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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
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland. Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical diabetology and metabolism.
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

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.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. , p. 91
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1529
Keywords [en]
Epidemiology, Organization, Personnel resources, Primary health-care, Type 2 diabetes mellitus
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-371496ISBN: 978-91-513-0548-6 (print)OAI: oai:DiVA.org:uu-371496DiVA, id: diva2:1273473
Public defence
2019-02-22, Samlingssalen, Psykiatricentrum ingång 29, Västmanlands sjukhus Västerås, Västerås, 13:15 (Swedish)
Opponent
Supervisors
Available from: 2019-02-01 Created: 2018-12-21 Last updated: 2019-02-18
List of papers
1. Resource allocation and organisational features in Swedish primary diabetes care: Changes from 2006 to 2013
Open this publication in new window or tab >>Resource allocation and organisational features in Swedish primary diabetes care: Changes from 2006 to 2013
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2017 (English)In: Primary Care Diabetes, ISSN 1751-9918, E-ISSN 1878-0210, Vol. 11, no 1, p. 20-28Article in journal (Refereed) Published
Abstract [en]

AIMS: To compare the resource allocation and organisational features in Swedish primary diabetes care for patients with type 2 diabetes mellitus (T2DM) between 2006 and 2013.

METHODS: Using a repeated cross-sectional study design, questionnaires covering personnel resources and organisational features for patients with T2DM in 2006 and 2013 were sent to all Swedish primary health care centres (PHCCs) during the following year. In total, 684 (74.3%) PHCCs responded in 2006 and 880 (76.4%) in 2013.

RESULTS: Compared with 2006, the median list size had decreased in 2013 (p<0.001), whereas the median number of listed patients with T2DM had increased (p<0.001). Time devoted to patients with T2DM and diabetes-specific education levels for registered nurses (RNs) had increased, and more PHCCs had in-house psychologists (all p<0.001). The use of follow-up systems and medical check-ups had increased (all p<0.05). Individual counselling was more often based on patients' needs, while arrangement of group-based education remained low. Patient participation in setting treatment targets mainly remained low.

CONCLUSIONS: Even though the diabetes-specific educational level among RNs increased, the arrangement of group-based education and patient participation in setting treatment targets remained low. These results are of concern and should be prioritised as key features in the care of patients with T2DM.

National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:uu:diva-304779 (URN)10.1016/j.pcd.2016.08.002 (DOI)000392679200003 ()27578488 (PubMedID)
Available from: 2016-10-10 Created: 2016-10-10 Last updated: 2019-01-25Bibliographically approved
2. Resources and organisation in primary health care are associated with HbA1c level: A nationwide study of 230958 people with Type 2 diabetes mellitus.
Open this publication in new window or tab >>Resources and organisation in primary health care are associated with HbA1c level: A nationwide study of 230958 people with Type 2 diabetes mellitus.
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2018 (English)In: Primary Care Diabetes, ISSN 1751-9918, E-ISSN 1878-0210, Vol. 12, no 1, p. 23-33Article in journal (Refereed) Published
Abstract [en]

AIMS: To examine the association between personnel resources and organisational features of primary health care centres (PHCCs) and individual HbA1c level in people with Type 2 diabetes mellitus (T2DM).

METHODS: People with T2DM attending 846 PHCCs (n=230958) were included in this cross-sectional study based on PHCC-level data from a questionnaire sent to PHCCs in 2013 and individual-level clinical data from 2013 for people with T2DM reported in the Swedish National Diabetes Register, linked to individual-level data on socio-economic status and comorbidities. Data were analysed using a generalized estimating equations linear regression models.

RESULTS: After adjusting for PHCC- and individual-level confounding factors, personnel resources associated with lower individual HbA1c level were mean credits of diabetes-specific education among registered nurses (RNs) (-0.02mmol/mol for each additional credit; P<0.001) and length of regular visits to RNs (-0.19mmol/mol for each additional 15min; P<0.001). Organisational features associated with HbA1c level were having a diabetes team (-0.18mmol/mol; P<0.01) and providing group education (-0.20mmol/mol; P<0.01).

CONCLUSIONS: In this large sample, PHCC personnel resources and organisational features were associated with lower HbA1c level in people with T2DM.

Keywords
HbA(1c), Organisation, Personnel resources, Primary health care system, Type 2 diabetes mellitus
National Category
Endocrinology and Diabetes
Identifiers
urn:nbn:se:uu:diva-332689 (URN)10.1016/j.pcd.2017.09.003 (DOI)000423008800003 ()28964673 (PubMedID)
Available from: 2017-10-31 Created: 2017-10-31 Last updated: 2020-01-19
3. Associations between quality of work features in primary health care and glycaemic control in people with Type 2 diabetes mellitus: A nationwide survey
Open this publication in new window or tab >>Associations between quality of work features in primary health care and glycaemic control in people with Type 2 diabetes mellitus: A nationwide survey
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(English)In: Primary Care Diabetes, ISSN 1751-9918, E-ISSN 1878-0210Article in journal (Refereed) Epub ahead of print
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-371494 (URN)
Available from: 2018-12-21 Created: 2018-12-21 Last updated: 2018-12-21
4. Organisation of primary diabetes care in people with type 2 diabetes in relation to all-cause mortality: a nationwide register-based cohort study
Open this publication in new window or tab >>Organisation of primary diabetes care in people with type 2 diabetes in relation to all-cause mortality: a nationwide register-based cohort study
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(English)Manuscript (preprint) (Other academic)
National Category
Clinical Medicine
Identifiers
urn:nbn:se:uu:diva-369430 (URN)
Available from: 2018-12-13 Created: 2018-12-13 Last updated: 2018-12-21

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