Structuring complexity? A systemic perspective on the implementation of a disease management programme for type II diabetes care in Denmark

Chronic diseases are major causes of death and reduction in the quality of life worldwide, and their prevalence is expected to rise due to changing demographics. Disease management programmes (DMPs) have been presented as a policy response to challenges of care coordination for such chronic diseases. This paper investigates the implementation of DMPs in a National Health Care system in the Nordic region using type II diabetes as an example. DMPs are detailed descriptions of the sequence and responsibilities for diagnostic, treatment, rehabilitation and prevention procedures. The paper applies a systemic implementation perspective to provide detailed analysis of implementation progress, issues and concerns. The implementation analysis shows that the framework of DMP has facilitated the development of new practices and attention to the roles that each of the stakeholders are playing within the service delivery. Many new initiatives contribute to improved coordination and overall management of the Type 2 diabetes (T2DB) population. Yet, there are also several cross-cutting challenges that are affecting the implementation process.

Bionomics of Scolytus schevyrewi (Coleoptera: Curculionidae) in Saskatchewan and Manitoba, Canada

The invasive alien Scolytus schevyrewi Semenov (Coleoptera: Curculionidae: Scolytinae) was detected in Saskatchewan and Manitoba, Canada, in 2007. Because S. schevyrewi is a potential vector of the Dutch elm disease pathogen (Ophiostomanovo-ulmi Brasier; Fungi: Ophiostomataceae), the natural history of the beetle was studied from 2009 to 2012 in the two provinces, where the disease is managed to protect Ulmus americana Linnaeus (Ulmaceae). Typically, healthy trees become infected when their xylem is contacted during feeding by spore-bearing scolytine adults that have flown from a diseased tree; adults emerging from brood galleries in diseased trees frequently carry spores. We caught flying S. schevyrewi adults from May to October; adults were weakly attracted to healthy Ulmus Linnaeus but were strongly attracted to Ulmus pumila Linnaeus stressed by girdling. Scolytus schevrewi colonised and completed development in girdled trees and trap logs of U. pumila. In contrast to other studies, U. americana – the major source of pathogen spores in the area – was never colonised as a brood host. Our results suggest that S. schevyrewi will primarily use U. pumila, which, in Manitoba and Saskatchewan, seldom exhibits symptoms of Dutch elm disease. Thus, arrival of S. schevyrewi does not appear to require changes to Dutch elm disease management programmes.

Patterns of morbidity and multimorbidity associated with early and late readmissions in an Australian regional health service

Objectives To describe morbidity and multimorbidity patterns among adults readmitted to an Australian regional health service, in terms of occurrence of the same and different morbidities at index admission and readmission. Methods This cohort study used hospital admissions data for patients admitted between 1 July 2014 and 30 June 2016 to estimate proportions of unplanned readmissions (‘early’ within 30 days and ‘late’ within 1–6 months) with the same and different morbidities as the index admission. Readmission rates were estimated by selected sociodemographic, admission and diagnostic characteristics. Results The majority of early and late readmissions were in different diagnostic groups and for different primary morbidities to the index admission. Only 38.8% of readmissions were in the same major diagnostic group as the index admission and 18.4% in the same Adjacent Diagnosis-Related Group. Twenty one percent of admitted patients were readmitted within six months, with this increasing to 35.3% among multimorbid patients. Conclusion With increasing prevalence of multimorbidity, particularly among those at increased risk of readmission, it is essential to step away from a single disease focus in the design of both hospital avoidance and chronic disease management programmes. Holistic interventions and strategies that address multiple chronic conditions are required.

