XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

This new edition of Ann Bowling's well-known and highly respected text has been thoroughly revised and updated to reflect key methodological developments in health research. It is a comprehensive, easy to read, guide to the range of methods used to study and evaluate health and health services. It describes the concepts and methods used by the main disciplines involved in health research, including: demography, epidemiology, health economics, psychology and sociology.The research methods described cover the assessment of health needs, morbidity and mortality trends and rates, costing health services, sampling for survey research, cross-sectional and longitudinal survey design, experimental methods and techniques of group assignment, questionnaire design, interviewing techniques, coding and analysis of quantitative data, methods and analysis of qualitative observational studies, and types of unstructured interviewing. With new material on topics such as cluster randomization, utility analyses, patients' preferences, and perception of risk, the text is aimed at students and researchers of health and health services. It has also been designed for health professionals and policy makers who have responsibility for applying research findings in practice, and who need to know how to judge the value of that research.

Research Methods in Health. Investigating health and health services

This study aimed to review the literature describing and quantifying time lags in the health research translation process. Papers were included in the review if they quantified time lags in the development of health interventions. The study identified 23 papers. Few were comparable as different studies use different measures, of different things, at different time points. We concluded that the current state of knowledge of time lags is of limited use to those responsible for R&D and knowledge transfer who face difficulties in knowing what they should or can do to reduce time lags. This effectively ‘blindfolds’ investment decisions and risks wasting effort. The study concludes that understanding lags first requires agreeing models, definitions and measures, which can be applied in practice. A second task would be to develop a process by which to gather these data.

The Answer Is 17 Years, What Is the Question

Evaluating the quality of medical care.

Health At A Glance

Background Research suggests that variation in laboratory requesting patterns may indicate unnecessary test use. Requesting patterns for serum immunoglobulins vary significantly between General Practitioners (GPs). This study aims to explore GP views on testing to identify the determinants of behaviour and recommend feasible intervention strategies for improving immunoglobulin test use in General Practice. Methods Qualitative semi-structured interviews were conducted with GPs requesting laboratory tests at Cork University Hospital or Kerry General Hospital in the South of Ireland. GPs were identified using a Health Service Executive laboratory list of GPs in the Cork-Kerry region. A random sample (stratified by GP requesting patterns) of GPs was generated from this list. GPs were purposively sampled based on the sampling criteria of: location (urban/rural); length of time qualified; and practice size (single-handed/group). Interviews were carried out between December 2014 and February 2015. Interviews were transcribed verbatim using NVivo 10 software, and analysed iteratively using thematic analysis. Emerging themes were then mapped to the theoretical domains framework (TDF), which identifies 12 domains that can enable or inhibit behaviour change. The behaviour change wheel and behaviour change technique (BCT) taxonomy were then used to recommend potential intervention strategies. Results Sixteen GPs were interviewed, including ten males and six females. Preliminary analysis, using the TDF and BCT taxonomy, found that serum immunoglobulin test use in General Practice is influenced by many social and contextual factors. The main domains from the TDF which emerged were: ‘knowledge’, ‘environmental context and resources’, ‘social influences’, ‘beliefs about capabilities’, ‘beliefs about consequences’, with the findings identifying a need for ‘shaping knowledge’. In particular, GPs identified education and feedback strategies as feasible interventions to change their behaviour. Conclusion This study identified GP challenges with serum Immunoglobulin testing, which included difficulty interpreting test results, patient expectations, personal experiences, and the lack of implementation of guidelines and knowledge about when to test for serum immunoglobulins. Study findings and the application of the TDF and BCT taxonomy, will inform the development of a feasible intervention for improving immunoglobulin test use in General Practice.

https://jech.bmj.com/content/jech/69/Suppl_1/A57.1.full.pdf

PP10 General practitioners’ attitudes towards serum immunoglobulin testing in the south of ireland: a qualitative study

