Experiences with tailoring of primary diabetes care in well-organised general practices: a mixed-methods study

Background Dutch standard diabetes care is generally protocol-driven. However, considering that general practices wish to tailor diabetes care to individual patients and encourage self-management, particularly in light of current COVID-19 related constraints, protocols and other barriers may hinder implementation. The impact of dispensing with protocol and implementation of self-management interventions on patient monitoring and experiences are not known. This study aims to evaluate tailoring of care by understanding experiences of well-organised practices 1) when dispensing with protocol; 2) determining the key conditions for successful implementation of self-management interventions; and furthermore exploring patients' experiences regarding dispensing with protocol and self-management interventions. Methods in this mixed-methods prospective study, practices (n = 49) were invited to participate if they met protocol-related quality targets, and their adult patients with well-controlled type 2 diabetes were invited if they had received protocol-based diabetes care for a minimum of 1 year. For practices, study participation consisted of the opportunity to deliver protocol-free diabetes care, with selection and implementation of self-management interventions. For patients, study participation provided exposure to protocol-free diabetes care and self-management interventions. Qualitative outcomes (practices: 5 focus groups, 2 individual interviews) included experiences of dispensing with protocol and the implementation process of self-management interventions, operationalised as implementation fidelity. Quantitative outcomes (patients: routine registry data, surveys) consisted of diabetes monitoring completeness, satisfaction, wellbeing and health status at baseline and follow-up (24 months). Results Qualitative: In participating practices ( = 4), dispensing with protocol encouraged reflection on tailored care and selection of various self-management interventions nA focus on patient preferences, team collaboration and intervention feasibility was associated with high implementation fidelity Quantitative: In patients ( = 126), likelihood of complete monitoring decreased significantly after two years (OR 0.2 (95% CI 0.1-0.5), < 0.001) npSatisfaction decreased slightly (- 1.6 (95% CI -2.6;-0.6), = 0.001) pNon-significant declines were found in wellbeing (- 1.3 (95% CI -5.4; 2.9), p = 0.55) and health status (- 3.0 (95% CI -7.1; 1.2), p = 0.16). Conclusions To tailor diabetes care to individual patients within well-organised practices, we recommend dispensing with protocol while maintaining one structural annual monitoring consultation, combined with the well-supported implementation of feasible self-management interventions. Interventions should be selected and delivered with the involvement of patients and should involve population preferences and solid team collaborations.Public Health and primary carePrevention, Population and Disease management (PrePoD

Socioeconomic status is not associated with delivery of care in people with diabetes but does modify HbA1c levels: an observational cohort study (ELZHA-cohort 1)

BackgroundStructured primary diabetes care within a collectively supported setting is associated with better monitoring of biomedical and lifestyle-related target indicators among people with type 2 diabetes and with better HbA1c levels. Whether socioeconomic status affects delivery of care in terms of monitoring and its association with HbA1c levels within this approach, is unclear. This study aims to understand whether, within a structured care approach, 1) socioeconomic categories differ concerning diabetes monitoring as recommended; 2) socioeconomic status modifies the association between monitoring as recommended and HbA1c.MethodsObservational real-life cohort study with primary care registry data from general practitioners within diverse socioeconomic areas, who are supported with implementation of structured diabetes care. People with type 2 diabetes mellitus were offered quarterly diabetes consultations. 'Monitoring as recommended' by professional guidelines implied minimally one annual registration of HbA1c, systolic blood pressure, LDL, BMI, smoking behaviour and physical activity. Regarding socioeconomic status, deprived, advantageous urban and advantageous suburban categories were compared to the intermediate category concerning 1) recommended monitoring; 2) association between recommended monitoring and HbA1c.ResultsAim 1 (n=13,601 people): Compared to the intermediate socioeconomic category, no significant differences in odds of being monitored as recommended were found in the deprived (OR 0.45 (95%CI 0.19-1.08)), advantageous-urban (OR 1.27 (95%CI 0.46-3.54)) and advantageous- suburban (OR 2.32 (95%CI 0.88-6.08)) categories. Aim 2 (n=11,164 people): People with recommended monitoring had significantly lower HbA1c levels than incompletely-monitored people (-2.4 (95%CI -2.9;-1.8)mmol/mol). SES modified monitoring-related HbA1c differences, which were significantly higher in the deprived (-3.3 (95%CI -4.3;-2.4)mmol/mol) than the intermediate category (-1.3 (95%CI -2.2;-0.4)mmol/mol). Conclusions Within a structured diabetes care setting, socioeconomic status is not associated with recommended monitoring. Socioeconomic differences in the association between recommended monitoring and HbA1c levels advocate further exploration of practice and patient-related factors contributing to appropriate monitoring and for care adjustment to population needs.Prevention, Population and Disease management (PrePoD)Public Health and primary car

