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Contextualizing the Effectiveness of a Lifestyle Intervention in Primary Care: A Qualitative Assessment
Abstracts / Can J Diabetes 38 (2014) S29eS74
hyperglycemia. The clinic accepted eligible patients from throughout the hospital, with a focus on the emergency department and cancer program. We conducted an evaluative study of the RADAR clinic’s impact on care delivery and resource utilization. Patients seen by Sunnybrook endocrinologists between January and May 2012 who would have been eligible for the RADAR clinic were compared with those seen in the RADAR clinic after its opening until July 2013. For each group, we calculated the mean wait time from referral to visit, and the proportion of patients whose care was coordinated between the endocrinologist and the diabetes education team. In addition, to determine the clinic’s impact on hospital inpatient resource utilization, the mean length of stay for cancer program patients hospitalized for hyperglycemia was calculated quarterly from 2011/12 Q1 to 2013/14 Q3. The mean wait time for urgent diabetes referrals was 59 days prior to the implementation of the RADAR clinic, and 4 days afterwards. The proportion of patients receiving coordinated interdisciplinary care increased from 62% with baseline “usual” care to 100% with the RADAR clinic. Lengths of hospital stay for hyperglycemia among cancer program patients declined (Figure 1, page S32). The implementation of the RADAR clinic was associated with faster access to care for complex diabetes patients with uncontrolled hyperglycemia, improved delivery of interdisciplinary care and shorter lengths of hospital stay.
84 Contextualizing the Effectiveness of a Collaborative Care Model for Diabetes and Depression in Primary Care: A Qualitative Assessment LISA WOZNIAK, ALLISON SOPROVICH*, SANDRA REES, FATIMA AL SAYAH, SUMIT R. MAJUMDAR, JEFFREY A. JOHNSON Edmonton, AB TeamCare in Primary Care Networks (TeamCare-PCN), a collaborative care model for depression and diabetes, was recently proven effective in improving depressive symptoms among type 2 diabetes patients in 4 Alberta PCNs. We contextualize its effectiveness by describing implementation fidelity and PCN staff’s perceptions of effectiveness. We used the RE-AIM framework to comprehensively evaluate TeamCare-PCN. Here, data related to the dimensions of Implementation and Effectiveness was collected through interviews with PCN staff (n¼36); formal reflections by researchers (n¼4) and systematic documentation (e.g., standardized checklist and field notes), managed using Nvivo 10, and analyzed using content analysis. Our results showed that TeamCare-PCN intervention components were implemented as intended but without optimal fidelity across the PCNs due to the degree of collaboration practiced, related to varying physician participation due to the existing culture (e.g., autonomy, referral practices), and limited comfort with collaborative care across team members. Despite the suboptimal fidelity, respondents identified implementation facilitators including: training; ongoing implementation support; pre-existing relationships; and professional and personal qualities of the care managers. PCN staff reported varying opinions regarding the perceived effectiveness of TeamCare-PCN; however, more PCN staff anticipated improved patient outcomes as a result of the key intervention components, including active patient follow up, specialist consultation and treat-to-target principles. TeamCare-PCN resulted in improved depression care and outcomes similar to those demonstrated in previous trials despite its suboptimal implementation in Alberta’s primary care context. However, a stronger culture of collaborative care may have yielded
S33
greater implementation fidelity possibly resulting in even better outcomes than achieved here.
