Process evaluation of team-based care in people aged >65 years with type 2 diabetes mellitus

Joanie Sims Gould, Catherine Tong, Jessica Ly, Sara Vazirian, Adriaan Windt, Karim Khan, Joanie Sims Gould, Catherine Tong, Jessica Ly, Sara Vazirian, Adriaan Windt, Karim Khan

Abstract

Objective: The prevalence of type 2 diabetes mellitus (T2DM) is increasing globally and there is critical need develop interventions to improve health outcomes among older people. The Group Appointments in Primary Care (GAP) study was a randomised controlled trial designed to test the efficacy of a group and team-based medical visit programme to lower haemoglobin A1c among patients with T2DM. We aimed to understand the barriers and facilitators to implement the GAP intervention within a primary care setting, with an emphasis on patient experience.

Research design and methods: This was a qualitative exploratory study. Data were gathered from semistructured interviews conducted with the first cohort of GAP study participants (n=15) at baseline and intervention completion. GAP participants were aged >65, diagnosed with T2DM and from one primary care clinic. The interview questions identified the patient perspectives and factors relating to their attendance at seven group medical visits that were part of the intervention programme. Data were analysed using framework analysis.

Results: We identified four themes that captured participants' experiences: (1) Education: learning with professionals, learning with one another; (2) Social Support: common interests, common problems; (3) Setting: ease of location, ease of conversation and (4) Impact: expectations met, empowerment gained. The GAP intervention increased participants' self-reported diabetes literacy and self-management skills.

Conclusions: We learnt that: accessible community centres, not primary care offices, were the ideal location for GAP; the consistent leadership of the primary care physician was valued by participants; and, the content related to exercise and healthy diet were viewed as impactful. Also, learning was achieved through content delivered by clinical experts, and by T2DM experts with lived experience-the GAP peers. Our findings highlight the important role of group learning.

Trial registration number: NCT02002143.

Keywords: general diabetes; geriatric medicine; qualitative research; team-based care.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

