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Population Health Management in Diabetes Care: Combining Clinical Audit, Risk Stratification, and Multidisciplinary Virtual Clinics in a Community Setting to Improve Diabetes Care in a Geographically Defined Population. An Integrated Diabetes Care Pilot in the North East Locality, Oxfordshire, UK Cover

Population Health Management in Diabetes Care: Combining Clinical Audit, Risk Stratification, and Multidisciplinary Virtual Clinics in a Community Setting to Improve Diabetes Care in a Geographically Defined Population. An Integrated Diabetes Care Pilot in the North East Locality, Oxfordshire, UK

By: O. Kozlowska,  S. Attwood,  A. Lumb,  G. D. Tan and  R. Rea  
Open Access
|Dec 2020

References

  1. 1World Health Organisation. Global Report on Diabetes. Geneva: WHO; 2016. [cited 26.02.2019]. Available from: https://apps.who.int/iris/bitstream/handle/10665/204871/9789241565257_eng.pdf;jsessionid=CCB21E4833142B3B04CAE43BAE4C2E32?sequence=1.
  2. 2NHS Digital. National Diabetes Audit, 2016–17. Report 1: Care Processes and Treatment Targets, England and Wales. Full report; 2018. [cited 27.02.2019]. Available from: https://files.digital.nhs.uk/pdf/s/k/national_diabetes_audit_2016-17_report_1__care_processes_and_treatment_targets.pdf.
  3. 3NHS England, Medical Directorate. Action for Diabetes. 2014. [cited 14.03.2019]. Available from: https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2016/08/act-for-diabetes-31-01.pdf.
  4. 4Diabetes UK. Best practice for commissioning diabetes services: An integrated care framework. 2013. [cited 20.11.2018]. Available from: https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/best-practice-commissioning-diabetes-services-integrated-care-framework-0313.pdf.
  5. 5Garrofé BC, Björnberg A, Yung Phang A. Euro Diabetes Index. Health Consumer Powerhouse Ltd. 2014. Available online at: https://old.healthpowerhouse.com/files/EDI-2014/EDI-2014-report.pdf [cited 17.02.2019].
  6. 6Malins JM, Stuart JM. Diabetic clinic in a general practice. British Medical Journal, 1971; 4: 161. DOI: 10.1136/bmj.4.5780.161
  7. 7Thorn PA, Russell RG. Diabetic clinics today and tomorrow: mini-clinics in general practice. British Medical Journal, 1973; 2: 534536. DOI: 10.1136/bmj.2.5865.534
  8. 8Wood J. A review of diabetes care initiatives in primary care settings. Health Trends, 1990; 22(1): 3943.
  9. 9Worswick J, Wayne SC, Bennett R, Fiander M, Mayhew A, Weir MC, Sullivan KJ, Grimshaw JM. Improving quality of care for persons with diabetes: an overview of systematic reviews – what does the evidence tell us? Systematic reviews, 2013; 2: 26. DOI: 10.1186/2046-4053-2-26
  10. 10Wilkes E, Lawton EE. The diabetic, the hospital and primary care. Journal of the Royal College of General Practitioners, 1980; 30: 199206.
  11. 11Royal College of Physicians Focus on physicians. Census of consultant physicians and higher specialty trainees 2017–18. 2017–18 consultant census data tool. 2018. Available online at: https://www.rcplondon.ac.uk/file/11458/download?token=B66sa0_H [cited 18.03.2019].
  12. 12Gosden JJ, Wincourt P, Walton C, Nagi D, Turner B, Williams R, Holt RIH. Diabetes specialist nurses and role evolvement: a survey by Diabetes UK and ABCD of specialist diabetes services 2007. Diabetic Medicine, 2007; 26: 560565. DOI: 10.1111/j.1464-5491.2009.02716.x
  13. 13Diabetes UK. Diabetes specialist nursing 2016 workforce survey: A workforce in crisis. London: DUK. 2016. Available online at: http://bit.ly/2gOi2EU [cited 21.02.2019].
