Introduction of diabetes passports involving both patients and professionals to improve hospital outpatient diabetes care
Introduction
Although there is, in general, a large consensus on the definition of high quality diabetes care, the actual delivery of care often appears to be disappointing. Strategies to improve diabetes care usually involve the dissemination of evidence or guidelines, often without success, to health professionals. There is increasing evidence that patient involvement plays an important role in improving the quality of care [1], [2], [3]. This may be especially relevant in the case of a chronic multi-systemic disease such as diabetes, because it is a growing problem worldwide and is an increasing burden on health care systems [4]. Studies on type 1 and type 2 diabetes patients showed that intensive treatment reduced morbidity and mortality [5], [6], and stressed that improvement in care is worthwhile. In daily practice, the quality of diabetes care has proved to be moderate [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], especially with regard to examination of patients’ feet and eyes, as well as helping patients to achieve recommended levels of blood pressure, cholesterol and HbA1c. As variations in care can mainly be explained on a patient level and not on the level of the practice or physician [17], [18], the greatest potential for improvement would be to involve patients in the management of their disease. Studies on patient involvement in diabetes care generally have focused more on enhancing patient self-care than on influencing the care provided by professionals [19], [20]. Recent studies have indicated that providing patients with personal feedback data improves health outcomes [21].
An important innovative tool in enhancing patient self-care is a patient held record, but various initiatives to introduce patient-held records in different settings have shown mixed results [22], [23], [24]. Within the framework of the 1989 Saint Vincent declaration [25], which focused on reducing diabetes complications, “diabetes passports” were developed in several countries. These patient-held, passport-size booklets contain information, descriptions, records and evaluations of medical screening results to enable patients to set personal goals and closely follow the monitoring of their disease (Fig. 1). The core of the diabetes passport consists of pages that summarise personal goals and the outcomes of medical or lab examinations for each year. The intention is to facilitate information sharing in a multi-professional setting. Theoretically, diabetes passports are ideally suited to a disease management model based on patient-centred care. In practice, however, professionals are sceptical and prefer educational interventions targeted at professionals only [26]. In recent studies in a primary care setting, the use of a diabetes passport led to mixed improvements in care [27], [28], but randomised controlled trials in secondary care are lacking. This study aimed to evaluate the effects of intervention strategy on the use of the diabetes passports. We hypothesised that the intervention along with closer patient involvement would lead to better care processes and health outcomes in internal medicine outpatient clinics.
Section snippets
Study population
For this multi-centre cluster randomised controlled trial, we approached 18 out of the 120 general hospitals in The Netherlands. Nine hospitals equally spread throughout The Netherlands, agreed to be randomised into an intervention and a control group. University hospitals and hospitals with ongoing intervention studies on diabetes were excluded.
In The Netherlands, most type 2 diabetic patients are treated in a primary care setting by their general practitioner, while the more complicated type
Results
A total of 769 patients were included in the analysis (Fig. 2). Patient response rates to the pre- and post-intervention questionnaires were 74 and 77%, respectively. When responders to non-responders were compared, the HbA1c in the responder group was 0.2% lower and they had 4.2% more type 1 patients. No differences were found with regard to age, gender, cholesterol levels and blood pressure. Table 1 shows some baseline characteristics of the study groups. The number of beds was higher at the
Discussion
The targeting of patients (passport, reminders, educational meeting) and professionals (meetings, reminders, audit and feedback) together to implement diabetes guidelines led to modest but significant improvement in HbA1c compared to the control group. The rise of mean HbA1c levels in the control group was similar to the UKPDS trends in HbA1c levels [6]. No relevant changes in blood pressure were observed, although treatment of hypertension was emphasised equally as strongly as treatment of
Acknowledgements
We thank the patients, diabetes specialist nurses and internists who participated in the study and Th. Lintmeijer (Dutch Diabetes Federation) and H. Baadenhuijsen and C.W. Weykamp (Dutch Foundation for Quality Assessment in Clinical Laboratories). This study was supported by a grant from The Netherlands Ministry of Health, Welfare and Sport (Grant number: 68659754527226605897).
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