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Despite the rapid growth of evidence on quality improvement (QI) strategies for improving diabetes care, much research has focused on single strategies, whereas, in typical practice, multiple strategies are used concurrently.[[1–5]] In New Zealand the Quality Standards for Diabetes Care Toolkit 2014 referred to the requirements for basic care;[[6]] self-management and patient education are outlined in other resources.[[6,7]] It remains unclear which strategies are more effective relative to each other or in combination.[[8]]

We conducted a non-systematic scan of the literature to identify QI strategies that can improve diabetes care in general practices. We identified a systematic review and meta-analysis by Tricco et al comparing the effectiveness of 11 QI strategies to improve intermediate outcomes in diabetes.[[9]] The study included more than 140 randomised controlled trials and showed that QI strategies could significantly improve HbA1c, LDL cholesterol, blood pressure, aspirin use, antihypertensive drug use, retinopathy screening, renal screening and foot screening. The effectiveness of some strategies varied with baseline HbA1c. For instance: team changes, case management, patient education and self-management support were more effective when the HbA1c was greater than 64mmol/mol (8.0%). The most effective strategies for patients with HbA1c less than 64mmol/mol were team changes, patient reminders and an electronic patient register.

We assume that improvements in health outcomes due to QI strategies depend on how well QI interventions are implemented within a given practice; therefore, assessing the level of implementation of QI strategies (and improving if needed) is an integral step to improving patient outcomes. Our study aims to describe the level of implementation of the six most effective of the QI strategies (for HbA1c reduction) outlined in Tricco et al’s study:

  1. self-management support
  2. team changes
  3. case management
  4. patient education
  5. electronic patient register
  6. patient reminders.

The study describes the variation between general practices and some of the challenges faced by clinical teams during the implementation process.

Methods

Study design, procedures and participants

This study is reported in line with the Strengthening the Reporting of Observational Studies (STROBE) guidelines. A survey and focus groups were conducted with health workers in general practices in South Auckland, one of the most deprived areas in New Zealand with a high prevalence of diabetes. Practices were eligible for inclusion if they had been included in a QI programme supported by the local district health board (DHB) and in which each practice had implemented self-selected QI initiatives. Diabetes Care and Management (known as DCM) was a 12-month project using a collaborative approach within 11 practices. With support from virtual consults, shared learning and improvement facilitators within other strategies, these practices were funded to improve poorly controlled patients. Those practices have 33% of people known to have poorly controlled diabetes in the district, and they were aiming to reduce HbA1c by 10% by June 2017.[[10]] The exposure of a standardised improvement process and the commitment with the collaborative project to improve diabetes care in the community were the two main factors for being included in the present study. The study was conducted between October 2018 and January 2019, a year after the QI implementation.

We constructed a questionnaire to assess the six QI strategies. The questionnaire included questions from published and validated instruments (available at https://osf.io/e74q5/), with minor adaptations to local terminology and context based on advice from local experts. General practitioners, nurses and other healthcare workers in participating practices completed the questionnaire. Then the clinical team in each practice participated in a focus group where the goal was to reach a practice-level consensus on the same survey questions. A researcher collected individual responses and the consensus response from the clinical team in each practice, along with the notes and conclusion from the focus groups.

Questionnaire

The final questionnaire consisted of 17 questions covering six QI strategies (available at https://osf.io/2dp54/).

“Self-management support” was defined as a strategy that supports people with diabetes to develop the confidence, knowledge and skills they need to manage their condition while working in partnership with clinicians. Self-management (SM) is what patients do; self-management support (SMS) is what healthcare workers do. SM includes problem-solving and action planning. Five questions were used from two existing tools.[[11,12]]

“Team changes” refer to changes to the structure or organisation of the primary healthcare team. The most basic team consists of general practitioners and practice nurses, and “team change” is defined as adding a team member (or sharing care with practitioners) from other disciplines, such as physicians or nurse specialists, pharmacists, nutritionists and podiatrists. It also includes substantive expansion of roles for existing staff (eg, nurse or pharmacist) to include a more active role in monitoring patients or adjusting drug regimens. Three questions were used from an existing tool.[[11]]

“Case management” was defined as any system for coordinating diagnosis, treatment or routine management of patients (eg, by arrangement for referrals or follow-up of test results) by a person or multidisciplinary team in collaboration with, or supplementary to, the usual primary care clinician. Three questions were used from existing tools.[[11,13,14]]

“Patient education” was defined as interventions designed to promote greater understanding of diabetes or to teach specific prevention or treatment strategies. Examples include individual or group sessions with a health worker or professional educator, or distribution of printed or electronic educational materials and electronic resources. Two questions were used from existing tools.[[13,14]]

An “electronic patient register” was defined as an electronic medical record with an electronic tracking system for patients with diabetes. Websites were excluded unless patients were tracked over time. Two questions were used from existing tools.[[11,14]]

“Patient reminders” were defined as any effort to remind patients about upcoming appointments or important aspects of self-care. If the intervention included case management, reminders to patients needed to be explicit and a task over and above case management alone. Two questions were used from existing tools.[[11,14]]

Questionnaire scores: Questions were grouped by QI strategy and each question was scored from 0 to 11. A score of 0–2 indicated limited support, 3–5 basic support, 6–8 good support and 9–11 full support. Short vignettes described the level of support that should be designated as limited, basic, good or full.

Practice’s feedback: Questionnaire results and conclusions from the focus group were presented in each practice. The aim of the presentation was to validate the results.

Ethics

Ethics approval was given by the University of Auckland Human Participants Ethics Committee on 11 July 2018 for three years (reference 021455).

Data analysis

Question scores were summed to provide a total score by QI strategy and by practice. A radar diagram was used to visualise the practice “pattern” of strategy implementation, and a bubble diagram was used to compare the average scores for the QI implementation.

A summary of the qualitative data, exploring the way practices implemented each QI strategy, is presented. We allocated a de-identified code to each practice participating in the study.

Results

Six general practices were not able to participate in the study as a result of other commitments. Five general practices agreed to participate in the study, and in these practices, 29 healthcare workers (eight doctors, 17 nurses and four other health professionals) participated in the study.

Quantitative results

All practices were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders. DR201820 showed more support for patient register, patient reminders and patient education, and DR201860 focused on team changes, self-management, case management and patient education. Degrees of implementation of each strategy are represented on the radar plots shown in Figure 1.

Figure 1: Radar plots, implementation scores for each QI strategy. View Figure 1.

Not all practices showed the same support for the QI implementation (Figure 2). Two practices were supporting QI implementation very close to the average (DR201820 and DR201840), but one practice showed low implementation for all QI initiatives (DR201830 and DR201810), and another (DR201860) showed a higher degree of QI implementation then the average.

Figure 2: Summary bubble graph, support for QI implementation. Score by practice and comparison against average QI.

Qualitative results

Self-management support

The scores for implementation of SMS and case management showed basic support in most of the practices, but one was noticeably higher (full support in DR201860).

SM and SMS documentation were mostly undertaken by nurses. Some of the information was collected in consultation notes and some in care plan templates. Data collection in free-text clinical records or templates were not consistent. Delays updating records were common (typically more than a week). Patient inclusion in SM programmes was dependant on patient interest and commitment rather than practice identification and proactive inclusion. Standardisation of practice-delivered SMS programmes was not apparent in any practice. Some SMS courses were provided by the primary health organisation (PHO) and conducted outside of the practice. Those programmes were standardised but were poorly utilised by general practitioners (GPs) and patients. Patients were said to complain about not being familiar with or engaging with the clinicians delivering the PHO programmes.

The number of people working in different disciplines had recently increased in some of the practices, such as from new hires of health coaches and community healthcare workers, or from delivering SMS in partnership with GPs. Patients’ confidence and engagement was developed through face-to-face conversations and phone calls. However, one of the unresolved problems we identified was how to include patients’ families in the SMS programme. Pamphlets and other printed material were used to support SMS implementation. Despite formal training in coaching being available from PHOs or the DHB, most nurses had not received formal education or training in SMS, except for those at practice DR201860.

Cultural aspects and staff and patient ethnicity were considered to play a significant role in SM success. Clinical teams talked of their difficulties engaging with and coordinating SMS with Māori and Pacific peoples. Part of the cost of delivering SM interventions was the need to pay for venue and offer food with the sessions.

