References
- 1Nolte E, Knai C, Saltman RB. (eds.) Assessing chronic disease management in European health systems: Concepts and approaches. Copenhagen, Denmark: European Observatory on Health Systems and Policies; 2014.
- 2Cash-Gibson L, Rosenmoller M. Project INTEGRATE – a common methodological approach to understand integrated health care in Europe. International Journal of Integrated Care. 2014; 14:
e035 . DOI: 10.5334/ijic.1980 - 3Shaw S, Rosen R, Rumbold B. What is integrated care? London: Nuffield Trust; 2011.
- 4World Health Organisation (WHO). ROADMAP. Strengthening people-centred health systems in the WHO European Region. WHO; 2013.
- 5Goodwin N. How do you build programmes of integrated care? The need to broaden our conceptual and empirical understanding. International Journal of Integrated Care. 2013; 13:
e040 . DOI: 10.5334/ijic.1207 - 6Busetto L, Luijkx K, Calciolari S, Gonzalez Ortiz LG, Vrijhoef HJM. Exploration of workforce changes in integrated chronic care: Findings from an interactive and emergent research design. PLoS One. 2017; 12(12):
e0187468 . DOI: 10.1371/journal.pone.0187468 - 7Kahn R, Anderson JE. Improving Diabetes Care: The Model for Health Care Reform. Diabetes Care. 2009; 32(6): 1115–8. DOI: 10.2337/dc09-0184
- 8World Health Organisation (WHO). Global Report on Diabetes. France: WHO Press; 2016.
- 9Fuchs S, Henschke C, Blümel M, Busse R. Disease Management Programs for Type 2 Diabetes in Germany: A Systematic Literature Review Evaluating Effectiveness. Deutsches Ärzteblatt International. 2014; 111(26): 453–63. DOI: 10.3238/arztebl.2014.0453
- 10Busetto L, Luijkx K, Huizing A, Vrijhoef B. Implementation of integrated care for diabetes mellitus type 2 by two Dutch care groups: a case study. BMC Family Practice. 2015; 16(1): 105. DOI: 10.1186/s12875-015-0320-z
- 11Wadmann S, Strandberg-Larsen M, Vrangboek K. Coordination between primary and secondary healthcare in Denmark and Sweden. International Journal of Integrated Care. 2009; 19(12). DOI: 10.5334/ijic.302
- 12Donohoe ME, Fletton JA, Hook A, Powell R, Robinson I, Stead JW, et al. Improving foot care for people with diabetes mellitus – a randomized controlled trial of an integrated care approach. Diabetic Medicine. 2001; 17(8): 581–7. DOI: 10.1046/j.1464-5491.2000.00336.x
- 13Smith S, Bury G, O’Leary M, Shannon W, Tynan A, Staines A, et al. The North Dublin randomized controlled trial of structured diabetes shared care. Family Practice. 2004; 21(1): 39–45. DOI: 10.1093/fampra/cmh109
- 14Diabetes Integrated Care Evaluation Team. Integrated care for diabetes: clinical, psychosocial, and economic evaluation. Diabetes Integrated Care Evaluation Team. BMJ. 1994; 308(6938): 1208–12. DOI: 10.1136/bmj.308.6938.1208
- 15Rothe U, Muller G, Schwarz PE, Seifert M, Kunath H, Koch R, et al. Evaluation of a diabetes management system based on practice guidelines, integrated care, and continuous quality management in a Federal State of Germany: a population-based approach to health care research. Diabetes Care. 2008; 31(5): 863–8. DOI: 10.2337/dc07-0858
- 16Borgermans L, Goderis G, Van Den Broeke C, Verbeke G, Carbonez A, Ivanova 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(1): 1–15. DOI: 10.1186/1472-6963-9-179
- 17Walsh JL, Harris BH, Roberts AW. Evaluation of a community diabetes initiative: Integrating diabetes care. Primary Care Diabetes. 2015; 9(3): 203–10. DOI: 10.1016/j.pcd.2014.10.003
- 18Johnson M, Goyder E. Changing roles, changing responsibilities and changing relationships: an exploration of the impact of a new model for delivering integrated diabetes care in general practice. Quality in Primary Care. 2005; 13(2): 85–90 6p.