Background and objective Ireland does not have a national strategy for diabetes management akin to policy frameworks developed in other European countries. In 2006, the Irish Health Service Executive (HSE) established an Expert Advisory Group for diabetes, to act ‘as the HSE’s primary source of operational policy and strategic advice9. The aim of this study is to examine the Diabetes Expert Advisory Group (EAG) process as an instrumental case study of policy formulation in the health service. Methods A case description was built through interviews and documentary analysis. Fifteen in-depth interviews were conducted with a purposive sample of EAG members. The topic guide was informed by three theories of policy formulation; Rational Model of Decision Making (1), Advocacy Coalition Framework (ACF) (2) and Multiple Streams Theory (3). Thematic analysis was conducted using the theoretical assumptions as analytical tools. NVIVO software was used for data management. Results Preliminary analysis suggests the EAG followed a sequential process; identifying priorities, developing recommendations and proposing a strategy for approval by the HSE. However the rational model of decision-making became less relevant as the process moved from approval to implementation. There was lack of clarity around what constituted a decision and who made decisions in the health system. ACF theory assumes ‘advocacy coalitions’ share ‘policy core beliefs’ although members may disagree about secondary beliefs. This fits with accounts of the EAG process; “I think we were all there with the same purpose but how we went about it, how the problem is going to be solved might be slightly different…” The economic recession could be considered an ‘external shock’ which constrained the resources available to the group and pushed implementation down the agenda. The Multiple Streams Theory identifies three streams in the policy arena (problem, policy, politics). By 2006 the problem of diabetes had been well established with an international evidence base informing the management of the illness (policy). However the political commitment (politics) to the EAG recommendations faded as the implications emerged; “in order to do it the way other countries do it, it is going to require investment. Our first report sketched out the sort of investment it might need and I think that just frightened them off.” Conclusions Different aspects of the policy formulation process were highlighted and hidden by applying an ‘alternative lens’ perspective (4). The story of the Diabetes EAG illuminates broader policy issues including the role of evidence in health policy, the impact of external events on decision making and the gap between decision-making and implementation.

https://jech.bmj.com/content/jech/65/Suppl_2/A2.2.full.pdf

Policy formulation in the health system: A case study of the Expert Advisory Group for Diabetes

Experiences of lifestyle management and support during pregnancy: a qualitative study of the attitudes and experiences of pregnant women and healthcare professionals

IDEAs study recruitment flyers

Deprescribing is associated with positive health outcomes for older adults in long-term care (LTC), however deprescribing is not universally implemented. The primary aim of this study was to estimate the prevalence of potentially inappropriate medications (PIMs) prescribed to frail older adults in Irish long-term care facilities (LTCFs), as identified by the Screening Tool of Older Persons Prescriptions in Frail adults with limited life expectancy, version 2 (STOPPFrail v2). A retrospective chart review was conducted in two publicly funded LTCFs in Ireland. Eligible participants were those (1) ≥ 65 years of age; (2) resident in a LTCF; (3) eligible as per the STOPPFrail v2 criteria by the site’s Medical Officer; and (4) receiving regular medication. Data collected included age, sex, drug, dose, frequency, regular/pro re nata prescribing and indication/relevant diagnoses. Rates of polypharmacy (taking five or more medications) and excessive polypharmacy (taking 10 or more medications) were calculated. STOPPFrail v2 was used to identify PIMs; however, clinical measurements were not taken. Descriptive and association statistics were calculated. Of the 103 residents, 89 were ≥ 65 years of age and categorised as frail and were therefore eligible for inclusion in the study. Of those eligible, 85 (95.5%) had polypharmacy and 57 (64%) experienced excessive polypharmacy. The mean number of regular medications was 10.8 (± 3.8), total medications 17.7 (± 5) and diagnoses 5.5 (± 2.5). The mean number of PIMs per resident was 4.8 (± 2.6). Of the eligible participants, 59.6% had at least one medicine without a documented indication, while 61.8%, 42.7% and 30.3% had at least one PIM from the vitamin D, antihypertensives and proton pump inhibitors drug classes, respectively. Medication and PIM use was high among LTC residents, with inappropriate polypharmacy of concern. Lack of clear indication for prescribing medications appears to be an issue in LTC, potentially affecting healthcare professionals’ engagement with deprescribing. The prevalence of PIMs may be overestimated in the antihypertensives/antidiabetic classes due to the lack of clinical measurements. 

/pdf/identification-of-potentially-inappropriate-medications-in-2svq6c5u.pdf

Sheena McHugh

Papers

PP10 General practitioners’ attitudes towards serum immunoglobulin testing in the south of ireland: a qualitative study

Policy formulation in the health system: A case study of the Expert Advisory Group for Diabetes

Experiences of lifestyle management and support during pregnancy: a qualitative study of the attitudes and experiences of pregnant women and healthcare professionals

IDEAs study recruitment flyers

Identification of Potentially Inappropriate Medications in Frail Older Adults Residing in Long-Term Care: A Retrospective Chart Review Study