  14. 14Price E, Baker R, Krause J, Keen C. Organisation of services for people with cardiovascular disorders in primary care: transfer to primary care or to specialist-generalist multidisciplinary teams? BMC Fam Pract., 2014; 15: 158. DOI: 10.1186/1471-2296-15-158
  15. 15Duran A, Runkle I, Matía P, de Miguel MP, et al. Family physician and endocrinologist coordination as the basis for diabetes care in clinical practice. BMC Endocr Disord., 2008 Jul 31; 8: 9. DOI: 10.1186/1472-6823-8-9
  16. 16Griffin S. Diabetes care in general practice: meta-analysis of randomised control trials. BMJ, 1998; 317: 390. DOI: 10.1136/bmj.317.7155.390
  17. 17Diabetes UK. Improving the delivery of adult diabetes care through integration. Sharing experience and learning. London: DUK. 2014. Available online at: https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/Integrated%2520diabetes%2520care%2C%2520Diabetes%2520UK%2520%28PDF%2C%2520648KB%29.pdf [cited 13.09.2019].
  18. 18Kar P. The Super Six Model: Integrated diabetes care across Portsmouth and south-east Hampshire. Diabetes & Primary Care, 2012; 14(5): 277283.
  19. 19Wills T, Chandok R, Delgado R, Robertson L, Dornhorst A. The North West London Diabetes Transformation Programme (NWL-DTP): the journey so far in optimising diabetes care within North West London. Practical Diabetes, 2019; 36(2): 5156. DOI: 10.1002/pdi.2214
  20. 20Future Hospital Commission. Future Hospital: caring for medical patients. A report from the Future Hospital Commission to the Royal College of Physicians. London: Royal College of Physicians; 2013.
  21. 21Royal College of Physicians. Delivering the Future Hospital. Full Report. London: Royal College of Physicians. 2017. Available online at file:///C:/Users/p0085541/Downloads/FHC%20final%20report_0_0%20(3).pdf [cited 17.09.2019].
  22. 22Golden SH, Maruthur N, Mathioudakis N, Spanakis E, Rubin D, Zilbermit M, Hill-Briggs F. The case for diabetes population health improvement: evidence-based programming for population outcomes in diabetes. Curr Diab Rep, 2017; 17(7): 51. DOI: 10.1007/s11892-017-0875-2
  23. 23Schmittdiel JA, Gopalan A, Adams AS. Population Health Management for Diabetes: Health Care System-Level Approaches for Improving Quality and Addressing Disparities. Curr Diab Rep, 2017; 17(5): 31. DOI: 10.1007/s11892-017-0858-3
  24. 24Kindig DA, Stoddart G. What Is Population Health? American Journal of Public Health, 2003; 93: 36669. DOI: 10.2105/AJPH.93.3.366
  25. 25Dunn JR, Hayes MV. Towards a lexicon of population health. Can J of Pub Health, 1999; 90 Suppl 1: S710. DOI: 10.1007/BF03403570
  26. 26Parsons JA, Yu CH, Baker NA, Mamdani MM, Bhattacharyya O, Zwarstein M, Shah BR. Practice Doesn’t Always Make Perfect: A Qualitative Study Explaining Why a Trial of an Educational Toolkit Did Not Improve Quality of Care. PLoS One, 2016; 11(12): e0167878. DOI: 10.1371/journal.pone.0167878
  27. 27Johnston G, Crombie IK, Davies HTO. Reviewing audit: barriers and facilitators for effective clinical audit. Quality in Health Care, 2000; 9: 2336. DOI: 10.1136/qhc.9.1.23
  28. 28Giguère A, Legare F, Grimshaw J, Turcott S, Fiander M, Grudniewicz A, et al. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, 2012; (10): 1197. DOI: 10.1002/14651858.CD004398.pub3
  29. 29Ivers NM, Tu K, Young J, Francis JJ, Barnsley J, Shah BR, Upshur RE, Moineddin R, Grimshaw JM, Zwarenstein M. Feedback GAP: pragmatic, cluster-randomized trial of goal setting and action plans to increase the effectiveness of audit and feedback interventions in primary care. Implementation science: IS, 2003; 8: 142. DOI: 10.1186/1748-5908-8-142
  30. 30Aronson R, Orzech N, Ye C, Brown RE, Goldenberg R, Brown V. Specialist-Led Diabetes Registries and Prevalence of Poor Glycemic Control in Type 2 Diabetes: The Diabetes Registry Outcomes Project for A1C Reduction (DROP A1C). Diabetes Care, 2016; 39: 17111717. DOI: 10.2337/dc15-2666