- 19McRae IS, Butler JRG, Sibthorpe BM, Ruscoe W, Snow J, Rubiano D, et al. A cost effectiveness study of integrated care in health services delivery: a diabetes program in Australia. BMC Health Services Research. 2008; 8: 205. DOI: 10.1186/1472-6963-8-205
- 20Foster M, Burridge L, Donald M, Zhang J, Jackson C. The work of local healthcare innovation: a qualitative study of GP-led integrated diabetes care in primary health care. BMC Health Services Research. 2016; 16: 11. DOI: 10.1186/s12913-016-1270-4
- 21Burridge LH, Foster MM, Donald M, Zhang J, Russell AW, Jackson CL. Making sense of change: patients’ views of diabetes and GP-led integrated diabetes care. Health Expectations. 2015. DOI: 10.1111/hex.12331
- 22Yeo SQ, Harris M, Majeed FA. Integrated care for diabetes—a Singapore approach. International Journal of Integrated Care. 2012; 12:
e8 . DOI: 10.5334/ijic.810 - 23Health Service Executive. National Clinical Programme for Diabetes. Available from:
http://www.hse.ie/eng/about/Who/clinical/natclinprog/diabetesprogramme/ [Accessed: 4th May 2022]. - 24Riordan F, McHugh SM, Murphy K, Barrett J, Kearney PM. The role of nurse specialists in the delivery of integrated diabetes care: a cross-sectional survey of diabetes nurse specialist services. BMJ Open. 2017; 7(8). DOI: 10.1136/bmjopen-2016-015049
- 25Mc Hugh SM, O’Keeffe J, Fitzpatrick A, de Siun A, O’Mullane M, Perry I, et al. Diabetes care in Ireland: a survey of general practitioners. Primary Care Diabetes. 2009; 3(4): 225–31. DOI: 10.1016/j.pcd.2009.09.002
- 26Mc Hugh SM, O’Mullane M, Perry IJ, Bradley C. Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice. BMJ Open. 2013; 3(8):
e003217 . DOI: 10.1136/bmjopen-2013-003217 - 27Elissen AM, Steuten LM, Lemmens LC, Drewes HW, Lemmens KM, Meeuwissen JA, et al. Meta-analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes. Journal of Evaluation in Clinical Practice. 2013; 19(5): 753–62. DOI: 10.1111/j.1365-2753.2012.01817.x
- 28Hoogeveen RC, Dorresteijn JA, Kriegsman DM, Valk GD. Complex interventions for preventing diabetic foot ulceration. The Cochrane Database of Systematic Reviews. 2015(8): Cd007610. DOI: 10.1002/14651858.CD007610.pub3
- 29Baxter S, Johnson M, Chambers D, Sutton A, Goyder E, Booth A. Understanding new models of integrated care in developed countries: a systematic review. Southampton, UK: NIHR Journals Library; 2018. DOI: 10.3310/hsdr06290
- 30Martinez-Gonzalez NA, Berchtold P, Ullman K, Busato A, Egger M. Integrated care programmes for adults with chronic conditions: a meta-review. International Journal of Quality in Health Care. 2014; 26(5): 561–70. DOI: 10.1093/intqhc/mzu071
- 31Busetto L, Luijkx KG, Elissen AMJ, Vrijhoef HJM. Context, mechanisms and outcomes of integrated care for diabetes mellitus type 2: a systematic review. BMC Health Services Research. 2016; 16(1): 1–14. DOI: 10.1186/s12913-015-1231-3
- 32Bongaerts BW, Müssig 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 Mar 20; 7(3):
e013076 . DOI: 10.1136/bmjopen-2016-013076 - 33Renders CM, Valk GD, Griffin S, Wagner EH, Eijk JT, Assendelft WJ. Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings. The Cochrane Database of Systematic Reviews. 2001; 1: Cd001481. DOI: 10.1002/14651858.CD001481
- 34Marchal B, van Belle S, van Olmen J, Hoerée T, Kegels G. Is realist evaluation keeping its promise? A review of published empirical studies in the field of health systems research. Evaluation. 2012; 18(2): 192–212. DOI: 10.1177/1356389012442444
- 35Walshe K, Freeman T. Effectiveness of quality improvement: learning from evaluations. Quality and Safety in Health Care. 2002; 11(1): 85. DOI: 10.1136/qhc.11.1.85