Although behaviour-change support was identified as vital to effective SM, it was not easy to access. A psychologist was available for limited hours and some PHOs had allocated temporary funding for additional psychologist input (eg, to practice DR201860). The coaching was undertaken mainly by nurses who were in formal training. In one practice this was done by a health coach who had completed formal training (practice DR201860).

Patients were receiving guidance on how to ask questions to the doctor. There was no formal assessment of outcomes, such as health literacy, so there were no data on how well patients understood their discussions with the clinical team.

Several practices noted that GPs could be reluctant to delegate clinical roles to nurses or other health professionals. Although this was considered a matter of trust and power, the main factor was the funding model. SMS requires new people in new roles with new training, all of which required financial resources that were beyond what practices could afford.

Team changes

In general, team changes (TC) received basic-good support as scored by the practices this study. The way these practices were working with patients with diabetes was based on a simple structure of GP and practice nurse. Two practices reported a podiatrist as part of the clinical team. A psychologist and social worker were reported in one of the practices, although these professionals were not employed directly in the practice.

Practices with higher scores for TC maintained regular clinical team meetings to discuss diabetes care, although frequency and time invested varied from practice to practice. It was clear that discussion between GPs and practice nurses were more frequent than between either of these and other health professionals. Even when engaged with practice patients, professionals such as podiatrists, psychologists, pharmacists, social workers and diabetes nurse specialists generally worked most of their time elsewhere, which prevented them from participating in routine meetings.

Practices estimated that, on average, patients saw one or more additional health professional (other than the GP or practice nurse) every six months. Access to such appointments was affected by co-location or referrals. However, one practice (DR201840) pointed out that, because they were intensifying actions in primary care through health coaching, it was likely that the number of referrals and visits to other professionals had decreased. This is a plausible comment that could be tested using secondary care datasets.

Few patients (between one and five per practice) were receiving home visits. Some of these visits were performed by a health worker with no formal connection to the practice. The most common reason for a home visit was the patient’s limited mobility, which was unrelated to any QI implementation. No one reported visits to patients to assess patient behaviours or needs, and this was attributed to lack of funding. The professionals most likely to visits patients at home were nurses or social workers, followed by GPs.

Case management

Case management (CM) as a QI strategy received good support from three practices (DR201820, DR201830 and DR201860) and was fully supported by two practices (DR201820 and DR201860). Overall, CM was restricted to “poorly controlled” patients. Most case managers did not have formal training in CM. Patients receiving CM were mostly referred by a GP to a nurse or health coach who then took control of coordinating practice activities for the patient. In some of the practices, the criteria for CM were standardised and explicit; in others, the process followed GP preference.

In those practice where CM was fully supported (DR201820 and DR201860), the case manager established a bridge between primary and secondary care. They coordinated services between providers and maintained communication with the patient. In the other practices, coordination and communication were not implemented in a systematic and consistent fashion. Coordination with secondary care could be problematic as it was based on inter-professional networking and informal interactions.

Those nurses with strong connections to secondary care nurses were more likely to achieve better coordination for their patients. Clinical teams in all practices were keen to participate in more planned home visits for their patients. However, restrictions in resources (number of health workers and time) and funding were the major obstacles. When a visit was performed, nurses and social workers were the most likely professionals involved.

Patient education

Practices mostly reported good implementation of patient education (PE). Most of the education to the patients was provided by nurses as printed material, with some customisation for individual patients. This section of the questionnaire provoked much discussion between GPs and nurses in most of the practices. Doctors tended to downgrade the practice score and questioned the consistency of this activity across patients. Nurses explained in detail the way they were delivering information to the patients. It was apparent that, in most practices, this work by nurses was not well known or recognised by the GPs.

According to the participants, continuity was driven by patients seeking to maintain a professional relationship with a known GP and/or practice nurse. Nevertheless, participants did not consider continuity a problem in the practices that organised care by a clinical team rather than an individual.

Electronic patient register

A patient register was readily available in all the practices. Practices reported that their electronic medical record allowed them to build queries to identify patients with diabetes, and this information was used by nurses to drive reminders and phone calls. Few doctors were using this information. One PHO provided a dashboard that supported filtering and patient-tracking, but this tool was not regularly used for planning, prioritisation or follow-up.

Patient reminders

This strategy was highly implemented by practices and mostly undertaken by nurses. Examples included reminders by text, email or patient portals to monitor glucose or mental health associated with diabetes, follow-up of test results, care plans and other important information for self-management.

Discussion

Some QI interventions might be more effective than others, but in this study, because each practice was implementing a variable combination of strategies in overlapping time frames, it was not possible to identify the contribution of a single strategy. It was clear that one practice (DR201860) had implemented QI strategies with more energy and greater resources than the other practices.

The lifestyle changes required for effective patient self-management of diabetes can be many and complex. Adherence to treatment and sustained changes in lifestyle reflect high self-efficacy, which is itself a prognostic factor for successful management of diabetes.[[15]] Implementation of SMS in the current sample of practices was quite limited. Fully implemented SMS is a coaching model run by expert peer champions and supported by expert healthcare coaches (GPs, nurses, dietitians, psychologists and others), following a standardised intervention.[[16,17]] It became clear in the focus groups that the level of education of the clinical team in coaching was limited, and there was no evidence of patient champions.

In the current sample of practices there was low implementation of team changes. Diabetes management is time and labour intensive for clinical teams, especially when strategies were focused on patient education, lifestyle changes and increased participation of the patient in decision-making and engagement. Hence most health systems were exploring the use of non-physician care delivery to people with chronic conditions. Team changes is a QI strategy to develop multidisciplinary teams and shift responsibilities from the single physician to a team of healthcare professionals. Previous research has shown that having professionals with different experiences and educational background working in a collaborative environment can improve patient outcomes and lower costs.[[18]]

The research participants acknowledged the challenges and barriers to developing the role of other health workers in primary care, especially expanding the role of practice nurses, a factor also found consistently in the literature.[[19–21]] The lack of linkages between primary care practices and the community through home visits or community-based resources was also identified in this study, despite the current evidence on the benefits of this relationship in terms of patient outcomes.[[22,23]]

Incorporating practice nurses in diabetes management has been reported to show high levels of patient satisfaction and greater engagement with their treatment.[[24]] Participants in the current study recognised and supported case management as a way to improve patient outcomes. Nursing was the most common profession managing those complex cases. Two practices (DR201840 and DR201860) had a dedicated nurse to plan and coordinate care for patients with higher levels of HbA1c (>8.5% or 69mmol/mol). Participants suggested that the effectiveness of this QI strategy could be measured by the percentage of patients engaged in their treatment and follow-up, which is consistent with research evidence.[[25,26]]

Diabetes management focuses on lifestyle changes and risk-factor modification, which requires intensive engagement of patients and providers in education processes.[[27]] The effectiveness of individual education for patients in terms of clinical, psychosocial and behavioural outcomes has been confirmed.[[28]] Practices in the current study supported patient education; nurses were heavily involved in this task.

A high-quality and appropriately used register of patients can contribute to reducing the risk of diabetes complications.[[29]] In the current study, most of the practices reported access to a patient register, which may have been paper-based or a computer dashboard. However, use of any register was limited to nursing groups, and we found limited evidence that they were using this tool for tracking or planning purposes. There is a need to standardise the tools and the processes.[[30 31]]

Patient reminders through phone calls and text messaging were well accepted and implemented. In the literature this strategy has shown positive results in young adults (teenagers) with diabetes, but evidence relating to the patient populations served in the current study is more limited.[[32]]

This study has several limitations. The number of practices and healthcare professionals involved was small. We depended on self-report from the practice teams, and we assumed that education delivered was equivalent across the practices given similar levels of training of those delivering the education. The duration of the intervention was not consistent across the practices and the definitions and documentation of each QI was not standardised across the practices. In the future, each QI strategy should be carefully described ahead of implementation in order to increase the reliability of comparisons. It is possible that practice composition, such as whether a psychologist or social worker is present, influenced some of the QI initiatives and patient outcomes, but we were not able to comment further given the limited number of practices that included those professionals.

