement (QI) scheme was launched in 2017, covering a large group of 25 general practices working with a deprived registered population. The aim was to improve the measurable quality of care in a population where type 2 diabetes (T2D) care had previously proved challenging. A complex set of QI interventions were co-designed by a team of primary care clinicians and educationalists and managers. These interventions included organisation-wide goal setting, using a data-driven approach, ensuring staff engagement, implementing an educational programme for pharmacists, facilitating web-based QI learning at-scale and using methods which ensured sustainability. This programme was used to optimise the management of T2D through improving the eight care processes and three treatment targets which form part of the annual national diabetes audit for patients with T2D. With the implemented improvement interventions, there was significant improvement in all care processes and all treatment targets for patients with diabetes. Achievement of all the eight care processes improved by 46.0% (p<0.001) while achievement of all three treatment targets improved by 13.5% (p<0.001). The QI programme provides an example of a data-driven large-scale multicomponent intervention delivered in primary care in ethnically diverse and socially deprived areas.

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Effect of Professional CGM (pCGM) on Glucose Management in Type 2 Diabetes Patients in Primary Care

Journal of Diabetes Science and Technology ◽

10.1177/1932296821998724 ◽

2021 ◽

pp. 193229682199872

Author(s):

Gregg D. Simonson ◽

Richard M. Bergenstal ◽

Mary L. Johnson ◽

Janet L. Davidson ◽

Thomas W. Martens

Keyword(s):

Type 2 Diabetes ◽

Primary Care ◽

Glucose Monitoring ◽

Care Model ◽

Time In Range ◽

Glucose Management ◽

The Impact ◽

Primary Care Management

Background: Little data exists regarding the impact of continuous glucose monitoring (CGM) in the primary care management of type 2 diabetes (T2D). We initiated a quality improvement (QI) project in a large healthcare system to determine the effect of professional CGM (pCGM) on glucose management. We evaluated both an MD and RN/Certified Diabetes Care and Education Specialist (CDCES) Care Model. Methods: Participants with T2D for >1 yr., A1C ≥7.0% to <11.0%, managed with any T2D regimen and willing to use pCGM were included. Baseline A1C was collected and participants wore a pCGM (Libre Pro) for up to 2 weeks, followed by a visit with an MD or RN/CDCES to review CGM data including Ambulatory Glucose Profile (AGP) Report. Shared-decision making was used to modify lifestyle and medications. Clinic follow-up in 3 to 6 months included an A1C and, in a subset, a repeat pCGM. Results: Sixty-eight participants average age 61.6 years, average duration of T2D 15 years, mean A1C 8.8%, were identified. Pre to post pCGM lowered A1C from 8.8% ± 1.2% to 8.2% ± 1.3% (n=68, P=0.006). The time in range (TIR) and time in hyperglycemia improved along with more hypoglycemia in the subset of 37 participants who wore a second pCGM. Glycemic improvement was due to lifestyle counseling (68% of participants) and intensification of therapy (65% of participants), rather than addition of medications. Conclusions: Using pCGM in primary care, with an MD or RN/CDCES Care Model, is effective at lowering A1C, increasing TIR and reducing time in hyperglycemia without necessarily requiring additional medications.

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Rates and estimated cost of primary care consultations in people diagnosed with type 2 diabetes and comorbidities: A retrospective analysis of 8.9 million consultations

Diabetes Obesity and Metabolism ◽

10.1111/dom.14340 ◽

2021 ◽

Author(s):

Briana Coles ◽

Francesco Zaccardi ◽

Sam Seidu ◽

Clare L. Gillies ◽

Melanie J. Davies ◽

...

Keyword(s):

Type 2 Diabetes ◽

Primary Care ◽

Retrospective Analysis

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Appropriateness of aspirin prescribing for primary and secondary prevention of cardiovascular disease in type 2 diabetes in different care settings

Irish Journal of Medical Science (1971 -) ◽

10.1007/s11845-021-02649-5 ◽

2021 ◽

Author(s):

Shi Ying Tan ◽

Heather Cronin ◽

Stephen Byrne ◽

Adrian O’Donovan ◽

Antoinette Tuthill

Keyword(s):

Type 2 Diabetes ◽

Cardiovascular Disease ◽

Primary Care ◽

Primary Prevention ◽

Secondary Prevention ◽

Shared Care ◽

University Hospital ◽

Cross Sectional ◽

Prevention Of Cardiovascular Disease

Abstract Background Type 2 diabetes is associated with an increased cardiovascular risk. Use of aspirin has been shown to be of benefit for secondary prevention of cardiovascular disease in patients with type 2 diabetes; benefits in primary prevention have not been clearly proven. Aims This study aims to (a) determine if aspirin is prescribed appropriately in type 2 diabetes for primary or secondary prevention of cardiovascular disease (CVD) and (b) evaluate whether there are differences in aspirin prescribing according to where people receive their care. Design Cross-sectional study Methods The medical records of individuals with type 2 diabetes aged over 18 years and attending Elmwood Primary Care Centre and Cork University Hospital Diabetes outpatient clinics (n = 400) between February and August 2017 were reviewed. Results There were 90 individuals exclusively attending primary care and 310 persons attending shared care. Overall, 49.0% (n = 196) of those were prescribed aspirin, of whom 42.3% were using it for secondary prevention. Aspirin was used significantly more in people attending shared care (p < 0.001). About 10.8% of individuals with diabetes and CVD attending shared care met guidelines for, but were not prescribed aspirin. Conclusion A significant number of people with type 2 diabetes who should have been prescribed aspirin for secondary prevention were not receiving it at the time of study assessment. In contrast, a substantial proportion who did not meet criteria for aspirin use was prescribed it for primary prevention.

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