Key Features for Successful Swedish Primary Diabetes Care – Reality or Fiction? : Nationwide studies of longitudinal follow-up, HbA1c levels and all-cause mortality in an organizational context

Aims To extend knowledge about the changes in Swedish primary diabetes care from 2006 to 2013 and investigate associations of personnel resources, organizational features and quality-of-work conditions of primary health-care centres (PHCCs) with individual HbA1c levels and all-cause mortality in people with type 2 diabetes mellitus (T2DM). Methods Information about organizational features, personnel resources and quality-of-work conditions were collected from responses of PHCC managers to the Swedish National Survey of the Quality and Organisation of Diabetes Care in Primary HealthCare (Swed-QOP) questionnaire. The longitudinal cross-sectional study included 74.3% and 76.4% of PHCCs in 2006 and 2013, respectively. Individual clinical data for 230,958 people with T2DM obtained from the Swedish National Diabetes Register were linked to the data from the Swed-QOP questionnaire. Individual data were linked to socio-economic and comorbidity data. All-cause mortality was followed up for a median of 4.2 years for 187,570 people with T2DM. Results The longitudinal follow-up study showed a decreased median PHCC list size but an increased median number of people with T2DM. The mean European Credit Transfer and Accumulation System (ECTS) credits in diabetes-specific education for registered nurses (RNs) increased. The number of PHCCs providing group education programs and involving the patient in goal setting remained low (I). PHCCs having diabetes teams and group education programs were associated with decreased HbA1c levels. Using call-recall system to general practitioners (GPs) was associated with increased HbA1c levels (II). Seven quality-of-work features were identified, of which Individualized treatment was associated with decreased HbA1c levels in people with controlled (≤ 52 mmol/mol), intermediate (53–69 mmol/mol) and uncontrolled (≥ 70 mmol/mol) HbA1c (III). GP staffing was associated with a decreased risk of early death and the mean ECTS credits in diabetes-specific and pedagogical education of RNs was associated with a decreased risk of early death in people aged ≥ 55 years and in men, respectively (IV). Conclusion This thesis adds to previous work on significant but less pronounced key features for successful organization of primary diabetes care, and indicates that the complexity of diabetes disease makes it difficult to identify success factors applicable to all people living with T2DM

The organisation of diabetes care for persons with type 2 diabetes mellitus : A nationwide cross-sectional study in Swedish primary health care

Aim To extend the current knowledge about changes in Swedish diabetes care from 2006 to 2013 (Paper I), and to investigate the association between personnel resources and organisational features of primary health care centres (PHCCs) and the individual level of glycated haemoglobin (HbA1c) among persons with type 2 diabetes mellitus (T2DM) (Paper II). Methods The longitudinal cross-sectional study described in Paper I included a total of 684 (74.3%) of eligible 921 PHCCs in 2006 and 880 (76.4%) of eligible 1152 PHCCs in 2013. The Swedish National Survey of the Quality and Organisation of Diabetes Care in Primary Healthcare (Swed-QOP) questionnaire was sent to PHCC managers in 2007 and 2014. In Paper II, persons with T2DM (n = 230 958) attending 846 PHCCs were included. The PHCC-level data for 2013 were obtained from the Swed-QOP questionnaire and the individual-level data for 2013 were obtained from the National Diabetes Register. These data were linked to national registers containing individual-level data on socio-economic status and comorbidities. Results From 2006 to 2013, the median list size of PHCCs decreased while the median number of persons with T2DM at the PHCC increased (all P < 0.001). The median number of whole time equivalent registered nurses (RNs) per 500 persons with T2DM increased from 0.64 in 2006 to 0.79 in 2013 (P < 0.001). Compared with 2006, 30% percentage points more PHCCs (17.0% in 2006 and 47.5% in 2013) had an RN with at least 16 European Credit Transfer and Accumulation System (ECTS) credits in diabetes-specific education in 2013 (P < 0.001). Access to an in-house psychologist increased from 25.9% in 2006 to 47.1% in 2013 (P < 0.001). No change was found regarding in-house access to dietitians, chiropodists, social workers or physiotherapists. Observed changes in the organisational features of PHCCs from 2006 to 2013 included increased frequency of medical check-ups, use of call–recall systems and use of systems for checking that persons with T2DM participated in annual visits to general practitioners (GPs) and RNs (all P < 0.05). Providing group education remained scarce in both years (Paper I). After adjusting for several important confounders, personnel resources associated with decreasing individual HbA1c levels were the number of ECTS credits in diabetes-specific education among RNs (P < 0.001) and the duration of regular visits to RNs (P < 0.001). However, the opposite effect (i.e., increased HbA1c levels) was found for the duration of visits to GPs (P < 0.001). Organisational features associated with decreased individual HbA1c levels were PHCCs having a diabetes team (P < 0.01) and providing group education (P < 0.01) (Paper II). Conclusions The findings presented in this thesis add important knowledge on evaluating changes in diabetes care in Sweden. Some findings can be interpreted as initiatives to focus on increasing the time RNs devote to caring for persons with T2DM, and in ensuring RNs undergo diabetes-specific education. Furthermore, factors such as diabetes-specific education, diabetes teams and group education were associated with lower individual HbA1c levels. These findings could stimulate decision-makers to prioritise these factors for offering high-quality, equitable care to persons with diabetes