Conclusions

Being able to measure implementation of QI strategies is a basic requirement for effective and sustained implementation. We assessed the level of implementation of six QI strategies in five practices. Practices engaged well with the assessment. Results were confirmed by the practices and appear to be plausible and discriminating between practices.

Funding

This research was founded by a research grant, Te Rangahau Puawai, from Counties Manukau District Health Board.

Role of the funding source

The funder was not involved in the designing the study, collecting or interpreting data, decision to publish or writing the manuscript.

Summary

Abstract

Aim

Our study aims to describe the level of implementation of six QI strategies for improving primary care of diabetes (self-management support, team changes, case management, patient education, electronic patient registers and patient reminders).

Method

A survey and focus groups were conducted between October 2018 and January 2019. We invited eleven general practices in South Auckland, New Zealand. We constructed a questionnaire assessing six QI initiatives, adapting questionnaire items from published instruments. A summary score was calculated by QI strategy and by practice.

Results

Five practices participated. All were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders, but type and level of implementations varied between the practices. The scoring system discriminated between practices with respect to both individual strategies and the practice summary score. Practices engaged well with the assessment. Results were reported back to practices who confirmed that the scoring was plausible. The study describes key features and challenges during the implementation process.

Conclusion

It is important to measure implementation of QI strategies. In this study of five practices, the instrument developed, and the associated measurement processes, were acceptable to practices and the results appear discriminatory and plausible.

Author Information

Nelson Aguirre-Duarte: Faculty of Medicine, Health Systems Department, School of Population Health, The University of Auckland, Auckland, New Zealand. John Øvretveit: Health Care Improvement Implementation and Evaluation, Medical Management Centre, The Karolinska Institute, Stockholm. Timothy Kenealy: Faculty of Medicine, The University of Auckland, Auckland, New Zealand.

Acknowledgements

The authors wish to thank Dr Brandon Orr-Walker, Dr Tim Hou, Dr Tana Fishman, Pauline Sanders and Professor Nicolette Sheridan for advice and discussion about aspects of conducting the study, and the staff at the five practices who took the time to participate in our study.

Correspondence

Dr Nelson Aguirre-Duarte, Faculty of Medicine, Health Systems Department, School of Population Health, The University of Auckland, Auckland, New Zealand

Correspondence Email

n.aguirre@auckland.ac.nz

Competing Interests

Dr Aguirre-Duarte reports grants from Counties Manukau District Health Board during the conduct of the study.

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3) Norris SL, Nichols PJ, Caspersen CJ, et al. The effectiveness of disease and case management for people with diabetes: A systematic review. American Journal of Preventive Medicine. 2002;22(4):15-38. doi: 10.1016/S0749-3797(02)00423-3

4) Balas AE, Krishna AS, Kretschmer RR, et al. Computerized Knowledge Management in Diabetes Care. Medical Care. 2004;42(6):610-21. doi: 10.1097/01.mlr.0000128008.12117.f8

5) Knight K, Badamgarav E, Henning JM, et al. A systematic review of diabetes disease management programs. Am J Manag Care. 2005;11(4):242-50.

6) New Zealand Ministry of Health. Quality Standards for Diabetes Cae Toolkit, 2014.

7) New Zealand Guidelines Group. Primary Care Handbook 3rd ed, 2012.

8) Shojania KG, Ranji SR, McDonald KM, et al. Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control A Meta-Regression Analysis. American Medical Association. 2006;296(4).

9) Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta- analysis. The Lancet. 2012;379(9833):2252-61. doi: 10.1016/S0140-6736(12)60480-2

10) CMDHB. Diabetes Care and Management in the Community 2020. Available from: https://www.countiesmanukau.health.nz/for-health-professionals/primary-care-information/diabetes-care/

11) Bonomi AE, Wagner EH, Glasgow RE, et al. Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement. Health services research. 2002;37(3):791-820.

12) Greenfield S, Kaplan S, Ware Jr JE. Expanding patient involvement in care: effects on patient outcomes. Annals of internal medicine. 1985;102(4):520-28.

13) Pearce G, Parke HL, Pinnock H, et al. The PRISMS taxonomy of self-management support: derivation of a novel taxonomy and initial testing of its utility. Journal of health services research & policy. 2016;21(2):73-82.

14) Bodenheimer T, Ghorob A, Willard-Grace R, et al. The 10 building blocks of high-performing primary care. The Annals of Family Medicine. 2014;12(2):166-71.

15) Barlow J, Wright C, Sheasby J, et al. Self-management approaches for people with chronic conditions: a review. Patient education and counseling. 2002;48(2):177-87.

16) Haas L, Maryniuk M, Beck J, et al. National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2014;37(Supplement 1):S144-S53. doi: 10.2337/dc14-S144

17) Van der Wulp I, de Leeuw J, Gorter K, et al. Effectiveness of peer‐led self‐management coaching for patients recently diagnosed with type 2 diabetes mellitus in primary care: A randomized controlled trial. Diabetic Medicine. 2012;29(10):e390-e97.

18) Litaker D, MION LC, Planavsky L, et al. Physician–nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care. Journal of interprofessional care. 2003;17(3):223-37.

19) Bosley S, Dale J. Healthcare assistants in general practice: practical and conceptual issues of skill-mix change. Br J Gen Pract. 2008;58(547):118-24.

20) Lockwood C. Nurses as substitutes for doctors in primary care. International journal of nursing studies. 2020;106:103362.

21) Maier CB, Aiken LH. Task shifting from physicians to nurses in primary care in 39 countries: a cross-country comparative study. European journal of public health. 2016;26(6):927-34.

22) Noël PH, Wang C-P, Finley EP, et al. Provider-Related Linkages Between Primary Care Clinics and Community-Based Senior Centers Associated With Diabetes-Related Outcomes. Journal of Applied Gerontology. 2020;39(6):635-43.

23) Noel PH, Romero RL, Robertson M, et al. Key activities used by community based primary care practices to improve the quality of diabetes care in response to practice facilitation. Quality in primary care. 2014;22(4):211-9.

24) Watts SA, Sood A. Diabetes nurse case management: Improving glucose control: 10 years of quality improvement follow-up data. Applied nursing research: ANR. 2016;29:202-5. doi: 10.1016/j.apnr.2015.03.011

25) Ishani A, Greer N, Taylor BC, et al. Effect of Nurse Case Management Compared With Usual Care on Controlling Cardiovascular Risk Factors in Patients With Diabetes. A randomized controlled trial. 2011;34(8):1689-94. doi: 10.2337/dc10-2121

26) Li D, Elliott T, Klein G, et al. Diabetes Nurse Case Management in a Canadian Tertiary Care Setting: Results of a Randomized Controlled Trial. Canadian journal of diabetes. 2017;41(3):297-304.

27) Adams RJ. Improving health outcomes with better patient understanding and education. Risk management and healthcare policy. 2010;3:61.

28) Sperl-Hillen J, Beaton S, Fernandes O, et al. Comparative Effectiveness of Patient Education Methods for Type 2 Diabetes: A Randomized Controlled Trial. JAMA Internal Medicine. 2011;171(22):2001-10. doi: 10.1001/archinternmed.2011.507

29) Peterson LE, Blackburn B, Phillips RL, et al. Improving quality of care for diabetes through a maintenance of certification activity: family physicians' use of the chronic care model. The Journal of continuing education in the health professions. 2014;34(1):47-55. doi: 10.1002/chp.21216

30) Peterson A, Gudbjornsdottir S, Lofgren UB, et al. Collaboratively Improving Diabetes Care in Sweden Using a National Quality Register: Successes and Challenges-A Case Study. Quality management in health care. 2015;24(4):212-21. doi: 10.1097/qmh.0000000000000068

31) Hallgren Elfgren IM, Grodzinsky E, Tornvall E. Swedish Diabetes Register, a tool for quality development in primary health care. Primary health care research & development. 2013;14(3):250-7. doi: 10.1017/s1463423612000515

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Despite the rapid growth of evidence on quality improvement (QI) strategies for improving diabetes care, much research has focused on single strategies, whereas, in typical practice, multiple strategies are used concurrently.[[1–5]] In New Zealand the Quality Standards for Diabetes Care Toolkit 2014 referred to the requirements for basic care;[[6]] self-management and patient education are outlined in other resources.[[6,7]] It remains unclear which strategies are more effective relative to each other or in combination.[[8]]

We conducted a non-systematic scan of the literature to identify QI strategies that can improve diabetes care in general practices. We identified a systematic review and meta-analysis by Tricco et al comparing the effectiveness of 11 QI strategies to improve intermediate outcomes in diabetes.[[9]] The study included more than 140 randomised controlled trials and showed that QI strategies could significantly improve HbA1c, LDL cholesterol, blood pressure, aspirin use, antihypertensive drug use, retinopathy screening, renal screening and foot screening. The effectiveness of some strategies varied with baseline HbA1c. For instance: team changes, case management, patient education and self-management support were more effective when the HbA1c was greater than 64mmol/mol (8.0%). The most effective strategies for patients with HbA1c less than 64mmol/mol were team changes, patient reminders and an electronic patient register.

