Individuell behandlingsplan gav bättre blodsockerkontroll
Press release

Vårdcentraler som har individuella behandlingsplaner för patienter med typ 2-diabetes lyckas bättre med behandlingen. Det visar en ny studie med data från Nationella Diabetesregistret. Effekten är störst för patienter med dåligt kontrollerat blodsocker.

Typ 2-diabetes är den vanligaste diabetesformen och den debuterar oftast i vuxen ålder. Ett välkontrollerat långtidsblodsocker är viktigt för att förebygga följdsjukdomar. I studien ingick drygt 230 000 patienter med typ 2-diabetes registrerade i Nationella Diabetesregistret. Information om vårdcentralernas sätt att arbeta kom från en enkät som gått ut till alla vårdcentraler i Sverige. 846 vårdcentraler (76 procent) besvarade enkäten.

Folkhälsovetaren Rebecka Husdal är huvudförfattare till studien som är en av de största på området. Hon menar att studier i den här omfattningen inte hade varit möjliga utan Nationella Diabetesregistret.

– Diabetesregistret är verkligen en guldgruva, otroligt välskött och med en mycket god täckningsgrad, säger hon.

Patienterna delades vid den statistiska analysen in i grupper baserat på hur väl kontrollerat långtidsblodsocker de hade. 56 procent av patienterna i studien hade välkontrollerat långtidsblodsocker (HbA1c  under 52 mmol/mol). 32 procent hade en acceptabel kontroll (HbA1c 53–69 mmol/mol). 12 procent hade mindre bra kontrollerat blodsocker (över 70 mmol/mol).

Vårdcentraler som hade individuella behandlingsplaner nådde bättre resultat för alla tre grupperna. Gruppen med välkontrollerat långtidsblodsocker gynnades av ytterligare en handfull faktorer. Dessa kunde främst kopplas till det som direkt rör vårdenhetens arbete. De patienter som fått en individuell behandlingsplan och behandlades av en vårdcentral med ett välfungerande kallelsesystem hade lägre HbA1c. Att vårdas av en verksamhet som hade koll på sina resultat och som tog ansvar för att insatserna gav effekt påverkade också HbA1c positivt.

- Bland de patienter som hade en acceptabel kontroll respektive dålig kontroll var det enbart individuell behandlingsplan som kunde associeras med ett lägre HbA1c, säger Rebecka Husdal.

En viktig slutsats av studien är att det krävs effektivare strategier för att hjälpa dessa patienter till bättre blodsockerkontroll.

Referens:
Associations between quality of work features in primary health care and glycaemic control in people with Type 2 diabetes mellitus

Rebecka Husdal, Eva Thors Adolfsson, Janeth Leksell, Björn Eliasson, Stefan Jansson, Lars Jerdén, Jan Stålhammar, Lars Steen, Thorne Wallman, Ann-Marie Svensson, Andreas Rosenblad

Primary Care Diabetes, 2018-12-10

https://www.sciencedirect.com/science/article/pii/S1751991818302778

Läs avhandlingen i sin helhet som pdf utan lösenord
https://www.avhandlingar.se/om/Rebecka+Husdal/


Associations between quality of work features in primary health care and glycaemic control in people with Type 2 diabetes mellitus: A nationwide survey

Under a Creative Commons license
open access
 

Highlights

Real life clinical data are needed to understand benefits of quality of work (QOW).

Examines associations between primary health care centres’ QOW and HbA1c levels.

An explorative factor analysis identified seven QOW features.

QOW involving an individualized treatment plan decreased HbA1c level in all groups.

More effective QOW strategies are needed to support people with uncontrolled HbA1c.

Abstract

Aims

To describe and analyse the associations between primary health care centres’ (PHCCs’) quality of work (QOW) and individual HbA1c levels in people with Type 2 diabetes mellitus (T2DM).

Methods

This cross-sectional study invited all 1152 Swedish PHCCs to answer a questionnaire addressing QOW conditions. Clinical, socio-economic and comorbidity data for 230,958 people with T2DM were linked to data on QOW conditions for 846 (73.4%) PHCCs.

Results

Of the participants, 56% had controlled (≤52 mmol/mol), 31.9% intermediate (53–69 mmol/mol), and 12.1% uncontrolled (≥70 mmol/mol) HbA1c. An explanatory factor analysis identified seven QOW features. The features having a call-recall system, having individualized treatment plans, PHCCs’ results always on the agenda, and having a follow-up strategy combined with taking responsibility of outcomes/results were associated with lower HbA1c levels in the controlled group (all < 0.05). For people with intermediate or uncontrolled HbA1c, having individualized treatment plans was the only QOW feature that was significantly associated with a lower HbA1c level (< 0.05).

Conclusions

This nationwide study adds important knowledge regarding associations between QOW in real life clinical practice and HbA1c levels. PHCCs’ QOW may mainly only benefit people with controlled HbA1c and more effective QOW strategies are needed to support people with uncontrolled HbA1c.

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https://www.sciencedirect.com/science/article/pii/S1751991818302778

 Introduction

Type 2 diabetes mellitus (T2DM) is an important public health problem worldwide. In many countries, people with T2DM are treated in the primary health care (PHC) system. The PHC system is being outstripped by the increased burden of T2DM and its complications, resulting in a major public health issue [1]. The quality of work (QOW) in primary diabetes care for people with T2DM is essential for postponing the development of diabetes-related complications [2]. People with T2DM who has poor glycaemic control (HbA1c ≥53 mmol/mol) is at increased risk of complications [3]. Despite the presence of guidelines for diabetes care [2], [4], the QOW is suboptimal and differs both within and between countries [5], [6]. Improving the QOW requires efforts such as working with prevention strategies for reducing diabetes-related complications [7], using national registries for receiving tailored feedback on clinical outcomes [8], and providing individualized treatment [9], [10].