- 36Chen HT. Theory-driven evaluation: Conceptual framework, application and advancement. In: Evaluation von Programmen und Projekten für eine demokratische Kultur. 2012; 17–40. DOI: 10.1007/978-3-531-19009-9_2
- 37Greenhalgh T, Humphrey T, Hughes J, MacFarlane F, Butler C, Pawson R. How do you modernize a health service? A realist evaluation of whole-scale transformation in London. Milbank Quarterly. 2009; 87. DOI: 10.1111/j.1468-0009.2009.00562.x
- 38Ranmuthugala G, Cunningham FC, Plumb JJ, Long J, Georgiou A, Westbrook JI, et al. A realist evaluation of the role of communities of practice in changing healthcare practice. Implementation Science. 2011; 6: 49. DOI: 10.1186/1748-5908-6-49
- 39Rycroft-Malone J, Fontenla M, Bick D, Seers K. A realistic evaluation: the case of protocol-based care. Implementation Science. 2010; 5: 38. DOI: 10.1186/1748-5908-5-38
- 40Pawson R, Tilley N. Realist evaluation, 2004. Available from:
http://www.communitymatters.com.au/RE_chapter.pdf [Accessed: 5th May 2022]. - 41Mc Hugh S, Marsden P, Brennan C, Murphy K, Croarkin C, Moran J, et al. Counting on commitment; the quality of primary care-led diabetes management in a system with minimal incentives. BMC Health Services Research. 2011; 11: 348. DOI: 10.1186/1472-6963-11-348
- 42Health Service Executive (HSE). Diabetes Expert Advisory Group. First Report: April 2008. Kildare: HSE; 2008.
- 43Health Service Executive (HSE). Model of Care for the Diabetic Foot. Dublin: HSE; 2011.
- 44McHugh SM, Tracey ML, Riordan F, O’Neill K, Mays N, Kearney PM. Evaluating the implementation of a national clinical programme for diabetes to standardise and improve services: a realist evaluation protocol. Implementation Science. 2016; 11(1): 107. DOI: 10.1186/s13012-016-0464-9
- 45Wong G, Westhorp G, Manzano A, Greenhalgh J, Jagosh J, Greenhalgh T. RAMESES II reporting standards for realist evaluations. BMC Medicine. 2016; 14(1): 96. DOI: 10.1186/s12916-016-0643-1
- 46Project. TRI. Retroduction in realist evaluation; 2017.
- 47Riordan F, McGrath N, McHugh SM, Kearney PM, Twamley H, Smyth N. Overview of Activity Data in Primary Care from Clinical Nurse Specialist (CNSp) Diabetes Integrated Care Group National Clinical Programme for Diabetes (NCPD); 2018. Available from:
https://www.hse.ie/eng/about/who/cspd/ncps/diabetes/resources/an-overview-of-activity-data-from-clinical-nurse-specialist-report-rev-8–2019.pdf [Accessed 5th May 2022]. - 48College of GPs withdraws from HSE clinical programmes in protest over fees [press release]. The Irish Times (online); 2013. Available from:
https://www.irishtimes.com/news/ireland/irish-news/college-of-gps-withdraws-from-hse-clinical-programmes-in-protest-over-fees-1.1466517 . [Accessed 5th May 2022]. - 49Stirman SW, Miller CJ, Toder K, Calloway A. Development of a framework and coding system for modifications and adaptations of evidence-based interventions. Implementation Science. 2013; 8: 65. DOI: 10.1186/1748-5908-8-65
- 50Hancock HC, Easen PR. The decision-making processes of nurses when extubating patients following cardiac surgery: an ethnographic study. International Journal of Nursing Studies. 2006; 43(6): 693–705. DOI: 10.1016/j.ijnurstu.2005.09.003
- 51Rycroft-Malone J, Fontenla M, Seers K, Bick D. Protocol-based care: the standardisation of decision-making? Journal of Clinical Nursing. 2009; 18(10): 1490–500. DOI: 10.1111/j.1365-2702.2008.02605.x
- 52Darker CD, Nicolson GH, Carroll A, Barry JM. The barriers and facilitators to the implementation of National Clinical Programmes in Ireland: using the MRC framework for process evaluations. BMC Health Services Research. 2018; 18(1): 733. DOI: 10.1186/s12913-018-3543-6
