Transition from specialist to primary diabetes care: A qualitative study of perspectives of primary care physicians

<p>Abstract</p> <p>Background</p> <p>The growing prevalence of diabetes and heightened awareness of the benefits of early and intensive disease management have increased service demands and expectations not only of primary care physicians but also of diabetes specialists. While research has addressed issues related to referral into specialist care, much less has been published about the transition from diabetes specialists back to primary care. Understanding the concerns of family physicians related to discharge of diabetes care from specialist centers can support the development of strategies that facilitate this transition and result in broader access to limited specialist services. This study was undertaken to explore primary care physician (PCP) perspectives and concerns related to reassuming responsibility for diabetes care after referral to a specialized diabetes center.</p> <p>Methods</p> <p>Qualitative data were collected through three focus groups. Sessions were audio-taped and transcribed verbatim. Data were coded and sorted with themes identified using a constant comparison method. The study was undertaken through the regional academic referral center for adult diabetes care in Ottawa, Canada. Participants included 22 primary care physicians representing a variety of referral frequencies, practice types and settings.</p> <p>Results</p> <p>Participants described facilitators and barriers to successful transition of diabetes care at the provider, patient and systems level. Major facilitators included clear communication of a detailed, structured plan of care, ongoing access to specialist services for advice or re-referral, continuing education and mentoring for PCPs. Identified provider barriers were gaps in PCP knowledge and confidence related to diabetes treatment, excessive workload and competing time demands. Systems deterrents included reimbursement policies for health professionals and inadequate funding for diabetes medications and supplies. At the PCP-patient interface, insufficient patient confidence or trust in PCP's ability to manage diabetes, poor motivation and "non-compliance" emerged as potential patient barriers to transition. Incongruence between PCP attitudes and expectations related to diabetes self-management and those of patients who had attended a multidisciplinary specialist center was also observed.</p> <p>Conclusion</p> <p>This study underlines the breadth of PCP concerns related to transition of diabetes care and the importance of this topic to them. While tools that promote timely information flow and care planning are cornerstones to successful transition, and may be sufficient for some practitioners, appropriately resourced decision support and education strategies should also be available to enhance PCP capacity and readiness to resume diabetes care after referral to a specialist center. Characteristics of the patient-care provider relationship that impact discharge were identified and are worthy of further research.</p

Into the abyss: diabetes process of care indicators and outcomes of defaulters from a Canadian tertiary care multidisciplinary diabetes clinic

Abstract Background Continuity of care is essential for good quality diabetes management. We recently found that 46% of patients defaulted from care (had no contact with the clinic for 18 months after a follow-up appointment was ordered) in a Canadian multidisciplinary tertiary care diabetes clinic. The primary aim was to compare characteristics, diabetes processes of care, and outcomes from referral to within 1 year after leaving clinic or to the end of the follow-up period among those patients who defaulted, were discharged or were retained in the clinic. Methods Retrospective cohort study of 193 patients referred to the Foustanellas Endocrine and Diabetes Center (FEDC) for type 2 diabetes from January 1, 2005 to June 30, 2005. The FEDC is the primary academic referral centre for the Ottawa Region and provides multidisciplinary diabetes management. Defaulters (mean age 58.5 ± 12.5 year, 60% M) were compared to patients who were retained in the clinic (mean age 61.4 ± 10.47 years, 49% M) and those who were formally discharged (mean age 61.5 ± 13.2 years, 53.3% M). The chart audit population was then individually linked on an individual patient basis for laboratory testing, physician visits billed through OHIP, hospitalizations and emergency room visits using Ontario health card numbers to health administrative data from the Ministry of Health and Long-Term Care at the Institute for Clinical and Evaluative Sciences (ICES). Results Retained and defaulted patients had significantly longer duration of diabetes, more microvascular complications, were more likely to be on insulin and less likely to have a HbA1c < 7.0% than patients discharged from clinic. A significantly lower proportion of patients who defaulted from tertiary care received recommended monitoring for their diabetes (HbA1c measurements, lipid measurements, and periodic eye examinations), despite no difference in median number of visits to a primary care provider (PCP). Emergency room visits were numerically higher in the defaulters group. Conclusions Patients defaulting from a tertiary care diabetes hospital do not receive the recommended monitoring for their diabetes management despite attending PCP appointments. Efforts should be made to minimize defaulting in this group of individuals

Geographic versus institutional drivers of nitrogen footprints: a comparison of two urban universities

Excess reactive nitrogen (N) is linked to a myriad of environmental problems that carry large social costs. Nitrogen footprint tools can help institutions understand how their direct and indirect activities are associated with N release to the environment through energy use, food, and transportation. However, little is known about how geographic context shapes the environmental footprints of institutions. Defining the system boundaries over which institutions are responsible and able to control individual drivers of N footprints is also a challenge. Here, we compare and contrast the circa 2017 N footprints for two research intensive universities located in Montréal, Canada, with a combined full-time equivalent campus population of ∼83 000. Our estimate of McGill University’s N footprint (121.2 t N yr ^−1 ) is 48% greater than Université de Montréal’s (74.1 t N yr ^−1 ), which is also reflected on a per capita basis (3.3 and 1.6 kg N capita ^−1 yr ^−1 , respectively). Key institutional factors that explain the differences include McGill’s larger residential and international student populations, research farm, and characteristics of its on-campus fuel use. We use a series of counterfactual scenarios to test how shared urban geographic context factors lead to an effective reduction of the N footprints at both universities: the relatively small direct role of both institutions in food intake on campus (29%–68% reduction compared to a counterfactual scenario), energy from hydroelectricity (17%–21% reduction), and minimal car commuting by students (2%–3% reduction). In contrast, the near-zero N removal from the municipal wastewater system effectively increases the N footprints (11%–13% increase compared to a modest N removal and offset scenario). Our findings suggest that a shared geographic context of a dense city with plentiful off-campus housing, food options, and access to hydroelectricity shapes the absolute N footprints of Montréal’s two main universities more than the divergent institutional characteristics that influence their relative N footprints