CCT Assessment Design Workshop

This guest lecture by Dr O\u27 Riordan explores assessment types and principles, assessment feedback and technology enhanced assessment

Improving the quality of diabetes care in a real world community context: influences, trends, and the implementation of a model of integrated care

Background and aim: Despite consensus on what optimal diabetes care should look like, this is not always achieved in ‘real world’ practice. Attention has shifted from solely testing the effectiveness of interventions to improve diabetes care, to also trying to uncover the influences, the how and why they work. Integrated care, organising care delivery within and between services, is a strategy to improve the quality of diabetes care; however, few studies have examined its implementation and whether quality improvements can be sustained. This thesis aims to understand whether and how integrated diabetes care can improve and sustain the quality of care in a real world community context using two approaches to integrated care in the Irish health system, a bottom-up locally-driven (structured primary care) initiative and recent top-down nationally-led reforms (a new model of integrated care supported by diabetes nurse specialists (DNS)). Methods: A systematic review comprising a narrative synthesis and meta-analysis was conducted to identify the evidence on physician and practice factors associated with the quality of diabetes primary care management. Trends in process of care recording and intermediate patient clinical outcomes (i.e. risk factors; blood pressure, cholesterol, HbA1c, creatinine) were examined over time using a series of cross-sections (1998, 2003, 2008, and 2016) from an existing structured primary care initiative. Data from the original cohort enrolled in this programme in 1999, were used to examine all-cause mortality and survival among people with diabetes, comparing mortality to the general population using Standardised Mortality Ratios (SMR). Excess mortality was compared with international estimates. The intended role of both hospital and community DNS is to support integrated care by managing patients with complicated type 2 diabetes, liaise with other professionals, deliver professional and patient education, and clinics. A national survey of DNS was conducted to examine their role. Interviews and focus groups were conducted with DNS, purposively sampled by region and type (hospital or community-based), to understand how they support the implementation of integrated care, including what factors influence their behaviours. Results: Physician factors (female gender, younger age, and a higher volume of patients with diabetes), and practice factors (Electronic Health Record (EHR) and low deprivation) were associated with higher quality of care. Process of care recording delivered by the structured care programme improved significantly over time (p < 0.001), although there was levelling-off in later years. Mortality among the original cohort was greater than the background population (overall SMR = 1.20 (95% Confidence Interval: 1.01-1.42)) though lower than some international estimates. Most DNS preformed their intended role. However, nurse-led clinics had variable support from other specialities, and access to the community DNS service was not available to all GPs. From qualitative analysis there was evidence that community DNS had to adapt and use initiative to make integrated care ‘workable’: responding to the lack of an integrated EHR between primary and secondary care by using workarounds, adapting to the lack of multidisciplinary team “safety net” in the community by working more autonomously, linking in with professional networks as an alternative ‘safety net’, managing role misconceptions by colleagues and managers, and adapting their service to “blend in” with differences in diabetes care organisation and experience at practices. Conclusions Integrated diabetes care within primary care is feasible in a real world community setting, achieving improvements over time, and integrated care across services is ‘workable’ through innovation and adaptation in a complex healthcare context. To scale up integrated care nationally, making this model available to all patients, practices may need targeted support, based on physician practice profile or other factors (e.g. information systems, deprivation, experience) to improve and organise diabetes care delivery. To embed and sustain integrated care requires system-level investment in building a supportive culture (e.g. acceptance of new roles, supporting professional networks) and infrastructure (e.g. integrated EHRs, access to specialists in the community or across boundaries). Integrated care should continue to be evaluated as services are delivered, recognising the local and system-level context (e.g. physician factors, EHRs, role understanding, available community resources) can challenge efforts to improve care. There is a need to learn from service delivery as it is implemented and consider how to guide adaptations to ensure integrated care in the real world is both ‘workable’ and effective

The role of nurse specialists in the delivery of integrated diabetes care: a cross-sectional survey of diabetes nurse specialist services