Att åldras med hälsa : Om levnadsvanor och hälsa bland den äldsta befolkningen i Västmanland

Befolkningen i Sverige består till cirka 17 procent av äldre individer över 65 år. Att åldras med hälsa är en central byggsten inom det hälsofrämjande arbetet. Vid kartläggning och undersökning av de äldstas hälsa, levnadsvanor och livsstil kan hälsofrämjande insatser tillämpas, riktade mot dess behov. Goda levnadsvanor kan främja hälsa och förbygga sjukdomar och funktionsnedsättningar. Syftet för uppsatsen var att redogöra för skillnader mellan levnadsvanor, kön och att vara ensamboende i förhållande till hälsa i den äldsta befolkningen 85-99 år. Detta är en epidemiologisk studie med en kvantitativ ansats som baseras på ett slumpmässigt urval på 480 personer över 85 år i Västmanlands län, varav 249 (52 %) personer svarade på enkäten. Materialet utgår från den nationella befolkningsenkäten Hälsa på lika villkor med tilläggsfrågor från enkäten Liv och hälsa. Kvinnor har ett sämre allmänt hälsotillstånd jämfört med män och de äldsta som är fysiskt aktiva har i större utsträckning ett bättre allmänt hälsotillstånd jämfört med de som är fysiskt inaktiva. Det allmänna hälsotillståndet påverkades inte om de var ensamboende eller av deras alkoholvanor. Det allmänna hälsotillståndet och levnadsvanorna påverkas av många faktorer som samvarierar. Resultaten ur denna studie kan användas genom att öka kunskapen om de äldstas hälsa och levnadsvanor. The population of Sweden consists of about 17 percent of elderly individuals over 65. Aging with health is an important area in health promotion. By getting new information about the conditions of older peoples health, improved health promotion programs can be created, that are focusing on the elderly’s needs. Healthy lifestyles can prevent people to get diseases or disabilities. The purpose of this paper was to describe the differences between lifestyles, living alone and the general health in the oldest population 85-99 years. This is an epidemiological study with a quantitative approach based on a random sample of 480 people aged over 85 in Västmanland County, of which 249 (52%) people responded to the survey. The material is based on the national population survey Hälsa på lika villkor with additional questions from the survey, Liv och Hälsa. Women have a poorer general health compared to men. Physically active people have a better general health compared with individuals who are physical inactive. The general health was not affected if they were living alone or of theirs drinking habits. The general health and lifestyle habits are not affected by only one factor but several factors that correlates with each other. The results from this study can be used by increasing the knowledge of the oldest people’s health and lifestyles.

Key Features for Successful Swedish Primary Diabetes Care – Reality or Fiction? : Nationwide studies of longitudinal follow-up, HbA1c levels and all-cause mortality in an organizational context

Aims To extend knowledge about the changes in Swedish primary diabetes care from 2006 to 2013 and investigate associations of personnel resources, organizational features and quality-of-work conditions of primary health-care centres (PHCCs) with individual HbA1c levels and all-cause mortality in people with type 2 diabetes mellitus (T2DM). Methods Information about organizational features, personnel resources and quality-of-work conditions were collected from responses of PHCC managers to the Swedish National Survey of the Quality and Organisation of Diabetes Care in Primary HealthCare (Swed-QOP) questionnaire. The longitudinal cross-sectional study included 74.3% and 76.4% of PHCCs in 2006 and 2013, respectively. Individual clinical data for 230,958 people with T2DM obtained from the Swedish National Diabetes Register were linked to the data from the Swed-QOP questionnaire. Individual data were linked to socio-economic and comorbidity data. All-cause mortality was followed up for a median of 4.2 years for 187,570 people with T2DM. Results The longitudinal follow-up study showed a decreased median PHCC list size but an increased median number of people with T2DM. The mean European Credit Transfer and Accumulation System (ECTS) credits in diabetes-specific education for registered nurses (RNs) increased. The number of PHCCs providing group education programs and involving the patient in goal setting remained low (I). PHCCs having diabetes teams and group education programs were associated with decreased HbA1c levels. Using call-recall system to general practitioners (GPs) was associated with increased HbA1c levels (II). Seven quality-of-work features were identified, of which Individualized treatment was associated with decreased HbA1c levels in people with controlled (≤ 52 mmol/mol), intermediate (53–69 mmol/mol) and uncontrolled (≥ 70 mmol/mol) HbA1c (III). GP staffing was associated with a decreased risk of early death and the mean ECTS credits in diabetes-specific and pedagogical education of RNs was associated with a decreased risk of early death in people aged ≥ 55 years and in men, respectively (IV). Conclusion This thesis adds to previous work on significant but less pronounced key features for successful organization of primary diabetes care, and indicates that the complexity of diabetes disease makes it difficult to identify success factors applicable to all people living with T2DM