Sweden is one of the leading countries in terms of primary diabetes care, and the Swedish National Diabetes Register (NDR) is the largest diabetes register globally [11]. A qualitative study by the Swedish Association of Local Authorities and Regions (SALAR) identified seven success factors in Swedish primary diabetes care, which were associated with county councils/regions having good performance regarding HbA1c level in people with T2DM: (i) focus on patients’ targets; (ii) targeted initiatives for patients with poor outcomes; (iii) PHCCs’ results are always on the agenda for management and healthcare professionals (HCPs); (iv) interpretation of new knowledge and clear expectations; (v) follow-up and feedback on results; (vi) long-term improvement initiatives for diabetes care; and (vii) ownership of results and focus on prevention [12]. This qualitative study examined HbA1c levels at an aggregated regional level, and it remains unclear whether these factors are important at an individual level. The study carried out by SALAR has had great impact on Swedish primary diabetes care and given that the organization of primary diabetes care is costly, there are reasons to study these effects of actions with different approaches. Further, although a meta-analysis by Tricco et al. [13] found that quality improvement (QI) strategies are essential for improving HbA1c levels and interventions targeting HCPs seems to be valuable for people with poor baseline HbA1c, the main challenge is to address the combination of strategies which people with T2DM will benefit the most from. More information on real life clinical practice is also needed to fully understand the benefits of QOW in PHC for people with T2DM. Thus, the aim of the present study was to describe and analyse the associations between PHCCs’ QOW and individual HbA1c levels in people with T2DM.


Discussion

The current study found a greater number of significant associations between QOW features and HbA1c level in people with controlled HbA1c than in people with intermediate or uncontrolled HbA1c. This contrasts with a previous systematic review and meta-analysis[13], where QOW strategies were reported to have the largest effect among people with intermediate/uncontrolled HbA1c. These conflicting results may be explained by limitations of the present cross-sectional study design and/or reflecting the need of more evidence-based QOW strategies to support people with uncontrolled HbA1c. Surprisingly, even though almost all PHCCs worked with the questions addressed in the QOW features Culture and prevention (Factor 6) and Strategies and responsibility (Factor 7), no significant associations were found for people in the intermediate or uncontrolled group. This may reflect that, even though PHCCs managers have an interest in pursuing these questions, their organization experiences challenges when translating this into clinical practice, especially for people with uncontrolled HbA1c [26].

The unexpected association between having more of the QOW feature Culture and prevention (Factor 6) and an increased HbA1c level in those with controlled HbA1c may reflect reverse causation. Notably, the QOW feature Follow up and feedback (Factor 5) was not significantly associated with lower HbA1c levels. Using the NDR provides the opportunity for PHCCs to get access to a systematic documentation, make comparisons, and come up with ideas for improvements [8]. Certainly, identifying associations could be challenging when the utilization of the NDR is unclear. The observed association between the QOW feature Individualized treatment plans (Factor 2) and lower HbA1c levels in people with intermediate/uncontrolled HbA1c confirms the importance of providing individualized care [9].

Systematic reviews [27], [28], [29] have found limited evidence for associations between the organisation of diabetes care and glycaemic control, which may be explained by poor methodological quality of the included studies. Moreover, these conclusions may be the result of heterogeneous studies with diverse participant characteristics, study settings, and reported outcomes [30]. The organization of primary diabetes care has no single universal pathway that can be applied in all settings [6]. However, this study adds important knowledge about the effects of QOW features within one of the most comprehensive PHC systems in Europe, which may be useful for benchmarking between countries.

To some extent, the findings of the present study are consistent with SALAR’s seven success factors in terms of identifying organizational features as important to the ability of HCPs to provide a diabetes care of good quality for people with T2DM [12]. Caution must, however, be taken when comparing the present study and SALAR’s qualitative study because of the different methodological approaches. Despite the limitations in the methodology and restricted generalizability of the results, SALAR’s qualitative study has had a large-scale impact on Swedish primary diabetes care. The seven QOW features addressed in the current study should be seen as complementary information to SALAR’s qualitative benchmarking study, making it possible for policy makers to better understand the meaning of success factors in primary diabetes care.

Limitations of the present study include the cross-sectional design, making it impossible to study causal relationships. Using self-reported questionnaires, although facilitating the collection of this large amount of data, increased the risk that respondents embellished answers or misinterpreted questions. To reduce this kind of bias, PHCC managers were encouraged to answer the questionnaire together with GPs and RNs having direct contact with the patients. There is also a risk of selection bias since well-functioning PHCCs may have been more inclined to complete the questionnaire. However, this is so far the first Swedish large-scale national survey to describe and analyse the associations between PHCCs’ QOW and HbA1c level in people with T2DM. The large sample size of people with T2DM and PHCCs increases the ability to generalize the results in the Swedish PHC setting. Using well-administrated registers covering individual-level data on clinical risk factors, socio-economics, and comorbidities made it possible to adjust for all known important confounders.

In conclusion, having individualized treatment plans was the only QOW feature that was significantly associated with lower HbA1c levels in all groups. The greatest effect was found for people with uncontrolled HbA1c. In addition to previous research assessing the effectiveness on QOW improvements based on randomized controlled trials, this nationwide observational study points to the importance of examining associations between QOW in real life clinical practice and HbA1c levels in people with T2DM. To date, the QOW carried out at Swedish PHCCs may only benefit people with good glycaemic control (HbA1c ≤ 52 mmol/mol). More effective QOW strategies are thus needed to support people with uncontrolled HbA1c.

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