Association between full monitoring of biomedical and lifestyle target indicators and HbA(1c) level in primary type 2 diabetes care: an observational cohort study (ELZHA-cohort 1)

Prevention, Population and Disease management (PrePoD)Public Health and primary car

Association between GP participation in a primary care group and monitoring of biomedical and lifestyle target indicators in people with type 2 diabetes: a cohort study (ELZHA cohort-1)

Objective Whether care group participation by general practitioners improves delivery of diabetes care is unknown. Using 'monitoring of biomedical and lifestyle target indicators as recommended by professional guidelines' as an operationalisation for quality of care, we explored whether (1) in new practices monitoring as recommended improved a year after initial care group participation (aim 1); (2) new practices and experienced practices differed regarding monitoring (aim 2).Design Observational, real-life cohort study.Setting Primary care registry data from Eerstelijns Zorggroep Haaglanden (ELZHA) care group.Participants Aim 1: From six new practices (n=538 people with diabetes) that joined care group ELZHA in January 2014, two practices (n=211 people) were excluded because of missing baseline data; four practices (n=182 people) were included. Aim 2: From all six new practices (n=538 people), 295 individuals were included. From 145 experienced practices (n=21 465 people), 13 744 individuals were included.Exposure Care group participation includes support by staff nurses on protocolised diabetes care implementation and availability of a system providing individual monitoring information. 'Monitoring as recommended' represented minimally one annual registration of each biomedical (HbA1c, systolic blood pressure, low-density lipoprotein) and lifestyle-related target indicator (body mass index, smoking behaviour, physical exercise).Primary outcome measures Aim 1: In new practices, odds of people being monitored as recommended in 2014 were compared with baseline (2013). Aim 2: Odds of monitoring as recommended in new and experienced practices in 2014 were compared.Results Aim 1: After 1-year care group participation, odds of being monitored as recommended increased threefold (OR 3.00, 95% CI 1.84 to 4.88, p<0.001). Aim 2: Compared with new practices, no significant differences in the odds of monitoring as recommended were found in experienced practices (OR 1.21, 95% CI 0.18 to 8.37, p=0.844).Conclusions We observed a sharp increase concerning biomedical and lifestyle monitoring as recommended after 1-year care group participation, and subsequently no significant difference between new and experienced practices-indicating that providing diabetes care within a collective approach rapidly improves registration of care

Differences in life history traits of related Epilobium species : clonality, seed size and seed number

Small changes in morphology can affect the performance and functions of organisms and hence their ecological success. In modular constructed plants, contrasting growth strategies may be realized by differences in the spatial arrangement and size of shoots. Such differences change the way in which meristems and resources are assigned to various functions during the lifespan of a plant. If such changes include the capacity to spread clonally, sexual reproduction may also be affected. I compare patterns in vegetative growth and sexual reproductive traits in four allopatric species of Epilobium which are sometimes considered as subspecies of a single polymorphic taxon. The four species differ in the location of the buds which annually renew the aerial shoot system. E. dodonaei and E. steveni do not spread clonally and are characterized by a shrub-like habit. E. fleischeri, a species occurring only in the Alps, and E. colchicum, which occurs in the upper region of the Caucasus mountains, both produce buds on horizontal roots or plagiotropic shoots. Both alpine species exhibiting clonal growth have smaller shoots, fewer fruits and smaller seeds than the lowland species. An intraspecific trade-off between seed number per fruit and seed mass is realized. Both alpine species produce mon seeds per fruit at the expense of seed mass. The morphological relationship between the four species and their geographical distribution suggest that clonal growth in E. fleischeri (restricted to the Alps) and E. colchicum (restricted to the Caucasus) is adaptively associated with the stressful conditions of alpine habitats. Our results suggest that clonal growth is not necessarily correlated with reduced reproduction by seeds. The success of plants which are already established may largely depend on clonal spread, but the colonization of new habitats depends on the production of a large number of small seeds with high dispersability