Patients' views on interactions with practitioners for type 2 diabetes: a longitudinal qualitative study in primary care over 10 years

Measuring treatment burden in people with Type 2 Diabetes Mellitus (T2DM): a mixed-methods systematic review

BACKGROUND

Measuring treatment burden is important for the effective management of Type 2 Diabetes Mellitus (T2DM) care. The purpose of this systematic review was to identify the most robust approach for measuring treatment burden in people with T2DM based on existing evidence.

METHODS

Articles from seven databases were retrieved. Qualitative, quantitative, and mixed-methods studies examining treatment burden in adults with T2DM and/or reporting relevant experiences were included. A convergent segregated approach with a mixed-methods design of systematic review was employed, creating a measurement framework in a narrative review for consistent critical appraisal. The quality of included studies was assessed using the Joanna Briggs Institute tool. The measurement properties of the instruments were evaluated using the Consensus based Standards for selection of Health Measurement Instruments (COSMIN) checklist.

RESULTS

A total of 21,584 records were screened, and 26 articles were included, comprising 11 quantitative, 11 qualitative, and 4 mixed-methods studies. A thematic analysis of qualitative data extracted from the included articles summarised a measurement framework encompassing seven core and six associated measurements. The core measurements, including financial, medication, administrative, lifestyle, healthcare, time/travel, and medical information burdens, directly reflect the constructs pertinent to the treatment burden of T2DM. In contrast, the associated measurement themes do not directly reflect the burdens or are less substantiated by current evidence. The results of the COSMIN checklist evaluation demonstrated that the Patient Experience with Treatment and Self-management (PETS), Treatment Burden Questionnaire (TBQ), and Multimorbidity Treatment Burden Questionnaire (MTBQ) have robust instrument development processes. These three instruments, with the highest total counts combining the number of themes covered and "positive" ratings in COSMIN evaluation, were in the top tertile stratification, demonstrating superior applicability for measuring T2DM treatment burden.

CONCLUSIONS

This systematic review provides evidence for the currently superior option of measuring treatment burden in people with T2DM. It also revealed that most current research was conducted in well-resourced institutions, potentially overlooking variability in under-resourced settings.

Understanding Gaps in the Hypertension and Diabetes Care Cascade: Systematic Scoping Review

BACKGROUND

Hypertension and diabetes are global health challenges requiring effective management to mitigate their considerable burden. The successful management of hypertension and diabetes requires the completion of a sequence of stages, which are collectively termed the care cascade.

OBJECTIVE

This scoping review aimed to describe the characteristics of studies on the hypertension and diabetes care cascade and identify potential interventions as well as factors that impact each stage of the care cascade.

METHODS

The method of this scoping review has been guided by the framework by Arksey and O'Malley. We systematically searched MEDLINE, Embase, and Web of Science using terms pertinent to hypertension, diabetes, and specific stages of the care cascade. Articles published after 2011 were considered, and we included all studies that described the completion of at least one stage of the care cascade of hypertension and diabetes. Study selection was independently performed by 2 paired authors. Descriptive statistics were used to elucidate key patterns and trends. Inductive content analysis was performed to generate themes regarding the barriers and facilitators for improving the care cascade in hypertension and diabetes management.

RESULTS

A total of 128 studies were included, with 42.2% (54/128) conducted in high-income countries. Of them, 47 (36.7%) focused on hypertension care, 63 (49.2%) focused on diabetes care, and only 18 (14.1%) reported on the care of both diseases. The majority (96/128, 75.0%) were observational in design. Cascade stages documented in the literature were awareness, screening, diagnosis, linkage to care, treatment, adherence to medication, and control. Most studies focused on the stages of treatment and control, while a relative paucity of studies examined the stages before treatment initiation (76/128, 59.4% vs 52/128, 40.6%). There was a wide spectrum of interventions aimed at enhancing the hypertension and diabetes care cascade. The analysis unveiled a multitude of individual-level and system-level factors influencing the successful completion of cascade sequences in both high-income and low- and middle-income settings.