We assume that improvements in health outcomes due to QI strategies depend on how well QI interventions are implemented within a given practice; therefore, assessing the level of implementation of QI strategies (and improving if needed) is an integral step to improving patient outcomes. Our study aims to describe the level of implementation of the six most effective of the QI strategies (for HbA1c reduction) outlined in Tricco et al’s study:

  1. self-management support
  2. team changes
  3. case management
  4. patient education
  5. electronic patient register
  6. patient reminders.

The study describes the variation between general practices and some of the challenges faced by clinical teams during the implementation process.

Methods

Study design, procedures and participants

This study is reported in line with the Strengthening the Reporting of Observational Studies (STROBE) guidelines. A survey and focus groups were conducted with health workers in general practices in South Auckland, one of the most deprived areas in New Zealand with a high prevalence of diabetes. Practices were eligible for inclusion if they had been included in a QI programme supported by the local district health board (DHB) and in which each practice had implemented self-selected QI initiatives. Diabetes Care and Management (known as DCM) was a 12-month project using a collaborative approach within 11 practices. With support from virtual consults, shared learning and improvement facilitators within other strategies, these practices were funded to improve poorly controlled patients. Those practices have 33% of people known to have poorly controlled diabetes in the district, and they were aiming to reduce HbA1c by 10% by June 2017.[[10]] The exposure of a standardised improvement process and the commitment with the collaborative project to improve diabetes care in the community were the two main factors for being included in the present study. The study was conducted between October 2018 and January 2019, a year after the QI implementation.

We constructed a questionnaire to assess the six QI strategies. The questionnaire included questions from published and validated instruments (available at https://osf.io/e74q5/), with minor adaptations to local terminology and context based on advice from local experts. General practitioners, nurses and other healthcare workers in participating practices completed the questionnaire. Then the clinical team in each practice participated in a focus group where the goal was to reach a practice-level consensus on the same survey questions. A researcher collected individual responses and the consensus response from the clinical team in each practice, along with the notes and conclusion from the focus groups.

Questionnaire

The final questionnaire consisted of 17 questions covering six QI strategies (available at https://osf.io/2dp54/).

“Self-management support” was defined as a strategy that supports people with diabetes to develop the confidence, knowledge and skills they need to manage their condition while working in partnership with clinicians. Self-management (SM) is what patients do; self-management support (SMS) is what healthcare workers do. SM includes problem-solving and action planning. Five questions were used from two existing tools.[[11,12]]

“Team changes” refer to changes to the structure or organisation of the primary healthcare team. The most basic team consists of general practitioners and practice nurses, and “team change” is defined as adding a team member (or sharing care with practitioners) from other disciplines, such as physicians or nurse specialists, pharmacists, nutritionists and podiatrists. It also includes substantive expansion of roles for existing staff (eg, nurse or pharmacist) to include a more active role in monitoring patients or adjusting drug regimens. Three questions were used from an existing tool.[[11]]

“Case management” was defined as any system for coordinating diagnosis, treatment or routine management of patients (eg, by arrangement for referrals or follow-up of test results) by a person or multidisciplinary team in collaboration with, or supplementary to, the usual primary care clinician. Three questions were used from existing tools.[[11,13,14]]

“Patient education” was defined as interventions designed to promote greater understanding of diabetes or to teach specific prevention or treatment strategies. Examples include individual or group sessions with a health worker or professional educator, or distribution of printed or electronic educational materials and electronic resources. Two questions were used from existing tools.[[13,14]]

An “electronic patient register” was defined as an electronic medical record with an electronic tracking system for patients with diabetes. Websites were excluded unless patients were tracked over time. Two questions were used from existing tools.[[11,14]]

“Patient reminders” were defined as any effort to remind patients about upcoming appointments or important aspects of self-care. If the intervention included case management, reminders to patients needed to be explicit and a task over and above case management alone. Two questions were used from existing tools.[[11,14]]

Questionnaire scores: Questions were grouped by QI strategy and each question was scored from 0 to 11. A score of 0–2 indicated limited support, 3–5 basic support, 6–8 good support and 9–11 full support. Short vignettes described the level of support that should be designated as limited, basic, good or full.

Practice’s feedback: Questionnaire results and conclusions from the focus group were presented in each practice. The aim of the presentation was to validate the results.

Ethics

Ethics approval was given by the University of Auckland Human Participants Ethics Committee on 11 July 2018 for three years (reference 021455).

Data analysis

Question scores were summed to provide a total score by QI strategy and by practice. A radar diagram was used to visualise the practice “pattern” of strategy implementation, and a bubble diagram was used to compare the average scores for the QI implementation.

A summary of the qualitative data, exploring the way practices implemented each QI strategy, is presented. We allocated a de-identified code to each practice participating in the study.

Results

Six general practices were not able to participate in the study as a result of other commitments. Five general practices agreed to participate in the study, and in these practices, 29 healthcare workers (eight doctors, 17 nurses and four other health professionals) participated in the study.

Quantitative results

All practices were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders. DR201820 showed more support for patient register, patient reminders and patient education, and DR201860 focused on team changes, self-management, case management and patient education. Degrees of implementation of each strategy are represented on the radar plots shown in Figure 1.

Figure 1: Radar plots, implementation scores for each QI strategy. View Figure 1.

Not all practices showed the same support for the QI implementation (Figure 2). Two practices were supporting QI implementation very close to the average (DR201820 and DR201840), but one practice showed low implementation for all QI initiatives (DR201830 and DR201810), and another (DR201860) showed a higher degree of QI implementation then the average.

Figure 2: Summary bubble graph, support for QI implementation. Score by practice and comparison against average QI.

Qualitative results

Self-management support

The scores for implementation of SMS and case management showed basic support in most of the practices, but one was noticeably higher (full support in DR201860).

SM and SMS documentation were mostly undertaken by nurses. Some of the information was collected in consultation notes and some in care plan templates. Data collection in free-text clinical records or templates were not consistent. Delays updating records were common (typically more than a week). Patient inclusion in SM programmes was dependant on patient interest and commitment rather than practice identification and proactive inclusion. Standardisation of practice-delivered SMS programmes was not apparent in any practice. Some SMS courses were provided by the primary health organisation (PHO) and conducted outside of the practice. Those programmes were standardised but were poorly utilised by general practitioners (GPs) and patients. Patients were said to complain about not being familiar with or engaging with the clinicians delivering the PHO programmes.

The number of people working in different disciplines had recently increased in some of the practices, such as from new hires of health coaches and community healthcare workers, or from delivering SMS in partnership with GPs. Patients’ confidence and engagement was developed through face-to-face conversations and phone calls. However, one of the unresolved problems we identified was how to include patients’ families in the SMS programme. Pamphlets and other printed material were used to support SMS implementation. Despite formal training in coaching being available from PHOs or the DHB, most nurses had not received formal education or training in SMS, except for those at practice DR201860.

Cultural aspects and staff and patient ethnicity were considered to play a significant role in SM success. Clinical teams talked of their difficulties engaging with and coordinating SMS with Māori and Pacific peoples. Part of the cost of delivering SM interventions was the need to pay for venue and offer food with the sessions.

Although behaviour-change support was identified as vital to effective SM, it was not easy to access. A psychologist was available for limited hours and some PHOs had allocated temporary funding for additional psychologist input (eg, to practice DR201860). The coaching was undertaken mainly by nurses who were in formal training. In one practice this was done by a health coach who had completed formal training (practice DR201860).