Objectives: International evidence suggests the diabetes nurse specialist (DNS) has a key role in supporting integrated management of diabetes. We examine whether hospital and community DNS currently support the integration of care, examine regional variation in aspects of the service relevant to the delivery of integrated care and identify barriers to service delivery and areas for improvement. Design: A cross-sectional survey of hospital and community-based DNS in Ireland. Methods: Between September 2015 and April 2016, a 67-item online survey, comprising closed and open questions on their clinical role, diabetes clinics, multidisciplinary working, and barriers and facilitators to service delivery, was administered to all eligible DNS (n=152) in Ireland. DNS were excluded if they were retired or on maternity leave or extended leave. Results: The response rate was 66.4% (n=101): 60.6% (n=74) and 89.3% (n=25) among hospital and community DNS, respectively. Most DNS had patients with stable (81.8%) and complicated type 2 diabetes mellitus (89.9%) attending their service. The majority were delivering nurse-led clinics (81.1%). Almost all DNS had a role liaising with (91%), and providing support and education to (95%), other professionals. However, only a third reported that there was local agreement on how their service should operate between the hospital and primary care. Barriers to service delivery that were experienced by DNS included deficits in the availability of specialist staff (allied health professionals, endocrinologists and DNS), insufficient space for clinics, structured education and issues with integration. Conclusions: Delivering integrated diabetes care through a nurse specialist-led approach requires that wider service issues, including regional disparities in access to specialist resources and formalising agreements and protocols on multidisciplinary working between settings, be explicitly addressed

What works to recruit general practices to trials? A rapid review [version 1; peer review: 2 approved, 1 not approved]

Background: Recruitment challenges are a barrier to the conduct of trials in general practice, yet little is known about which recruitment strategies work best to recruit practices for randomised controlled trials (RCTs). We aimed to describe the types of strategies used to recruit general practices for trials and synthesize any available evidence of effectiveness. Methods: We conducted a rapid evidence review in line with guidance from Tricco et al. Eligible studies reported or evaluated any strategy to improve practice recruitment to participate in clinical or implementation RCTs. PubMed, Embase, and Cochrane Central Library were searched from inception to June 22nd, 2021. Reference lists of included studies were screened. Data were synthesized narratively. Results: Over 9,162 articles were identified, and 19 studies included. Most (n=13, 66.7%) used a single recruitment strategy. The most common strategies were: in-person practice meetings/visits by the research team (n=12, 63.2%); phone calls (n=10, 52.6%); financial incentives (n=9, 47.4%); personalised emails (n=7, 36.8%) or letters (n=6, 52.6%) (as opposed to email ‘blasts’ or generic letters); targeting practices that participated in previous studies or with which the team had existing links (n=6, 31.6%) or targeting of practices within an existing practice or research network (n=6, 31.6%).  Three studies reporting recruitment rates >80%, used strategies such as invitation letters with a follow-up phone call to non-responders, presentations by the principal investigator and study coordinator, or in-person meetings with practices with an existing affiliation with the University or research team.  Conclusions: Few studies directly compared recruitment approaches making it difficult to draw conclusions about their comparative effectiveness. However, the role of more personalised letter/email, in-person, or phone contact, and capitalising on existing relationships appears important. Further work is needed to standardise how recruitment methods are reported and to directly compare different recruitment strategies within one study. PROSPERO registration: CRD42021268140 (15/08/2021

Sustaining quality in the community: trends in the performance of a structured diabetes care programme in primary care over 16 years

Aim: To examine the quality of care delivered by a structured primary care‐led programme for people with Type 2 diabetes mellitus in 1999–2016. Methods: The Midland Diabetes Structured Care Programme provides structured primary care‐led management. Trends over time in care processes were examined (using a chi‐squared trend test and age‐ and gender‐adjusted logistic regression). Screening and annual review attendance were reviewed. A composite of eight National Institute for Health and Care Excellence‐recommended processes was used as a quality indicator. Participants who were referred to diabetes nurse specialists were compared with those not referred (Student's t‐test, Pearson's chi‐squared test, Wilcoxon–Mann–Whitney test). Proportions achieving outcome targets [HbA1c ≤58 mmol/mol (7.5%), blood pressure ≤140/80 mmHg, cholesterol <5.0 mmol/l] were calculated. Results: Data were available for people with diabetes aged ≥18 years: 1998/1999 (n=336); 2003 (n=843); 2008 (n=988); and 2016 (n=1029). Recording of some processes improved significantly over time (HbA1c, cholesterol, blood pressure, creatinine), and in 2016 exceeded 97%. Foot assessment and annual review attendance declined. In 2016, only 29% of participants had all eight National Institute for Health and Care Excellence processes recorded. A higher proportion of people with diabetes who were referred to a diabetes nurse specialist had poor glycaemic control compared with those not referred. The proportions meeting blood pressure and lipid targets increased over time. Conclusions: Structured primary care led to improvements in the quality of care over time. Poorer recording of some processes, a decline in annual review attendance, and participants remaining at high risk suggest limits to what structured care alone can achieve. Engagement in continuous quality improvement to target other factors, including attendance and self‐management, may deliver further improvements. What's new? Most studies on the impact of multifaceted, structured, primary care programmes on the quality of diabetes care have a short follow‐up time; studies demonstrating long‐term sustainability are lacking. We found significant improvements in quality of care (care processes delivered) among practices enrolled in a primary care programme over a 16‐year period. Lifestyle processes were less well recorded, and there were declines in foot assessment and attendance at annual review, and participants continued to have poor risk factor control. Programmes may be limited when operating within the constraints of primary care and the wider service context