CONCLUSIONS

This review offers a comprehensive understanding of hypertension and diabetes management, emphasizing the pivotal factors that impact each stage of care. Future research should focus on upstream cascade stages and context-specific interventions to optimize patient retention and care outcomes.

Patient involvement in the encounter between general practice and patients with a chronic disease. Results of a scoping review focusing on type 2 diabetes and obstructive pulmonary disease

INTRODUCTION

Research has shown improved health outcomes when patients are involved in managing their health conditions and when their individual needs are considered.

OBJECTIVES

This scoping review aimed to map the existing research regarding chronic disease patients' involvement in their encounters with general practice, with a specific focus on patients with Type 2 diabetes (TD2) or chronic obstructive pulmonary disease (COPD) and from the perspectives of both general practitioners and patients.

METHODS

Studies of any design, date, and language were included. A systematic search was conducted using the following databases: Medline, CINAHL, PsycInfo, Scopus, and EMBASE from August until October 2020 and renewed September 2021. Data were systematically charted by the following study characteristics: bibliographic aims; study aims; setting; area of interest; results; conclusion.

RESULTS

Eighteen studies were included; they conducted qualitative methods, surveys or mixed methods. From the patients' perspectives, the importance of being more involved in treatment discussions during consultations as well as a friendly environment, was underscored. A good relationship and relational continuity make it easier for patients to be more involved in treatment decisions. From the general practitioner (GP) perspectives, they mentioned their high workload, long-standing relationships, knowledge about the patients and prepared patients as factors influencing their ability to involve patients in treatment discussions.

CONCLUSION

A good GP-patient relationship was considered an important aspect to providing and facilitating for involvement of patients with COPD or TD2. Scoping review registration: https://osf.io/ynqt2.

"I still feel so lost": experiences of women receiving SANE care during the year after sexual assault

OBJECTIVE

Emergency caregivers provide initial care to women sexual assault (SA) survivors. An improved understanding of the issues facing this population can aide emergency care practitioners in providing high quality care. The goal of this study was to share the experiences of women SA survivors with the emergency care practitioners that care for them.

METHODS

English-speaking adult women (n = 706) who received SA Nurse Examiner (SANE) evaluation within 72 hours of SA at 1 of 13 geographically distributed sites were enrolled in a prospective, longitudinal multi-site observational study. We qualitatively analyzed responses to the open-ended question: "What do you think is most important for researchers to understand about your experience since the assault?" asked 1 week, 6 weeks, 6 months, and 1 year after enrollment.

RESULTS

Themes from responses (n = 1434) from 590 women (84% of study sample) fell into 12 broad categories: daily life, justice, medical, and social services, mental health, physical health, prior trauma, recovery, romantic relationships, safety, self, shame, and social interactions. Responses demonstrated that the assault permeates many aspects of assault survivors' daily lives.

CONCLUSIONS

Qualitative analyses of open-ended responses from a large cohort of women SA survivors receiving SANE care highlight the challenges for survivors and can increase understanding among the emergency care practitioners who care for them. The authors propose a brief acronym to help emergency care practitioners recall important messages for SA survivors.

Data Mining of Free-Text Responses: An Innovative Approach to Analyzing Patient Perspectives on Treatment for Chronic Rhinosinusitis with Nasal Polyps in a Phase IIa Proof-of-Concept Study for Dupilumab

PURPOSE

Patient perspective is an important and increasingly sought-after complement to clinical assessment. The aim of this study was to transcribe individual patients' experience of treatment in a dupilumab clinical trial through free-text responses with analysis using natural language processing (NLP) to obtain the unique perspective of patients on disease impact and unmet needs with existing treatment to inform future trial design.

PATIENTS AND METHODS

Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) who were enrolled in a Phase IIa randomized controlled trial comparing dupilumab with placebo (NCT01920893) were invited to complete a self-assessment of treatment (SAT) tool at the end of treatment, asking, "What is your opinion on the treatment you had during the trial? What did you like or dislike about the treatment?" Free-text responses were analyzed for the overall cohort and according to treatment assignment using natural language processing including sentiment scoring. In a mixed-methods approach, quantitative patient-reported outcome (PRO) results were utilized to complement the qualitative analysis of free-text responses.