Patients were receiving guidance on how to ask questions to the doctor. There was no formal assessment of outcomes, such as health literacy, so there were no data on how well patients understood their discussions with the clinical team.

Several practices noted that GPs could be reluctant to delegate clinical roles to nurses or other health professionals. Although this was considered a matter of trust and power, the main factor was the funding model. SMS requires new people in new roles with new training, all of which required financial resources that were beyond what practices could afford.

Team changes

In general, team changes (TC) received basic-good support as scored by the practices this study. The way these practices were working with patients with diabetes was based on a simple structure of GP and practice nurse. Two practices reported a podiatrist as part of the clinical team. A psychologist and social worker were reported in one of the practices, although these professionals were not employed directly in the practice.

Practices with higher scores for TC maintained regular clinical team meetings to discuss diabetes care, although frequency and time invested varied from practice to practice. It was clear that discussion between GPs and practice nurses were more frequent than between either of these and other health professionals. Even when engaged with practice patients, professionals such as podiatrists, psychologists, pharmacists, social workers and diabetes nurse specialists generally worked most of their time elsewhere, which prevented them from participating in routine meetings.

Practices estimated that, on average, patients saw one or more additional health professional (other than the GP or practice nurse) every six months. Access to such appointments was affected by co-location or referrals. However, one practice (DR201840) pointed out that, because they were intensifying actions in primary care through health coaching, it was likely that the number of referrals and visits to other professionals had decreased. This is a plausible comment that could be tested using secondary care datasets.

Few patients (between one and five per practice) were receiving home visits. Some of these visits were performed by a health worker with no formal connection to the practice. The most common reason for a home visit was the patient’s limited mobility, which was unrelated to any QI implementation. No one reported visits to patients to assess patient behaviours or needs, and this was attributed to lack of funding. The professionals most likely to visits patients at home were nurses or social workers, followed by GPs.

Case management

Case management (CM) as a QI strategy received good support from three practices (DR201820, DR201830 and DR201860) and was fully supported by two practices (DR201820 and DR201860). Overall, CM was restricted to “poorly controlled” patients. Most case managers did not have formal training in CM. Patients receiving CM were mostly referred by a GP to a nurse or health coach who then took control of coordinating practice activities for the patient. In some of the practices, the criteria for CM were standardised and explicit; in others, the process followed GP preference.

In those practice where CM was fully supported (DR201820 and DR201860), the case manager established a bridge between primary and secondary care. They coordinated services between providers and maintained communication with the patient. In the other practices, coordination and communication were not implemented in a systematic and consistent fashion. Coordination with secondary care could be problematic as it was based on inter-professional networking and informal interactions.

Those nurses with strong connections to secondary care nurses were more likely to achieve better coordination for their patients. Clinical teams in all practices were keen to participate in more planned home visits for their patients. However, restrictions in resources (number of health workers and time) and funding were the major obstacles. When a visit was performed, nurses and social workers were the most likely professionals involved.

Patient education

Practices mostly reported good implementation of patient education (PE). Most of the education to the patients was provided by nurses as printed material, with some customisation for individual patients. This section of the questionnaire provoked much discussion between GPs and nurses in most of the practices. Doctors tended to downgrade the practice score and questioned the consistency of this activity across patients. Nurses explained in detail the way they were delivering information to the patients. It was apparent that, in most practices, this work by nurses was not well known or recognised by the GPs.

According to the participants, continuity was driven by patients seeking to maintain a professional relationship with a known GP and/or practice nurse. Nevertheless, participants did not consider continuity a problem in the practices that organised care by a clinical team rather than an individual.

Electronic patient register

A patient register was readily available in all the practices. Practices reported that their electronic medical record allowed them to build queries to identify patients with diabetes, and this information was used by nurses to drive reminders and phone calls. Few doctors were using this information. One PHO provided a dashboard that supported filtering and patient-tracking, but this tool was not regularly used for planning, prioritisation or follow-up.

Patient reminders

This strategy was highly implemented by practices and mostly undertaken by nurses. Examples included reminders by text, email or patient portals to monitor glucose or mental health associated with diabetes, follow-up of test results, care plans and other important information for self-management.

Discussion

Some QI interventions might be more effective than others, but in this study, because each practice was implementing a variable combination of strategies in overlapping time frames, it was not possible to identify the contribution of a single strategy. It was clear that one practice (DR201860) had implemented QI strategies with more energy and greater resources than the other practices.

The lifestyle changes required for effective patient self-management of diabetes can be many and complex. Adherence to treatment and sustained changes in lifestyle reflect high self-efficacy, which is itself a prognostic factor for successful management of diabetes.[[15]] Implementation of SMS in the current sample of practices was quite limited. Fully implemented SMS is a coaching model run by expert peer champions and supported by expert healthcare coaches (GPs, nurses, dietitians, psychologists and others), following a standardised intervention.[[16,17]] It became clear in the focus groups that the level of education of the clinical team in coaching was limited, and there was no evidence of patient champions.

In the current sample of practices there was low implementation of team changes. Diabetes management is time and labour intensive for clinical teams, especially when strategies were focused on patient education, lifestyle changes and increased participation of the patient in decision-making and engagement. Hence most health systems were exploring the use of non-physician care delivery to people with chronic conditions. Team changes is a QI strategy to develop multidisciplinary teams and shift responsibilities from the single physician to a team of healthcare professionals. Previous research has shown that having professionals with different experiences and educational background working in a collaborative environment can improve patient outcomes and lower costs.[[18]]

The research participants acknowledged the challenges and barriers to developing the role of other health workers in primary care, especially expanding the role of practice nurses, a factor also found consistently in the literature.[[19–21]] The lack of linkages between primary care practices and the community through home visits or community-based resources was also identified in this study, despite the current evidence on the benefits of this relationship in terms of patient outcomes.[[22,23]]

Incorporating practice nurses in diabetes management has been reported to show high levels of patient satisfaction and greater engagement with their treatment.[[24]] Participants in the current study recognised and supported case management as a way to improve patient outcomes. Nursing was the most common profession managing those complex cases. Two practices (DR201840 and DR201860) had a dedicated nurse to plan and coordinate care for patients with higher levels of HbA1c (>8.5% or 69mmol/mol). Participants suggested that the effectiveness of this QI strategy could be measured by the percentage of patients engaged in their treatment and follow-up, which is consistent with research evidence.[[25,26]]

Diabetes management focuses on lifestyle changes and risk-factor modification, which requires intensive engagement of patients and providers in education processes.[[27]] The effectiveness of individual education for patients in terms of clinical, psychosocial and behavioural outcomes has been confirmed.[[28]] Practices in the current study supported patient education; nurses were heavily involved in this task.

A high-quality and appropriately used register of patients can contribute to reducing the risk of diabetes complications.[[29]] In the current study, most of the practices reported access to a patient register, which may have been paper-based or a computer dashboard. However, use of any register was limited to nursing groups, and we found limited evidence that they were using this tool for tracking or planning purposes. There is a need to standardise the tools and the processes.[[30 31]]

Patient reminders through phone calls and text messaging were well accepted and implemented. In the literature this strategy has shown positive results in young adults (teenagers) with diabetes, but evidence relating to the patient populations served in the current study is more limited.[[32]]

This study has several limitations. The number of practices and healthcare professionals involved was small. We depended on self-report from the practice teams, and we assumed that education delivered was equivalent across the practices given similar levels of training of those delivering the education. The duration of the intervention was not consistent across the practices and the definitions and documentation of each QI was not standardised across the practices. In the future, each QI strategy should be carefully described ahead of implementation in order to increase the reliability of comparisons. It is possible that practice composition, such as whether a psychologist or social worker is present, influenced some of the QI initiatives and patient outcomes, but we were not able to comment further given the limited number of practices that included those professionals.

Conclusions

Being able to measure implementation of QI strategies is a basic requirement for effective and sustained implementation. We assessed the level of implementation of six QI strategies in five practices. Practices engaged well with the assessment. Results were confirmed by the practices and appear to be plausible and discriminating between practices.

Funding

This research was founded by a research grant, Te Rangahau Puawai, from Counties Manukau District Health Board.

Role of the funding source

The funder was not involved in the designing the study, collecting or interpreting data, decision to publish or writing the manuscript.