Overestimation of Risk and Increased Fear of Long-term Complications of Diabetes in People with Type 1 and 2 Diabetes

AbstrAct Objective The quality report of the disease management programmes of North Rhine Westphalia 2016 showed prevalences for long-term complications (neuropathy, nephropathy, retinopathy) of less than 30% for people with diabetes type 1 (DM1) and type 2 (DM2). The aim of this study was to assess risk expectations and fear regarding long-term complications of diabetes in people with DM1 and DM2. Methods We assessed risk expectations and fear regarding diabetes complications in people with DM1 (n=110) and DM2 (n=143 without insulin, n=249 with insulin) visiting an University outpatient department of metabolic diseases. Fear of long-term complications was measured with the “Fear of Complications Questionnaire (FCQ)” (range 0–45 points, scores ≥30 suggest elevated fear). Participants were asked to estimate general and personal risks of long-term complications 10 years after developing diabetes in %. Results Elevated fear of complications (FCQ scores ≥30) was observed in 34.5, 25.9, and 43.0% of those with DM1, DM2 without insulin and DM2 with insulin, respectively. Participants estimated a mean general risk of diabetes-related complications after 10 years amounting to 45.9±15.8% (DM1), 49.7±15.4% (DM2 without insulin), and 52.5±16.4% (DM2 with insulin) and personal risk with 52.5±24.4% (DM1), 45.8±22.7% (DM2 without insulin), and 54.1±23.4% (DM2 with insulin), respectively. Higher risk expectations were associated with higher fear of complications (p<0.001). Conclusion Risk estimations regarding long-term complications were exaggerated in people with DM1 and DM2. About one third of the participants reported elevated fear of complications. Participants’ risk expectations and fear regarding diabetes complications appear excessive compared to population-based prevalence rates.

The New Heart Failure Association Definition of Advanced Heart Failure

The clinical course of heart failure is characterised by progressive worsening of cardiac function and symptoms. Patients progress to a condition where traditional treatment is no longer effective and advanced therapies, such as mechanical circulatory support, heart transplantation and/or palliative care, are needed. This condition is called advanced chronic heart failure. The Heart Failure Association first defined it in 2007 and this definition was updated in 2018. The updated version emphasises the role of comorbidities, including tachyarrhythmias, and the role of heart failure with preserved ejection fraction. Improvements in mechanical circulatory support technology and better disease management programmes are major advances and are radically changing the management of these patients.

‘More constricting than inspiring’ — GPs find chronic care programmes of limited clinical utility. A qualitative study

BackgroundAs in other countries, Danish health authorities have introduced disease management programmes (DMPs) to improve care quality. These contain clinical practice guidelines (CPGs) and guidelines for patient stratification based on doctors’ assessments of disease severity and self-care. However, these programmes are challenged when patients have complex chronic conditions.AimTo explore how GPs experience the clinical applicability of disease management programmes for patients with multiple chronic conditions and lowered self-care ability.Design & settingA qualitative study from general practice, conducted in rural areas of Denmark with economically disadvantaged populations.MethodData were collected through case-based, semi-structured interviews with 12 GPs. The principles of systematic text condensation were used in the analysis.ResultsGPs found DMPs inadequate, particularly for patients with multiple conditions and lowered self-care ability. Their experience was that adhering to multiple programmes’ CPGs resulted in too much medication, conflicting treatments, an overload of appointments, and fragmented health care. They disregarded stratifying according to guidelines because they deemed stratification criteria to reflect neither patients’ need for self-care support, nor flexible referral options to hospitals and municipalities. Therefore, GPs were often solely responsible for treatment of patients with very complex chronic conditions.ConclusionGPs found DMPs to be of limited clinical applicability due to challenges related to CPGs, patient stratification, and lack of adequate health services to support patients with complex healthcare needs. To increase the benefits of these programmes, they should be more flexible, and adjusted to the needs of patients with multiple chronic conditions and lowered self-care ability.

Clinical management

Clinical management of depression includes targeted screening, comprehensive assessment, developing a therapeutic alliance, selecting treatment(s), monitoring outcomes, and regular follow up. The treatment of depression has two phases: the acute phase to achieve full remission of symptoms and restore functioning, and the maintenance phase to prevent relapse/recurrence and optimize functioning and quality of life. Measurement-based care using validated rating scales to guide clinical decisions can improve patient outcomes. Self-management by patients is an important component of disease management programmes for depression. Self-management can be enhanced by books and e-health resources, including internet information sites and health applications and emerging mobile apps for tablets and smartphones.