RESULTS

Of 60 patients enrolled in the study, 43 (71.6%) completed the SAT and responses from 37 patients were analyzed (placebo, n = 16; dupilumab, n = 21). Word analyses showed that the most common words were "smell," "improve," "staff," "great," "time," and "good." Across the whole cohort, "smell" was the most common symptom-related word. The words "smell" and "experience" were more likely to occur in patients treated with dupilumab. Patients treated with dupilumab also had more positive sentiment in their SAT responses than those who received placebo. The results from this qualitative analysis were reflected in quantitative PRO results.

CONCLUSION

"Smell" was important to patients with CRSwNP, highlighting its importance as a patient-centric efficacy outcome measure in the context of clinical trials in CRSwNP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01920893. Registered 12 August 2013, https://www.clinicaltrials.gov/ct2/show/NCT01920893.

Provision of services in primary care for type 2 diabetes: a qualitative study with patients, GPs, and nurses in the East of England

BACKGROUND

There is little evidence on the impact of national pressures on primary care provision for type 2 diabetes from the perspectives of patients, their GPs, and nurses.

AIM

To explore experiences of primary care provision for people with type 2 diabetes and their respective GPs and nurses.

DESIGN AND SETTING

A qualitative primary care interview study in the East of England.

METHOD

Semi-structured interviews were conducted, between August 2017 and August 2018, with people who have type 2 diabetes along with their respective GPs and nurses. Purposive sampling was used to select for heterogeneity in glycaemic control and previous healthcare experiences. Interviews were audio-recorded and analysed thematically. The consolidated criteria for reporting qualitative research were followed.

RESULTS

The authors interviewed 24 patients and 15 GPs and nurses, identifying a changing landscape of diabetes provision owing to burgeoning pressures that were presented repeatedly. Patient responders wanted GP-delivered care with continuity. They saw GPs as experts best placed to support them in managing diabetes, but were increasingly receiving nurse-led care. Nurses reported providing most of the in-person care, while GPs remained accountable but increasingly distanced from face-to-face diabetes care provision. A reluctant acknowledgement surfaced among GPs, nurses, and their patients that only minimum care standards could be maintained, with aspirations for high-quality provision unlikely to be met.

CONCLUSION

Type 2 diabetes is a tracer condition that reflects many aspects of primary care. Efforts to manage pressures have not been perceived favourably by patients and providers, despite some benefits. Reframing expectations of care, by communicating solutions to both patients and providers so that they are understood, managed, and realistic, may be one way forward.

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study

Background

Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.

Objectives

We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.

Design and setting

We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.

Participants

Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.

Interventions

Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).

Main outcome measures

Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.

Results

Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.

Limitations

There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.

Conclusions

Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.

Future work

Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.

Impact of family practice continuity of care on unplanned hospital use for people with serious mental illness

Objective

To investigate whether continuity of care in family practice reduces unplanned hospital use for people with serious mental illness (SMI).

Data Sources

Linked administrative data on family practice and hospital utilization by people with SMI in England, 2007‐2014.

Study Design

This observational cohort study used discrete‐time survival analysis to investigate the relationship between continuity of care in family practice and unplanned hospital use: emergency department (ED) presentations, and unplanned admissions for SMI and ambulatory care‐sensitive conditions (ACSC). The analysis distinguishes between relational continuity and management/ informational continuity (as captured by care plans) and accounts for unobserved confounding by examining deviation from long‐term averages.

Data Collection/Extraction Methods

Individual‐level family practice administrative data linked to hospital administrative data.

Principal Findings

Higher relational continuity was associated with 8‐11 percent lower risk of ED presentation and 23‐27 percent lower risk of ACSC admissions. Care plans were associated with 29 percent lower risk of ED presentation, 39 percent lower risk of SMI admissions, and 32 percent lower risk of ACSC admissions.