Summary

Abstract

Aim

Our study aims to describe the level of implementation of six QI strategies for improving primary care of diabetes (self-management support, team changes, case management, patient education, electronic patient registers and patient reminders).

Method

A survey and focus groups were conducted between October 2018 and January 2019. We invited eleven general practices in South Auckland, New Zealand. We constructed a questionnaire assessing six QI initiatives, adapting questionnaire items from published instruments. A summary score was calculated by QI strategy and by practice.

Results

Five practices participated. All were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders, but type and level of implementations varied between the practices. The scoring system discriminated between practices with respect to both individual strategies and the practice summary score. Practices engaged well with the assessment. Results were reported back to practices who confirmed that the scoring was plausible. The study describes key features and challenges during the implementation process.

Conclusion

It is important to measure implementation of QI strategies. In this study of five practices, the instrument developed, and the associated measurement processes, were acceptable to practices and the results appear discriminatory and plausible.

Author Information

Nelson Aguirre-Duarte: Faculty of Medicine, Health Systems Department, School of Population Health, The University of Auckland, Auckland, New Zealand. John Øvretveit: Health Care Improvement Implementation and Evaluation, Medical Management Centre, The Karolinska Institute, Stockholm. Timothy Kenealy: Faculty of Medicine, The University of Auckland, Auckland, New Zealand.

Acknowledgements

The authors wish to thank Dr Brandon Orr-Walker, Dr Tim Hou, Dr Tana Fishman, Pauline Sanders and Professor Nicolette Sheridan for advice and discussion about aspects of conducting the study, and the staff at the five practices who took the time to participate in our study.

Correspondence

Dr Nelson Aguirre-Duarte, Faculty of Medicine, Health Systems Department, School of Population Health, The University of Auckland, Auckland, New Zealand

Correspondence Email

n.aguirre@auckland.ac.nz

Competing Interests

Dr Aguirre-Duarte reports grants from Counties Manukau District Health Board during the conduct of the study.

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3) Norris SL, Nichols PJ, Caspersen CJ, et al. The effectiveness of disease and case management for people with diabetes: A systematic review. American Journal of Preventive Medicine. 2002;22(4):15-38. doi: 10.1016/S0749-3797(02)00423-3

4) Balas AE, Krishna AS, Kretschmer RR, et al. Computerized Knowledge Management in Diabetes Care. Medical Care. 2004;42(6):610-21. doi: 10.1097/01.mlr.0000128008.12117.f8

5) Knight K, Badamgarav E, Henning JM, et al. A systematic review of diabetes disease management programs. Am J Manag Care. 2005;11(4):242-50.

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7) New Zealand Guidelines Group. Primary Care Handbook 3rd ed, 2012.

8) Shojania KG, Ranji SR, McDonald KM, et al. Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control A Meta-Regression Analysis. American Medical Association. 2006;296(4).

9) Tricco AC, Ivers NM, Grimshaw JM, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta- analysis. The Lancet. 2012;379(9833):2252-61. doi: 10.1016/S0140-6736(12)60480-2

10) CMDHB. Diabetes Care and Management in the Community 2020. Available from: https://www.countiesmanukau.health.nz/for-health-professionals/primary-care-information/diabetes-care/

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16) Haas L, Maryniuk M, Beck J, et al. National Standards for Diabetes Self-Management Education and Support. Diabetes Care. 2014;37(Supplement 1):S144-S53. doi: 10.2337/dc14-S144

17) Van der Wulp I, de Leeuw J, Gorter K, et al. Effectiveness of peer‐led self‐management coaching for patients recently diagnosed with type 2 diabetes mellitus in primary care: A randomized controlled trial. Diabetic Medicine. 2012;29(10):e390-e97.

18) Litaker D, MION LC, Planavsky L, et al. Physician–nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care. Journal of interprofessional care. 2003;17(3):223-37.

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22) Noël PH, Wang C-P, Finley EP, et al. Provider-Related Linkages Between Primary Care Clinics and Community-Based Senior Centers Associated With Diabetes-Related Outcomes. Journal of Applied Gerontology. 2020;39(6):635-43.

23) Noel PH, Romero RL, Robertson M, et al. Key activities used by community based primary care practices to improve the quality of diabetes care in response to practice facilitation. Quality in primary care. 2014;22(4):211-9.

24) Watts SA, Sood A. Diabetes nurse case management: Improving glucose control: 10 years of quality improvement follow-up data. Applied nursing research: ANR. 2016;29:202-5. doi: 10.1016/j.apnr.2015.03.011

25) Ishani A, Greer N, Taylor BC, et al. Effect of Nurse Case Management Compared With Usual Care on Controlling Cardiovascular Risk Factors in Patients With Diabetes. A randomized controlled trial. 2011;34(8):1689-94. doi: 10.2337/dc10-2121

26) Li D, Elliott T, Klein G, et al. Diabetes Nurse Case Management in a Canadian Tertiary Care Setting: Results of a Randomized Controlled Trial. Canadian journal of diabetes. 2017;41(3):297-304.

27) Adams RJ. Improving health outcomes with better patient understanding and education. Risk management and healthcare policy. 2010;3:61.

28) Sperl-Hillen J, Beaton S, Fernandes O, et al. Comparative Effectiveness of Patient Education Methods for Type 2 Diabetes: A Randomized Controlled Trial. JAMA Internal Medicine. 2011;171(22):2001-10. doi: 10.1001/archinternmed.2011.507

29) Peterson LE, Blackburn B, Phillips RL, et al. Improving quality of care for diabetes through a maintenance of certification activity: family physicians' use of the chronic care model. The Journal of continuing education in the health professions. 2014;34(1):47-55. doi: 10.1002/chp.21216

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32) Hanauer DA, Wentzell K, Laffel N, et al. Computerized Automated Reminder Diabetes System (CARDS): E-Mail and SMS Cell Phone Text Messaging Reminders to Support Diabetes Management. DIABETES TECHNOLOGY & THERAPEUTICS. 2009;11(2)

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Despite the rapid growth of evidence on quality improvement (QI) strategies for improving diabetes care, much research has focused on single strategies, whereas, in typical practice, multiple strategies are used concurrently.[[1–5]] In New Zealand the Quality Standards for Diabetes Care Toolkit 2014 referred to the requirements for basic care;[[6]] self-management and patient education are outlined in other resources.[[6,7]] It remains unclear which strategies are more effective relative to each other or in combination.[[8]]

We conducted a non-systematic scan of the literature to identify QI strategies that can improve diabetes care in general practices. We identified a systematic review and meta-analysis by Tricco et al comparing the effectiveness of 11 QI strategies to improve intermediate outcomes in diabetes.[[9]] The study included more than 140 randomised controlled trials and showed that QI strategies could significantly improve HbA1c, LDL cholesterol, blood pressure, aspirin use, antihypertensive drug use, retinopathy screening, renal screening and foot screening. The effectiveness of some strategies varied with baseline HbA1c. For instance: team changes, case management, patient education and self-management support were more effective when the HbA1c was greater than 64mmol/mol (8.0%). The most effective strategies for patients with HbA1c less than 64mmol/mol were team changes, patient reminders and an electronic patient register.

We assume that improvements in health outcomes due to QI strategies depend on how well QI interventions are implemented within a given practice; therefore, assessing the level of implementation of QI strategies (and improving if needed) is an integral step to improving patient outcomes. Our study aims to describe the level of implementation of the six most effective of the QI strategies (for HbA1c reduction) outlined in Tricco et al’s study:

  1. self-management support
  2. team changes
  3. case management
  4. patient education
  5. electronic patient register
  6. patient reminders.

The study describes the variation between general practices and some of the challenges faced by clinical teams during the implementation process.

Methods

Study design, procedures and participants

This study is reported in line with the Strengthening the Reporting of Observational Studies (STROBE) guidelines. A survey and focus groups were conducted with health workers in general practices in South Auckland, one of the most deprived areas in New Zealand with a high prevalence of diabetes. Practices were eligible for inclusion if they had been included in a QI programme supported by the local district health board (DHB) and in which each practice had implemented self-selected QI initiatives. Diabetes Care and Management (known as DCM) was a 12-month project using a collaborative approach within 11 practices. With support from virtual consults, shared learning and improvement facilitators within other strategies, these practices were funded to improve poorly controlled patients. Those practices have 33% of people known to have poorly controlled diabetes in the district, and they were aiming to reduce HbA1c by 10% by June 2017.[[10]] The exposure of a standardised improvement process and the commitment with the collaborative project to improve diabetes care in the community were the two main factors for being included in the present study. The study was conducted between October 2018 and January 2019, a year after the QI implementation.