References

    1. Statistics Canada Canada year book. Ottawa, ON: Statistics Canada, 2018.
    1. 2 Statistics Canada A portrait of the population aged 85 and older in 2016 in Canada. Ottawa, ON: Statistics Canada, 2018.
    1. Public Health Agency of Canada Diabetes in Canada: facts and figures from a public health perspective. Ottawa, on: government of Canada from Available: [Accessed June 2018].
    1. Meneilly GS. Diabetes in the elderly : JE M, Medical clinics of North America—geriatric medicine. 90 Philadelphia, PA: Elsevier Saunders, 2006: 909–23. 10.1016/j.mcna.2006.05.011
    1. Doucet G, Beatty M. The cost of diabetes in Canada: the economic tsunami. Can J Diabetes 2010;34:27–9. 10.1016/S1499-2671(10)41005-9
    1. Knowler WC. Prevention of type 2 diabetes: comment on "Lifestyle modification and prevention of type 2 diabetes in overweight Japanese with impaired fasting glucose levels". Arch Intern Med 2011;171:1361–2. 10.1001/archinternmed.2011.367
    1. Steinsbekk A, Rygg L, Lisulo M, et al. . Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Serv Res 2012;12:213 10.1186/1472-6963-12-213
    1. Umpierre D, Ribeiro PAB, Schaan BD, et al. . Volume of supervised exercise training impacts glycaemic control in patients with type 2 diabetes: a systematic review with meta-regression analysis. Diabetologia 2013;56:242–51. 10.1007/s00125-012-2774-z
    1. Ferchak CV, Meneghini LF, Obesity ML. Obesity, bariatric surgery and type 2 diabetes?a systematic review. Diabetes Metab Res Rev 2004;20:438–45. 10.1002/dmrr.507
    1. Staimez L, Weber M, Narayan K, et al. . A systematic review of overweight, obesity, and type 2 diabetes among Asian American subgroups. Curr Diabetes Rev 2013;9:312–31. 10.2174/15733998113099990061
    1. Knowler WC, Barrett-Connor E, Fowler SE, et al. . Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002;346:393–403. 10.1056/NEJMoa012512
    1. Buehler AM, Cavalcanti AB, Berwanger O, et al. . Effect of tight blood glucose control versus conventional control in patients with type 2 diabetes mellitus: a systematic review with meta-analysis of randomized controlled trials. Cardiovasc Ther 2013;31:147–60. 10.1111/j.1755-5922.2011.00308.x
    1. Al Sayah F, Williams B, Johnson JA. Measuring health literacy in individuals with diabetes: a systematic review and evaluation of available measures. Health Educ Behav 2013;40:42–55. 10.1177/1090198111436341
    1. Lindström J, Ilanne-Parikka P, Peltonen M, et al. . Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish diabetes prevention study. The Lancet 2006;368:1673–9. 10.1016/S0140-6736(06)69701-8
    1. Cauch-Dudek K, Victor JC, Sigmond M, et al. . Disparities in attendance at diabetes self-management education programs after diagnosis in Ontario, Canada: a cohort study. BMC Public Health 2013;13:85 10.1186/1471-2458-13-85
    1. Sanz C, Gautier J-F, Hanaire H. Physical exercise for the prevention and treatment of type 2 diabetes. Diabetes Metab 2010;36:346–51. 10.1016/j.diabet.2010.06.001
    1. Alexander GC, Sehgal NL, Moloney RM, et al. . National trends in treatment of type 2 diabetes mellitus, 1994-2007. Arch Intern Med 2008;168:2088–94. 10.1001/archinte.168.19.2088
    1. Housden L, Wong ST, Dawes M. Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis. Can Med Assoc J 2013;185:E635–E644. 10.1503/cmaj.130053
    1. Trento M, Passera P, Tomalino M, et al. . Group visits improve metabolic control in type 2 diabetes: a 2-year follow-up. Diabetes Care 2001;24:995–1000. 10.2337/diacare.24.6.995
    1. Khan KM, Windt A, Davis JC, et al. . Group medical visits (GMVs) in primary care: an RCT of group-based versus individual appointments to reduce HbA1c in older people. BMJ Open 2015;5:e007441–10. 10.1136/bmjopen-2014-007441
    1. Oakley A, Strange V, Bonell C, et al. . Process evaluation in randomised controlled trials of complex interventions. BMJ 2006;332:413–6. 10.1136/bmj.332.7538.413
    1. Craig P, Dieppe P, Macintyre S, et al. . Developing and evaluating complex interventions: the new medical Research Council guidance. BMJ 2008;337:a1655–61. 10.1136/bmj.a1655
    1. Moore GF, Audrey S, Barker M, et al. . Process evaluation of complex interventions: medical research council guidance. BMJ 2015;350:h1258–65. 10.1136/bmj.h1258
    1. Bodenheimer T, et al. Patient self-management of chronic disease in primary care. JAMA 2002;288:2469–75. 10.1001/jama.288.19.2469
    1. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775–9. 10.1001/jama.288.14.1775
    1. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA 2002;288:1909–14.
    1. Trento M, Gamba S, Gentile L, et al. . Rethink organization to iMprove education and outcomes (ROMEO): a multicenter randomized trial of lifestyle intervention by group care to manage type 2 diabetes. Diabetes Care 2010;33:745–7. 10.2337/dc09-2024
    1. Trento M, Passera P, Borgo E, et al. . A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Diabetes Care 2004;27:670–5. 10.2337/diacare.27.3.670
    1. Caelli K, Ray L, Mill J. ‘Clear as mud’: toward greater clarity in generic qualitative research. International Journal of Qualitative Methods 2003;2:1–13. 10.1177/160940690300200201
    1. Srivastava A, Thomson SB. Framework analysis: a qualitative methodology for applied policy research. J Admin Governance 2009;72:1–8.
    1. Gale NK, Heath G, Cameron E, et al. . Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Med Res Methodol 2013;13:117–25. 10.1186/1471-2288-13-117
    1. Morse JM. The significance of saturation. Thousand Oaks, CA: Sage Publications, 1995: 147–9.
    1. Warburton DER, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. Can Med Assoc J 2006;174:801–9. 10.1503/cmaj.051351
    1. Tuomilehto J, Lindström J, Eriksson JG, et al. . Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343–50. 10.1056/NEJM200105033441801
    1. Delahanty LM, Grant RW, Wittenberg E, et al. . Association of diabetes-related emotional distress with diabetes treatment in primary care patients with Type 2 diabetes. Diabet Med 2007;24:48–54. 10.1111/j.1464-5491.2007.02028.x
    1. Polonsky WH, Anderson BJ, Lohrer PA, et al. . Assessment of diabetes-related distress. Diabetes Care 1995;18:754–60. 10.2337/diacare.18.6.754
    1. Litaker D, Mion LC, Planavsky L, et al. . Physician–nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care. J Interprof Care 2003;17:223–37. 10.1080/1356182031000122852
    1. Grumbach K, Bodenheimer T. Can health care teams improve primary care practice? JAMA 2004;291:1246–51. 10.1001/jama.291.10.1246
    1. Emery MJ. Effectiveness of the clinical instructor: students' perspective. Phys Ther 1984;64:1079–83.
    1. George SR, Thomas SP. Lived experience of diabetes among older, rural people. J Adv Nurs 2010;66:1092–100. 10.1111/j.1365-2648.2010.05278.x
    1. Truluck E, Bradley C, Courtenay J. Learning style preferences among older adults. Educ Gerontol 1999;25:221–36.
    1. Browne JL, Ventura A, Mosely K, et al. . ‘I call it the blame and shame disease’: a qualitative study about perceptions of social stigma surrounding type 2 diabetes. BMJ Open 2013;3:e003384–10. 10.1136/bmjopen-2013-003384

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