  31. 31Munch L, Arreskov AB, Sperling M, Overgaard D, Knop FK, Vilsbøll T, Røder ME. Risk stratification by endocrinologists of patients with type 2 diabetes in a Danish specialised outpatient clinic: a cross sectional study. BMC Health Services Research, 2016; 16(124). DOI: 10.1186/s12913-016-1365-y
  32. 32Clark CM, Snyder JW, Meek RL, Stutz LM, Parkin CG. A systematic approach to risk stratification and intervention within a managed care environment improves diabetes outcomes and patient satisfaction. Diabetes Care, 24(6): 10791086. DOI: 10.2337/diacare.24.6.1079
  33. 33Basudev N, Crosby-Nwaobi R, Thomas S, et al. A prospective randomized controlled study of a virtual clinic integrating primary and specialist care for patients with type 2 diabetes mellitus. Diabet Med, 2016; 33: 76876. DOI: 10.1111/dme.12985
  34. 34Raymond JK, Berget CL, Driscoll KA, Ketchum K, Cain C, Fred Thomas JF. CoYoT1 Clinic: Innovative Telemedicine Care Model for Young Adults with Type 1 Diabetes. Diabetes Technology and Therapeutics, 2016; 18(6): 38590. DOI: 10.1089/dia.2015.0425
  35. 35Fatehi F, Martin-Khan M, Smith AC, Russell AW, Gray LC. Patient satisfaction with video tele consultation in a virtual diabetes outreach clinic. Diabetes Technology and Therapeutics, 2015; 17(1): 438. DOI: 10.1089/dia.2014.0159
  36. 36Powell J, Jennings A, Armstrong N, Dale J. Pilot study of a virtual clinic: satisfaction and usability. Journal of Telemedicine and Telecare, 2009; 15(3): 1502. DOI: 10.1258/jtt.2009.003014
  37. 37Murphy ME, Byrne M, Galvin R, Boland F, Fahey T, Smith SM. Improving risk factor management for patients with poorly controlled type 2 diabetes: a systematic review of healthcare interventions in primary care and community settings. BMJ Open, 2017; 7: e015135. DOI: 10.1136/bmjopen-2016-015135
  38. 38Foy R, Hempel S, Rubenstein L, Suttorp M, Seelig M, Shanman R, Shekelle PG. Meta-analysis: Effect of Interactive Communication Between Collaborating Primary Care Physicians and Specialists. Annals of Internal Medicine, 2010; 152: 247258. DOI: 10.7326/0003-4819-152-4-201002160-00010
  39. 39Russell AW, Donald M, Bor SJ, Zhang J, Burridge L, Ware RS, Begum N, McIntyre HD, Jackson CL. Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non-inferiority randomised controlled trial. Diabetologia, 2019; 62(1): 4152. DOI: 10.1007/s00125-018-4740-x
  40. 40Ritholz MD, Beverly EA, Abrahamson MJ, Brooks KM, Hultgren BA, Weinger K. Physicians’ perceptions of the type 2 diabetes multi-disciplinary treatment team: a qualitative study. Diabetes Educ, 2011; 37(6): 794800. DOI: 10.1177/0145721711423320
  41. 41McGill M, Blonde L, Chan JCN, Khunti K, Lavalle FJ, Bailey CJ. The Global Partnership for Effective Diabetes Management The interdisciplinary team in type 2 diabetes management: Challenges and best practice solutions from real-world scenarios. J Clin Transl Endocrinol, 2017; 7: 2127. DOI: 10.1016/j.jcte.2016.12.001
  42. 42Armstrong N, Baines D, Baker R, Crossman R, Davies M, et al. A cluster randomised controlled trial of the effectiveness and cost-effectiveness of Intermediate Care Clinics for Diabetes (ICCD): Study protocol for a randomised controlled trial. Trials, 2012; 13: 164. DOI: 10.1186/1745-6215-13-164
  43. 43Wilson A, O’Hare JP, Hardy A, Raymond N, Szczepura A, Crossman R, Baines D, Khunti K, Kumar S, Saravanan P. Evaluation of the Clinical and Cost Effectiveness of Intermediate Care Clinics for Diabetes (ICCD): A Multicentre Cluster Randomised Controlled Trial. PLoS One, 2014; 9(4): e93964. DOI: 10.1371/journal.pone.0093964
  44. 44Bongaerts BW, Mussig K, Wens J, Lang C, Schwarz P, Roden M, Rathmann W. Effectiveness of chronic care models for the management of type 2 diabetes mellitus in Europe: a systematic review and meta-analysis. BMJ Open, 2017; 7: e013076. DOI: 10.1136/bmjopen-2016-013076
  45. 45Greenhalgh T. Commentary: Meta-analysis is a blunt and potentially misleading instrument for analysing models of service delivery. BMJ, 1998; 317: 395396. DOI: 10.1136/bmj.317.7155.390
  46. 46Nocon A, Leese B. The role of UK general practitioners with special clinical interests: implications for policy and service delivery. Br J Gen Pract, 2004; 54: 5056.