We constructed a questionnaire to assess the six QI strategies. The questionnaire included questions from published and validated instruments (available at https://osf.io/e74q5/), with minor adaptations to local terminology and context based on advice from local experts. General practitioners, nurses and other healthcare workers in participating practices completed the questionnaire. Then the clinical team in each practice participated in a focus group where the goal was to reach a practice-level consensus on the same survey questions. A researcher collected individual responses and the consensus response from the clinical team in each practice, along with the notes and conclusion from the focus groups.

Questionnaire

The final questionnaire consisted of 17 questions covering six QI strategies (available at https://osf.io/2dp54/).

“Self-management support” was defined as a strategy that supports people with diabetes to develop the confidence, knowledge and skills they need to manage their condition while working in partnership with clinicians. Self-management (SM) is what patients do; self-management support (SMS) is what healthcare workers do. SM includes problem-solving and action planning. Five questions were used from two existing tools.[[11,12]]

“Team changes” refer to changes to the structure or organisation of the primary healthcare team. The most basic team consists of general practitioners and practice nurses, and “team change” is defined as adding a team member (or sharing care with practitioners) from other disciplines, such as physicians or nurse specialists, pharmacists, nutritionists and podiatrists. It also includes substantive expansion of roles for existing staff (eg, nurse or pharmacist) to include a more active role in monitoring patients or adjusting drug regimens. Three questions were used from an existing tool.[[11]]

“Case management” was defined as any system for coordinating diagnosis, treatment or routine management of patients (eg, by arrangement for referrals or follow-up of test results) by a person or multidisciplinary team in collaboration with, or supplementary to, the usual primary care clinician. Three questions were used from existing tools.[[11,13,14]]

“Patient education” was defined as interventions designed to promote greater understanding of diabetes or to teach specific prevention or treatment strategies. Examples include individual or group sessions with a health worker or professional educator, or distribution of printed or electronic educational materials and electronic resources. Two questions were used from existing tools.[[13,14]]

An “electronic patient register” was defined as an electronic medical record with an electronic tracking system for patients with diabetes. Websites were excluded unless patients were tracked over time. Two questions were used from existing tools.[[11,14]]

“Patient reminders” were defined as any effort to remind patients about upcoming appointments or important aspects of self-care. If the intervention included case management, reminders to patients needed to be explicit and a task over and above case management alone. Two questions were used from existing tools.[[11,14]]

Questionnaire scores: Questions were grouped by QI strategy and each question was scored from 0 to 11. A score of 0–2 indicated limited support, 3–5 basic support, 6–8 good support and 9–11 full support. Short vignettes described the level of support that should be designated as limited, basic, good or full.

Practice’s feedback: Questionnaire results and conclusions from the focus group were presented in each practice. The aim of the presentation was to validate the results.

Ethics

Ethics approval was given by the University of Auckland Human Participants Ethics Committee on 11 July 2018 for three years (reference 021455).

Data analysis

Question scores were summed to provide a total score by QI strategy and by practice. A radar diagram was used to visualise the practice “pattern” of strategy implementation, and a bubble diagram was used to compare the average scores for the QI implementation.

A summary of the qualitative data, exploring the way practices implemented each QI strategy, is presented. We allocated a de-identified code to each practice participating in the study.

Results

Six general practices were not able to participate in the study as a result of other commitments. Five general practices agreed to participate in the study, and in these practices, 29 healthcare workers (eight doctors, 17 nurses and four other health professionals) participated in the study.

Quantitative results

All practices were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders. DR201820 showed more support for patient register, patient reminders and patient education, and DR201860 focused on team changes, self-management, case management and patient education. Degrees of implementation of each strategy are represented on the radar plots shown in Figure 1.

Figure 1: Radar plots, implementation scores for each QI strategy. View Figure 1.

Not all practices showed the same support for the QI implementation (Figure 2). Two practices were supporting QI implementation very close to the average (DR201820 and DR201840), but one practice showed low implementation for all QI initiatives (DR201830 and DR201810), and another (DR201860) showed a higher degree of QI implementation then the average.

Figure 2: Summary bubble graph, support for QI implementation. Score by practice and comparison against average QI.

Qualitative results

Self-management support

The scores for implementation of SMS and case management showed basic support in most of the practices, but one was noticeably higher (full support in DR201860).

SM and SMS documentation were mostly undertaken by nurses. Some of the information was collected in consultation notes and some in care plan templates. Data collection in free-text clinical records or templates were not consistent. Delays updating records were common (typically more than a week). Patient inclusion in SM programmes was dependant on patient interest and commitment rather than practice identification and proactive inclusion. Standardisation of practice-delivered SMS programmes was not apparent in any practice. Some SMS courses were provided by the primary health organisation (PHO) and conducted outside of the practice. Those programmes were standardised but were poorly utilised by general practitioners (GPs) and patients. Patients were said to complain about not being familiar with or engaging with the clinicians delivering the PHO programmes.

The number of people working in different disciplines had recently increased in some of the practices, such as from new hires of health coaches and community healthcare workers, or from delivering SMS in partnership with GPs. Patients’ confidence and engagement was developed through face-to-face conversations and phone calls. However, one of the unresolved problems we identified was how to include patients’ families in the SMS programme. Pamphlets and other printed material were used to support SMS implementation. Despite formal training in coaching being available from PHOs or the DHB, most nurses had not received formal education or training in SMS, except for those at practice DR201860.

Cultural aspects and staff and patient ethnicity were considered to play a significant role in SM success. Clinical teams talked of their difficulties engaging with and coordinating SMS with Māori and Pacific peoples. Part of the cost of delivering SM interventions was the need to pay for venue and offer food with the sessions.

Although behaviour-change support was identified as vital to effective SM, it was not easy to access. A psychologist was available for limited hours and some PHOs had allocated temporary funding for additional psychologist input (eg, to practice DR201860). The coaching was undertaken mainly by nurses who were in formal training. In one practice this was done by a health coach who had completed formal training (practice DR201860).

Patients were receiving guidance on how to ask questions to the doctor. There was no formal assessment of outcomes, such as health literacy, so there were no data on how well patients understood their discussions with the clinical team.

Several practices noted that GPs could be reluctant to delegate clinical roles to nurses or other health professionals. Although this was considered a matter of trust and power, the main factor was the funding model. SMS requires new people in new roles with new training, all of which required financial resources that were beyond what practices could afford.

Team changes

In general, team changes (TC) received basic-good support as scored by the practices this study. The way these practices were working with patients with diabetes was based on a simple structure of GP and practice nurse. Two practices reported a podiatrist as part of the clinical team. A psychologist and social worker were reported in one of the practices, although these professionals were not employed directly in the practice.

Practices with higher scores for TC maintained regular clinical team meetings to discuss diabetes care, although frequency and time invested varied from practice to practice. It was clear that discussion between GPs and practice nurses were more frequent than between either of these and other health professionals. Even when engaged with practice patients, professionals such as podiatrists, psychologists, pharmacists, social workers and diabetes nurse specialists generally worked most of their time elsewhere, which prevented them from participating in routine meetings.

Practices estimated that, on average, patients saw one or more additional health professional (other than the GP or practice nurse) every six months. Access to such appointments was affected by co-location or referrals. However, one practice (DR201840) pointed out that, because they were intensifying actions in primary care through health coaching, it was likely that the number of referrals and visits to other professionals had decreased. This is a plausible comment that could be tested using secondary care datasets.

Few patients (between one and five per practice) were receiving home visits. Some of these visits were performed by a health worker with no formal connection to the practice. The most common reason for a home visit was the patient’s limited mobility, which was unrelated to any QI implementation. No one reported visits to patients to assess patient behaviours or needs, and this was attributed to lack of funding. The professionals most likely to visits patients at home were nurses or social workers, followed by GPs.