Conclusions

Family practice continuity of care can reduce unplanned hospital use for physical and mental health of people with SMI.

Using chronic kidney disease trigger tools for safety and learning: a qualitative evaluation in East London primary care

BACKGROUND

An innovative programme to improve identification and management of chronic kidney disease (CKD) in primary care was implemented across three clinical commissioning groups (CCGs) in 2016. This included a falling estimated glomerular filtration rate (eGFR) trigger tool built from data in the electronic health record (EHR). This tool notifies GP practices of falling eGFR values. By alerting clinicians to patients with possible CKD progression the tool invites clinical review, a referral option, and written reflection on management.

AIM

To identify practitioner perceptions of trigger tool use from interviews, and compare these with reflections on clinical management recorded within the tools.

DESIGN AND SETTING

A qualitative analysis set in 136 practices across East London during 2016-2018.

METHOD

Eight semi-structured interviews with GPs and practice staff were recorded, and thematic analysis was undertaken using framework analysis. The reflective comments recorded in the trigger tools of 1921 cases were categorised by age group, referral status, and by the drop in eGFR (>15 or >25 ml/min).

RESULTS

Three themes emerged from the interviews: getting started, patient safety, and trigger tools for learning. Well-organised practices found the tool was readily embedded into workflow and expressed greater motivation for using it. The tool was seen to support patient safety, and was used for learning about CKD management, both individually and as a practice. Reflective comments from 1921 trigger tools were reviewed. These supported the theme of patient safety. The free-text data, stratified by age, challenged the expectation that younger cases, at higher risk of progressive CKD, would have higher referral rates.

CONCLUSION

Building electronic trigger tools from the EHR can identify patients with a falling eGFR, prompting review of the eGFR trajectory and management plan. Interview and reflective data illustrated that practice use of the tool supports the patient safety agenda and encourages learning about CKD management.

Association Between Primary Care Practitioner Empathy and Risk of Cardiovascular Events and All-Cause Mortality Among Patients With Type 2 Diabetes: A Population-Based Prospective Cohort Study

PURPOSE

To examine the association between primary care practitioner (physician and nurse) empathy and incidence of cardiovascular disease (CVD) events and all-cause mortality among patients with type 2 diabetes.

METHODS

This was a population-based prospective cohort study of 49 general practices in East Anglia (United Kingdom). The study population included 867 individuals with screen-detected type 2 diabetes who were followed up for an average of 10 years until December 31, 2014 in the Anglo-Danish-Dutch Study of Intensive Treatment in People With Screen Detected Diabetes in Primary Care (ADDITION)-Cambridge trial. Twelve months after diagnosis, patients assessed practitioner empathy and their experiences of diabetes care during the preceding year using the consultation and relational empathy (CARE) measure questionnaire. CARE scores were grouped into tertiles. The main outcome measures were first recorded CVD event (a composite of myocardial infarction, revascularization, nontraumatic amputation, stroke, and fatal CVD event) and all-cause mortality, obtained from electronic searches of the general practitioner record, national registries, and hospital records. Hazard ratios (HRs) were estimated using Cox models adjusted for relevant confounders. The ADDITION-Cambridge trial is registered as ISRCTN86769081.

RESULTS

Of the 628 participants with a completed CARE score, 120 (19%) experienced a CVD event, and 132 (21%) died during follow up. In the multivariable model, compared with the lowest tertile, higher empathy scores were associated with a lower risk of CVD events (although this did not achieve statistical significance) and a lower risk of all-cause mortality (HRs for the middle and highest tertiles, respectively: 0.49; 95% CI, 0.27-0.88, P = .01 and 0.60; 95% CI, 0.35-1.04, P = .05).

CONCLUSIONS

Positive patient experiences of practitioner empathy in the year after diagnosis of type 2 diabetes may be associated with beneficial long-term clinical outcomes. Further work is needed to understand which aspects of patient perceptions of empathy might influence health outcomes and how to incorporate this understanding into the education and training of practitioners.