Key Features for Successful Swedish Primary Diabetes Care – Reality or Fiction? : Nationwide studies of longitudinal follow-up, HbA1c levels and all-cause mortality in an organizational context

Aims To extend knowledge about the changes in Swedish primary diabetes care from 2006 to 2013 and investigate associations of personnel resources, organizational features and quality-of-work conditions of primary health-care centres (PHCCs) with individual HbA1c levels and all-cause mortality in people with type 2 diabetes mellitus (T2DM). Methods Information about organizational features, personnel resources and quality-of-work conditions were collected from responses of PHCC managers to the Swedish National Survey of the Quality and Organisation of Diabetes Care in Primary HealthCare (Swed-QOP) questionnaire. The longitudinal cross-sectional study included 74.3% and 76.4% of PHCCs in 2006 and 2013, respectively. Individual clinical data for 230,958 people with T2DM obtained from the Swedish National Diabetes Register were linked to the data from the Swed-QOP questionnaire. Individual data were linked to socio-economic and comorbidity data. All-cause mortality was followed up for a median of 4.2 years for 187,570 people with T2DM. Results The longitudinal follow-up study showed a decreased median PHCC list size but an increased median number of people with T2DM. The mean European Credit Transfer and Accumulation System (ECTS) credits in diabetes-specific education for registered nurses (RNs) increased. The number of PHCCs providing group education programs and involving the patient in goal setting remained low (I). PHCCs having diabetes teams and group education programs were associated with decreased HbA1c levels. Using call-recall system to general practitioners (GPs) was associated with increased HbA1c levels (II). Seven quality-of-work features were identified, of which Individualized treatment was associated with decreased HbA1c levels in people with controlled (≤ 52 mmol/mol), intermediate (53–69 mmol/mol) and uncontrolled (≥ 70 mmol/mol) HbA1c (III). GP staffing was associated with a decreased risk of early death and the mean ECTS credits in diabetes-specific and pedagogical education of RNs was associated with a decreased risk of early death in people aged ≥ 55 years and in men, respectively (IV). Conclusion This thesis adds to previous work on significant but less pronounced key features for successful organization of primary diabetes care, and indicates that the complexity of diabetes disease makes it difficult to identify success factors applicable to all people living with T2DM

Diabetes care provided by national standards can improve patients' self‐management skills : A qualitative study of how people with type 2 diabetes perceive primary diabetes care

Background The increasing incidence of type 2 diabetes mellitus [T2DM] has resulted in extensive research into the characteristics of successful primary diabetes care. Even if self-management support and continuity are increasingly recognized as important, there is still a need for deeper understanding of how patients' experiences of continuity of care coincide with their needs for self-management and/or self-management support. Objective To gain a deeper understanding of how people with T2DM perceive Swedish primary diabetes care and self-management support. Methods This qualitative study used focus groups as the means for data collection. Participants were identified through a purposive sampling method differing in age, sex, diabetes duration and latest registered glycated haemoglobin level. Twenty-eight participants formed five focus groups. Qualitative content analysis was applied to interview transcripts. Results The main theme emerging from the focus group data was that diabetes care provided by national standards improved self-management skills. Two themes that emerged from the analysis were (a) the importance of a clarification of structures and procedures in primary diabetes care and (b) health-care staff 'being there' and providing support enables trust and co-operation to enhance self-management. Conclusions Individual patients' self-management resources are strengthened if the importance of providing relational continuity, management continuity and informational continuity is considered. Patients also need assistance on 'how' self-management activities should be performed. Patient contribution Prior to the study, one pilot focus group was conducted with patients to obtain their perspectives on the content of the planned focus groups; thus, patients were involved in both planning and conduct of the study

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

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 p < 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 (p < 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