  47. 47Sharp PS. Glycaemic outcomes following discharge from an intermediate care diabetes clinic. Practical Diabetes International, 2010; 27: 5354. DOI: 10.1002/pdi.1443
  48. 48Halfyard C, McGowan D, Whyte M, Gayle C. Diabetes rapid access clinic: a bridge between primary and secondary care (Diabetes UK poster presentation). Diabetic Medicine, 2010; 27: 137.
  49. 49Tricco AC, Antony J, Ivers NM, Ashoor HM, Khan PA, Blondal E, Ghassemi M, MacDonald H, Chen MH, Kark Ezer L, Straus SE. Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis. CMAJ, 2014; 186(15): E568E578. DOI: 10.1503/cmaj.140289
  50. 50Borgermans L, Godersi G, Van Den Broeke C, Verbeke G, Carbonez A, et al. Interdisciplinary diabetes care teams operating on the interface between primary and specialty care are associated with improved outcomes of care: findings from the Leuven Diabetes Project. BMC Health Services Research, 2009; 9: 179. DOI: 10.1186/1472-6963-9-179
  51. 51Greer R, Boulware E. Reducing CKD risks among vulnerable populations in primary care. Adv Chronic Kidney Dis, 2015; 22(1): 7480. DOI: 10.1053/j.ackd.2014.06.003
  52. 52Tricco AC, Ivers NM, Grimshaw JM, Moher D, Turner L, et al. Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis. Lancet, 2012; 379: 22522261. DOI: 10.1016/S0140-6736(12)60480-2
  53. 53Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, Sundaram V, Rushakoff RJ, Owens DK Effects of Quality Improvement Strategies for Type 2 Diabetes on Glycemic Control. A Meta-Regression Analysis. JAMA, 2006; 296(4): 427440. DOI: 10.1001/jama.296.4.427
  54. 54Lamb BW, Sevdalis N, Vincent C, Green JS. Development and Evaluation of a Checklist to Support Decision Making in Cancer Multidisciplinary Team Meetings: MDT-QuIC. Annals of Surgical Oncology, 2011; 19(6): 175965. DOI: 10.1245/s10434-011-2187-0
  55. 55NHS Digital. National Diabetes Audit, 2016–17. Report 1: Care Processes and Treatment Targets, England and Wales. Full report; 2018. Available online at: https://files.digital.nhs.uk/pdf/s/k/national_diabetes_audit_2016-17_report_1__care_processes_and_treatment_targets.pdf [cited 27.02.2019].
  56. 56Lu BJ, Danko KJ, Elfassy MD, Welch V, Grimshaw JM, Ivers NM. Do quality improvement initiatives for diabetes care address social inequities? Secondary analysis of a systematic review. BMJ Open, 2018; 8: e018826. DOI: 10.1136/bmjopen-2017-018826
  57. 57Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Charm. Washington, DC: National Academic Press, US. 2001. Available online at: http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf [cited 17.02.2019].
  58. 58Greenhalgh T, Robert G, Bate SP, Macfarlane F, Kyriakidou O. Diffusion of Innovations in Health Service Organisations. Oxford: Blackwells; 2005. DOI: 10.1002/9780470987407
DOI: https://doi.org/10.5334/ijic.5177 | Journal eISSN: 1568-4156
Language: English
Submitted on: Aug 5, 2019
Accepted on: Oct 28, 2020
Published on: Dec 2, 2020
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year

© 2020 O. Kozlowska, S. Attwood, A. Lumb, G. D. Tan, R. Rea, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.