- 53Riordan F, McGrath N, Dinneen SF, Kearney PM, McHugh SM. ‘Sink or Swim’: A Qualitative Study to Understand How and Why Nurses Adapt to Support the Implementation of Integrated Diabetes Care. International Journal of Integrated Care. 2019; 19(2): 2. DOI: 10.5334/ijic.4215
- 54Martin GP, Currie G, Finn R. Reconfiguring or reproducing intra-professional boundaries? Specialist expertise, generalist knowledge and the ‘modernization’ of the medical workforce. Social Science & Medicine. 2009; 68(7): 1191–8. DOI: 10.1016/j.socscimed.2009.01.006
- 55Nancarrow SA, Borthwick AM. Dynamic professional boundaries in the healthcare workforce. Sociology of Health and Illness. 2005; 27(7): 897–919. DOI: 10.1111/j.1467-9566.2005.00463.x
- 56Rushforth B, McCrorie C, Glidewell L, Midgley E, Foy R. Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review. British Journal of General Practice. 2016; 66(643): e114–27. DOI: 10.3399/bjgp16X683509
- 57Hunter B. Implementing a national policy initiative to support normal birth: lessons from the All Wales Clinical Pathway for Normal Labour. Journal of Midwifery & Women’s Health. 2010; 55(3): 226–33. DOI: 10.1016/j.jmwh.2009.12.014
- 58Cheyne H, Abhyankar P, McCourt C. Empowering change: realist evaluation of a Scottish Government programme to support normal birth. Midwifery. 2013; 29(10): 1110–21. DOI: 10.1016/j.midw.2013.07.018
- 59Huby G, Harris FM, Powell AE, Kielman T, Sheikh A, Williams S, et al. Beyond professional boundaries: relationships and resources in health services’ modernisation in England and Wales. Sociology of Health and Illness. 2014; 36(3): 400–15. DOI: 10.1111/1467-9566.12067
- 60Ling T, Brereton L, Conklin A, Newbould J, Roland M. Barriers and facilitators to integrating care: experiences from the English Integrated Care Pilots. International journal of Integrated Care. 2012; 12:
e129 . DOI: 10.5334/ijic.982 - 61Pearson C, Watson N. Implementing health and social care integration in Scotland: Renegotiating new partnerships in changing cultures of care. Health & Social Care in the Community. 2018; 26(3): e396–e403. DOI: 10.1111/hsc.12537
- 62Sunaert P, Bastiaens H, Feyen L, Snauwaert B, Nobels F, Wens J, et al. Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: “the Belgian experience”. BMC Health Services Research. 2009; 9(1): 152. DOI: 10.1186/1472-6963-9-152
- 63Longpre C, Dubois CA. Fostering development of nursing practices to support integrated care when implementing integrated care pathways: what levers to use? BMC Health Services Research. 2017; 17(1): 790. DOI: 10.1186/s12913-017-2687-0
- 64Lawton R, Parker D. Procedures and the professional: the case of the British NHS. Social Science & Medicine. 1999; 48(3): 353–61. DOI: 10.1016/S0277-9536(98)00345-1
- 65Barach P, Phelps G. Clinical sensemaking: a systematic approach to reduce the impact of normalised deviance in the medical profession. Journal of the Royal Society of Medicine. 2013; 106(10): 387–90. DOI: 10.1177/0141076813505045
- 66Stone MA, Charpentier G, Doggen K, Kuss O, Lindblad U, Kellner C, et al. Quality of care of people with type 2 diabetes in eight European countries: findings from the Guideline Adherence to Enhance Care (GUIDANCE) study. Diabetes Care. 2013; 36(9): 2628–38. DOI: 10.2337/dc12-1759
- 67Khunti K, Ceriello A, Cos X, De Block C. Achievement of guideline targets for blood pressure, lipid, and glycaemic control in type 2 diabetes: A meta-analysis. Diabetes Research and Clinical Practice. 2017; 137: 137–48. DOI: 10.1016/j.diabres.2017.12.004
- 68Barry MBK, Brick A, Morgenroth E, Normand C, O’Reilly J, Thomas S, Wiley M. Projecting the Impact of Demographic Change on the Demand for and Delivery of Health Care in Ireland. Dublin: Economic and Social Research Institute; 2009.