Understanding the uptake of a national retinopathy screening programme: An audit of patients with diabetes in two large primary care centres [version 1; peer review: awaiting peer review

Background: Diabetic retinopathy (DR) affects 8.2% of the Irish population with type 2 diabetes over 50 years and is one of the leading causes of blindness among working-age adults. Regular diabetic retinopathy screening (DRS) can reduce the risk of sight loss. In 2013, the new national screening programme (RetinaScreen) was introduced in Ireland. Maximising DRS uptake (consent to participate in the programme and attendance once invited) is a priority, therefore it is important to identify characteristics which determine DRS uptake among those with diabetes in Ireland. We report uptake in an Irish primary care population during the initial phase of implementation of RetinaScreen and investigate factors which predict consenting to participate in the programme. Methods: In two primary care practices, data were extracted from records of people with diabetes (type 1 and type 2) aged ≥18 years who were eligible to participate in RetinaScreen between November 2013 and August 2015. Records were checked for a RetinaScreen letter. RetinaScreen were contacted to establish the status of those without a letter on file. Multivariable Poisson regression was used to examine associations between socio-demographic variables and consenting. Adjusted incident rate ratios (IRR) with 95% CI were generated as a measure of association. Results: Of 722 people with diabetes, one fifth (n=141) were not registered with RetinaScreen. Of 582 who were registered, 63% (n=365) had participated in screening. Most people who consented subsequently attended (n=365/382, 96%). People who had attended another retinopathy screening service were less likely to consent (IRR 0.65 [95%CI 0.5-0.8]; p<0.001). Other predictors were not significantly associated with consent. Conclusions: Over one third of people eligible to participate in RetinaScreen had not consented. Research is needed to understand barriers and enablers of DRS uptake in the Irish context. Implementing strategies to improve DRS uptake (consent and attendance) should be a priority

‘Sink or Swim’: A Qualitative Study to Understand How and Why Nurses Adapt to Support the Implementation of Integrated Diabetes Care

Background: Integrated care, organising care delivery within and between services, is an approach to improve the quality of care. Existing specialist roles have evolved to work across settings and services to integrate care. However, there is limited insight into how these expanded roles are implemented, including how they may be shaped by context. This paper examines how new diabetes nurse specialists working across care boundaries, together with hospital-based diabetes nurse specialists, adapt to support the implementation of integrated care. Methods: We conducted semi-structured focus groups and interviews with diabetes nurse specialists purposively sampled by work setting and health service region (n = 30). Analysis was data-driven, coding actions or processes to stay closer to the data and using 'In Vivo' codes to preserve meaning. Findings: Community nurse specialists described facing a choice of “sink or swim” when appointed with limited guidance on their role. To ‘swim’ and implement their role, required them to use their initiative and adapt to the local context. When first appointed, both community and hospital nurse specialists actively managed misconceptions of their role by other staff. To establish clinics in general practices, community nurse specialists capitalised on professional contacts to access GPs who might utilise their role. They built GP trust by adopting practice norms and responding to individual needs. They adapted to the lack of a multidisciplinary team “safety net” in the community, by “practicing at a higher level”, working more autonomously. Developing professional links and pursuing on-going education was a way to create an alternative ‘safety net’ so as to feel confident in their clinical decision-making when working in the community. Workarounds facilitated information flow (i.e. patient blood results, treatment, and appointments) between settings in the absence of an electronic record shared between general practices and hospital settings. Conclusions: Flexibility and innovation facilitates a new way of working across boundaries. Successful implementation of nurse specialist-led integrated care requires strategies to address elements in the inner (differences in practice organisation, role acceptance) and outer (information systems) context

Physical and psychosomatic health outcomes in people bereaved by suicide compared to people bereaved by other modes of death: a systematic review

