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Resources and organisation in primary health care are associated with HbA1c level: A nationwide study of 230958 people with Type 2 diabetes mellitus.
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.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, Centre for Clinical Research, County of Västmanland.ORCID iD: 0000-0003-3691-8326
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Clinical diabetology and metabolism.
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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.

Place, publisher, year, edition, pages
2018. Vol. 12, no 1, p. 23-33
Keywords [en]
HbA(1c), Organisation, Personnel resources, Primary health care system, Type 2 diabetes mellitus
National Category
Endocrinology and Diabetes
Identifiers
URN: urn:nbn:se:uu:diva-332689DOI: 10.1016/j.pcd.2017.09.003ISI: 000423008800003PubMedID: 28964673OAI: oai:DiVA.org:uu-332689DiVA, id: diva2:1153773
Available from: 2017-10-31 Created: 2017-10-31 Last updated: 2018-12-21Bibliographically approved
In thesis
1. The organisation of diabetes care for persons with type 2 diabetes mellitus: A nationwide cross-sectional study in Swedish primary health care
Open this publication in new window or tab >>The organisation of diabetes care for persons with type 2 diabetes mellitus: A nationwide cross-sectional study in Swedish primary health care
2017 (English)Licentiate thesis, comprehensive summary (Other academic)
Abstract [en]

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.

Place, publisher, year, edition, pages
Uppsala universitet, 2017
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-348089 (URN)978-91-639-3277-9 (ISBN)
Opponent
Supervisors
Available from: 2018-04-19 Created: 2018-04-10 Last updated: 2018-04-19Bibliographically approved
2. 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
Open this publication in new window or tab >>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
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
Epidemiology, Organization, Personnel resources, Primary health-care, Type 2 diabetes mellitus
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-371496 (URN)978-91-513-0548-6 (ISBN)
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

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Husdal, RebeckaKarlsson, AndreasLeksell, JanethJerden, LarsStålhammar, JanWallman, ThorneThors Adolfsson, Eva

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