Case management

Case management (CM) as a QI strategy received good support from three practices (DR201820, DR201830 and DR201860) and was fully supported by two practices (DR201820 and DR201860). Overall, CM was restricted to “poorly controlled” patients. Most case managers did not have formal training in CM. Patients receiving CM were mostly referred by a GP to a nurse or health coach who then took control of coordinating practice activities for the patient. In some of the practices, the criteria for CM were standardised and explicit; in others, the process followed GP preference.

In those practice where CM was fully supported (DR201820 and DR201860), the case manager established a bridge between primary and secondary care. They coordinated services between providers and maintained communication with the patient. In the other practices, coordination and communication were not implemented in a systematic and consistent fashion. Coordination with secondary care could be problematic as it was based on inter-professional networking and informal interactions.

Those nurses with strong connections to secondary care nurses were more likely to achieve better coordination for their patients. Clinical teams in all practices were keen to participate in more planned home visits for their patients. However, restrictions in resources (number of health workers and time) and funding were the major obstacles. When a visit was performed, nurses and social workers were the most likely professionals involved.

Patient education

Practices mostly reported good implementation of patient education (PE). Most of the education to the patients was provided by nurses as printed material, with some customisation for individual patients. This section of the questionnaire provoked much discussion between GPs and nurses in most of the practices. Doctors tended to downgrade the practice score and questioned the consistency of this activity across patients. Nurses explained in detail the way they were delivering information to the patients. It was apparent that, in most practices, this work by nurses was not well known or recognised by the GPs.

According to the participants, continuity was driven by patients seeking to maintain a professional relationship with a known GP and/or practice nurse. Nevertheless, participants did not consider continuity a problem in the practices that organised care by a clinical team rather than an individual.

Electronic patient register

A patient register was readily available in all the practices. Practices reported that their electronic medical record allowed them to build queries to identify patients with diabetes, and this information was used by nurses to drive reminders and phone calls. Few doctors were using this information. One PHO provided a dashboard that supported filtering and patient-tracking, but this tool was not regularly used for planning, prioritisation or follow-up.

Patient reminders

This strategy was highly implemented by practices and mostly undertaken by nurses. Examples included reminders by text, email or patient portals to monitor glucose or mental health associated with diabetes, follow-up of test results, care plans and other important information for self-management.

Discussion

Some QI interventions might be more effective than others, but in this study, because each practice was implementing a variable combination of strategies in overlapping time frames, it was not possible to identify the contribution of a single strategy. It was clear that one practice (DR201860) had implemented QI strategies with more energy and greater resources than the other practices.

The lifestyle changes required for effective patient self-management of diabetes can be many and complex. Adherence to treatment and sustained changes in lifestyle reflect high self-efficacy, which is itself a prognostic factor for successful management of diabetes.[[15]] Implementation of SMS in the current sample of practices was quite limited. Fully implemented SMS is a coaching model run by expert peer champions and supported by expert healthcare coaches (GPs, nurses, dietitians, psychologists and others), following a standardised intervention.[[16,17]] It became clear in the focus groups that the level of education of the clinical team in coaching was limited, and there was no evidence of patient champions.

In the current sample of practices there was low implementation of team changes. Diabetes management is time and labour intensive for clinical teams, especially when strategies were focused on patient education, lifestyle changes and increased participation of the patient in decision-making and engagement. Hence most health systems were exploring the use of non-physician care delivery to people with chronic conditions. Team changes is a QI strategy to develop multidisciplinary teams and shift responsibilities from the single physician to a team of healthcare professionals. Previous research has shown that having professionals with different experiences and educational background working in a collaborative environment can improve patient outcomes and lower costs.[[18]]

The research participants acknowledged the challenges and barriers to developing the role of other health workers in primary care, especially expanding the role of practice nurses, a factor also found consistently in the literature.[[19–21]] The lack of linkages between primary care practices and the community through home visits or community-based resources was also identified in this study, despite the current evidence on the benefits of this relationship in terms of patient outcomes.[[22,23]]

Incorporating practice nurses in diabetes management has been reported to show high levels of patient satisfaction and greater engagement with their treatment.[[24]] Participants in the current study recognised and supported case management as a way to improve patient outcomes. Nursing was the most common profession managing those complex cases. Two practices (DR201840 and DR201860) had a dedicated nurse to plan and coordinate care for patients with higher levels of HbA1c (>8.5% or 69mmol/mol). Participants suggested that the effectiveness of this QI strategy could be measured by the percentage of patients engaged in their treatment and follow-up, which is consistent with research evidence.[[25,26]]

Diabetes management focuses on lifestyle changes and risk-factor modification, which requires intensive engagement of patients and providers in education processes.[[27]] The effectiveness of individual education for patients in terms of clinical, psychosocial and behavioural outcomes has been confirmed.[[28]] Practices in the current study supported patient education; nurses were heavily involved in this task.

A high-quality and appropriately used register of patients can contribute to reducing the risk of diabetes complications.[[29]] In the current study, most of the practices reported access to a patient register, which may have been paper-based or a computer dashboard. However, use of any register was limited to nursing groups, and we found limited evidence that they were using this tool for tracking or planning purposes. There is a need to standardise the tools and the processes.[[30 31]]

Patient reminders through phone calls and text messaging were well accepted and implemented. In the literature this strategy has shown positive results in young adults (teenagers) with diabetes, but evidence relating to the patient populations served in the current study is more limited.[[32]]

This study has several limitations. The number of practices and healthcare professionals involved was small. We depended on self-report from the practice teams, and we assumed that education delivered was equivalent across the practices given similar levels of training of those delivering the education. The duration of the intervention was not consistent across the practices and the definitions and documentation of each QI was not standardised across the practices. In the future, each QI strategy should be carefully described ahead of implementation in order to increase the reliability of comparisons. It is possible that practice composition, such as whether a psychologist or social worker is present, influenced some of the QI initiatives and patient outcomes, but we were not able to comment further given the limited number of practices that included those professionals.

Conclusions

Being able to measure implementation of QI strategies is a basic requirement for effective and sustained implementation. We assessed the level of implementation of six QI strategies in five practices. Practices engaged well with the assessment. Results were confirmed by the practices and appear to be plausible and discriminating between practices.

Funding

This research was founded by a research grant, Te Rangahau Puawai, from Counties Manukau District Health Board.

Role of the funding source

The funder was not involved in the designing the study, collecting or interpreting data, decision to publish or writing the manuscript.

Summary

Abstract

Aim

Our study aims to describe the level of implementation of six QI strategies for improving primary care of diabetes (self-management support, team changes, case management, patient education, electronic patient registers and patient reminders).

Method

A survey and focus groups were conducted between October 2018 and January 2019. We invited eleven general practices in South Auckland, New Zealand. We constructed a questionnaire assessing six QI initiatives, adapting questionnaire items from published instruments. A summary score was calculated by QI strategy and by practice.

Results

Five practices participated. All were simultaneously implementing clinical team changes, patient education, electronic patient registers and patient reminders, but type and level of implementations varied between the practices. The scoring system discriminated between practices with respect to both individual strategies and the practice summary score. Practices engaged well with the assessment. Results were reported back to practices who confirmed that the scoring was plausible. The study describes key features and challenges during the implementation process.

Conclusion

It is important to measure implementation of QI strategies. In this study of five practices, the instrument developed, and the associated measurement processes, were acceptable to practices and the results appear discriminatory and plausible.

Author Information

Nelson Aguirre-Duarte: Faculty of Medicine, Health Systems Department, School of Population Health, The University of Auckland, Auckland, New Zealand. John Øvretveit: Health Care Improvement Implementation and Evaluation, Medical Management Centre, The Karolinska Institute, Stockholm. Timothy Kenealy: Faculty of Medicine, The University of Auckland, Auckland, New Zealand.

Acknowledgements

The authors wish to thank Dr Brandon Orr-Walker, Dr Tim Hou, Dr Tana Fishman, Pauline Sanders and Professor Nicolette Sheridan for advice and discussion about aspects of conducting the study, and the staff at the five practices who took the time to participate in our study.

Correspondence

Dr Nelson Aguirre-Duarte, Faculty of Medicine, Health Systems Department, School of Population Health, The University of Auckland, Auckland, New Zealand

Correspondence Email

n.aguirre@auckland.ac.nz

Competing Interests

Dr Aguirre-Duarte reports grants from Counties Manukau District Health Board during the conduct of the study.

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