- 69McDaid DWM, Maresso M, Mossialos E.
Ireland: Health system review . Health Systems in Transition. European Observatory on Health Systems and Policies; 2009. - 70National Doctor Training and Planning HD. Medical Workforce Planning. Future Demand for General Practitioners. 2015–2025. Dublin: Health Service Executive; 2015.
- 71Majeed A. Shortage of general practitioners in the NHS. BMJ. 2017; 358: j3191. DOI: 10.1136/bmj.j3191
- 72Papp M, Korosi L, Sandor J, Nagy C, Juhasz A, Adany R. Workforce crisis in primary healthcare worldwide: Hungarian example in a longitudinal follow-up study. BMJ Open. 2019; 9(7):
e024957 . DOI: 10.1136/bmjopen-2018-024957 - 73Berwick DM, Hackbarth AD. Eliminating Waste in US Health Care. JAMA. 2012; 307(14): 1513–6. DOI: 10.1001/jama.2012.362
- 74Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion required to avoid projected primary care physician shortages by 2035. Annals of Family Medicine. 2015; 13(2): 107–14. DOI: 10.1370/afm.1760
- 75Bryant-Lukosius D, Dicenso A, Browne G, Pinelli J. Advanced practice nursing roles: development, implementation and evaluation. Journal of Advanced Nursing. 2004; 48(5): 519–29. DOI: 10.1111/j.1365-2648.2004.03234.x
- 76Contandriopoulos D, Brousselle A, Dubois C-A, Perroux M, Beaulieu M-D, Brault I, et al. A process-based framework to guide nurse practitioners integration into primary healthcare teams: results from a logic analysis. BMC Health Services Research. 2015; 15: 78. DOI: 10.1186/s12913-015-0731-5
- 77Powell BJ, Waltz TJ, Chinman MJ, Damschroder LJ, Smith JL, Matthieu MM, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implementation Science. 2015; 10: 21. DOI: 10.1186/s13012-015-0209-1
- 78Flodgren G, Parmelli E, Doumit G, Gattellari M, O’Brien MA, Grimshaw J, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2011; 8. DOI: 10.1002/14651858.CD000125.pub4
- 79Willard C, Luker K. Working with the team: strategies employed by hospital cancer nurse specialists to implement their role. Journal of Clinical Nursing. 2007; 16(4): 716–24. DOI: 10.1111/j.1365-2702.2006.01560.x
- 80Fulop NJ, Ramsay AI, Perry C, Boaden RJ, McKevitt C, Rudd AG, et al. Explaining outcomes in major system change: a qualitative study of implementing centralised acute stroke services in two large metropolitan regions in England. Implementation Science. 2016; 11(1): 80. DOI: 10.1186/s13012-016-0445-z
- 81Djulbegovic B, Elqayam S. Many faces of rationality: Implications of the great rationality debate for clinical decision-making. Journal of Evaluation in Clinical Practice. 2017; 23(5): 915–22. DOI: 10.1111/jep.12788
- 82Health Service Executive. Chronic Disease Management Programme; 2020. Available from:
https://www.hse.ie/eng/about/who/gmscontracts/2019agreement/chronic-disease-management-programme/ [Accessed 5th May 2022]. - 83Suter E, Oelke ND, Adair CE, Armitage GD. Ten Key Principles for Successful Health Systems Integration. Healthcare Quarterly (Toronto, Ontario). 2009; 13(Spec No): 16–23. DOI: 10.12927/hcq.2009.21092
- 84Jackson SF, Kolla G. A New Realistic Evaluation Analysis Method: Linked Coding of Context, Mechanism, and Outcome Relationships. American Journal of Evaluation. 2012; 33(3): 339–349. DOI: 10.1177/1098214012440030