Background: Little research has been conducted into the physical health implications of suicide bereavement compared to other causes of death. There is some evidence that suicide bereaved parents have higher morbidity, particularly in terms of chronic illness. This systematic review aims to examine the physical and psychosomatic morbidities of people bereaved by a family member's suicide and compare them with family members bereaved by other modes of death. Methods: MEDLINE, EMBASE, CINAHL, and PsycINFO were searched from 1985 to February 2016. The search was re-run in March 2017. Peer-reviewed English language articles comparing suicide-bereaved family members to non-suicide bereaved family members on measures of physical or psychosomatic health were eligible for inclusion. Cohort, cross-sectional, case-control and cohort-based register studies were eligible for inclusion. A modified version of the Newcastle Ottawa Scale was used for quality assessment. Results were synthesised using narrative synthesis. Results: The literature search located 24 studies which met the inclusion criteria. Seven studies found statistically significant associations between physical health and suicide bereavement. Five of the studies found that suicide-bereaved family members were more likely to experience pain, more physical illnesses and poorer general health. They were also at increased risk of cardiovascular disease, hypertension, diabetes and chronic obstructive pulmonary disease. In contrast, another study in Denmark found that those bereaved by suicide had a lower risk of a number of physical health disorders, including cancers, diabetes, cardiovascular and chronic lower respiratory tract disorders compared to those bereaved by other causes of death. Additionally, a further study conducted in the United States found that suicide-bereaved children visited a GP less frequently than non-suicide bereaved children. Conclusions: Review findings are relevant for clinicians working with people bereaved by suicide as they highlight that such clients are at increased risk of several adverse physical health outcomes. Future research should examine health risk behaviours of suicide-bereaved and non-suicide bereaved family members as they may confound the association between exposure and outcome

A systematic review of methods to assess intake of fruits and vegetables among healthy European adults and children: a DEDIPAC (DEterminants of DIet and Physical Activity) study

Evidence suggests that health benefits are associated with consuming recommended amounts of fruits and vegetables (F&V), yet standardised assessment methods to measure F&V intake are lacking. The current review aims to identify methods to assess F&V intake among children and adults in pan-European studies and inform the development of the DEDIPAC (DEterminants of DIet and Physical Activity) toolbox of methods suitable for use in future European studies. A literature search was conducted using three electronic databases and by hand-searching reference lists. English-language studies of any design which assessed F&V intake were included in the review. Studies involving two or more European countries were included in the review. Healthy, free-living children or adults. The review identified fifty-one pan-European studies which assessed F&V intake. The FFQ was the most commonly used (n 42), followed by 24 h recall (n 11) and diet records/diet history (n 7). Differences existed between the identified methods; for example, the number of F&V items on the FFQ and whether potatoes/legumes were classified as vegetables. In total, eight validated instruments were identified which assessed F&V intake among adults, adolescents or children. The current review indicates that an agreed classification of F&V is needed in order to standardise intake data more effectively between European countries. Validated methods used in pan-European populations encompassing a range of European regions were identified. These methods should be considered for use by future studies focused on evaluating intake of F&V

Feasibility of an implementation intervention to increase attendance at diabetic retinopathy screening: protocol for a cluster randomised pilot trial

Background: Diabetic retinopathy screening (DRS) leads to the earlier detection of retinopathy and treatment that can prevent or delay the development of diabetes-related blindness. However, uptake continues to be sub-optimal in many countries, including Ireland. Routine management of type 2 diabetes largely takes place in primary care. As such, there may be an opportunity in primary care to introduce interventions to improve DRS uptake. However, few studies test the feasibility of interventions to enhance DRS uptake in this context. Our aim is to investigate the feasibility of an implementation intervention (IDEAs (Improving Diabetes Eye screening Attendance)) delivered in general practice to improve the uptake of the national DRS programme, RetinaScreen. Methods: The IDEAs study is a cluster randomised pilot trial with an embedded process evaluation and economic evaluation. Following stratification by practice size, eight general practices (clusters) will be randomly allocated to intervention (n = 4) or wait-list control groups (n = 4). The intervention will be delivered for 6 months, after which, it will be administered to wait-list control practices. The intervention is multi-faceted and comprises provider-level components (training, audit and feedback, health care professional prompt, reimbursement) and patient-level components (GP-endorsed reminder with information leaflet delivered opportunistically face-to-face, and systematically by phone and letter). Patient inclusion criteria are type 1 or type 2 diabetes and DRS programme non-attendance. A multi-method approach will be used to determine screening uptake, evaluate the trial and study procedures and examine the acceptability and feasibility of the intervention from staff and patient perspectives. Quantitative and qualitative data will be collected on intervention uptake and delivery, research processes and outcomes. Data will be collected at the practice, health professional and patient level. A partial economic evaluation will be conducted to estimate the cost of delivering the implementation intervention in general practice. Formal continuation criteria will be used to determine whether IDEAs should progress to a definitive trial. Discussion: Findings will determine whether IDEAsis feasible and acceptable and will be used to refine the intervention and study procedures. A definitive trial will determine whether IDEAs is a cost-effective intervention to improve DRS uptake and reduce diabetes-related blindness. Trial registration: ClinicalTrials.gov NCT03901898. Registered 3rd April 2019