85 Contextualizing the Effectiveness of a Lifestyle Intervention in Primary Care: A Qualitative Assessment LISA WOZNIAK, ALLISON SOPROVICH*, CLARK MUNDT, JEFFREY A. JOHNSON, STEVEN T. JOHNSON Edmonton, AB The Healthy Eating and Active Living for Diabetes (HEALD) proved effective in increasing physical activity among type 2 diabetes patients in 4 community-based Primary Care Networks (PCNs) in Alberta. We contextualize its effectiveness by describing implementation fidelity and PCN staff’s perceptions of effectiveness. Utilizing Glasgow’s RE-AIM framework to guide our approach, we comprehensively evaluated HEALD. The qualitative data sources, related to the dimensions of Implementation and Effectiveness, were: interviews with PCN staff (n¼24); formal reflections by researchers (n¼4) and systematic documentation (e.g., standardized checklist and field notes). Data were managed using Nvivo 10 and analyzed using content analysis. Our results suggest the HEALD intervention components were implemented as intended with adequate fidelity across PCNs. Respondents identified implementation facilitators including: appropriate human resources; training; ongoing implementation support; provision of space and simplicity of the intervention. Role satisfaction was high among exercise specialists. PCN staff reported varying opinions regarding the perceived effectiveness of HEALD in improving patient outcomes. Rationales for perceived limited effectiveness included lack of intensity or “dose” (i.e., frequency or duration) of the intervention, patients were already well managed and that the quality of usual care for people in the PCNs with diabetes was equally sufficient compared to HEALD. The demonstrated effectiveness of HEALD was a result of adequate implementation and sound intervention theory. It is possible that increasing the dose of HEALD could result in additional improvements in patient outcomes; however, the feasibility at an organization or patient level remains to be determined.
86 Postpartum Barriers for Completing the 75 g Oral Glucose Tolerance Test SUE BONK, SUSAN ORAM Markham, ON Objective: In our diabetes clinic, half of all women who had gestational diabetes mellitus (GDM) didn’t follow up with the 75 g OGTT postpartum, as recommended in the current guidelines. Barriers to completing testing were explored with an outcome to develop strategies to improving clinical practice. Method: Participants who developed GDM were referred to the adult diabetes education clinic (ADEC) by an obstetrician or midwife. They received their initial education, either a group format or individual appointment with a registered dietitian (RD) + registered nurse (RN). Ongoing appointments during the pregnancy were provided with the RD, RN and endocrinologist, during which time they received a lab requisition for the 75 g OGTT to be done between 6 weeksd6 months postpartum. A list was generated for pending postpartum 75 g OGTT and women were contacted via telephone and interviewed using a developed script.
hyperglycemia. The clinic accepted eligible patients from throughout the hospital, with a focus on the emergency department and cancer program. We conducted an evaluative study of the RADAR clinic’s impact on care delivery and resource utilization. Patients seen by Sunnybrook endocrinologists between January and May 2012 who would have been eligible for the RADAR clinic were compared with those seen in the RADAR clinic after its opening until July 2013. For each group, we calculated the mean wait time from referral to visit, and the proportion of patients whose care was coordinated between the endocrinologist and the diabetes education team. In addition, to determine the clinic’s impact on hospital inpatient resource utilization, the mean length of stay for cancer program patients hospitalized for hyperglycemia was calculated quarterly from 2011/12 Q1 to 2013/14 Q3. The mean wait time for urgent diabetes referrals was 59 days prior to the implementation of the RADAR clinic, and 4 days afterwards. The proportion of patients receiving coordinated interdisciplinary care increased from 62% with baseline “usual” care to 100% with the RADAR clinic. Lengths of hospital stay for hyperglycemia among cancer program patients declined (Figure 1, page S32). The implementation of the RADAR clinic was associated with faster access to care for complex diabetes patients with uncontrolled hyperglycemia, improved delivery of interdisciplinary care and shorter lengths of hospital stay.
84 Contextualizing the Effectiveness of a Collaborative Care Model for Diabetes and Depression in Primary Care: A Qualitative Assessment LISA WOZNIAK, ALLISON SOPROVICH*, SANDRA REES, FATIMA AL SAYAH, SUMIT R. MAJUMDAR, JEFFREY A. JOHNSON Edmonton, AB TeamCare in Primary Care Networks (TeamCare-PCN), a collaborative care model for depression and diabetes, was recently proven effective in improving depressive symptoms among type 2 diabetes patients in 4 Alberta PCNs. We contextualize its effectiveness by describing implementation fidelity and PCN staff’s perceptions of effectiveness. We used the RE-AIM framework to comprehensively evaluate TeamCare-PCN. Here, data related to the dimensions of Implementation and Effectiveness was collected through interviews with PCN staff (n¼36); formal reflections by researchers (n¼4) and systematic documentation (e.g., standardized checklist and field notes), managed using Nvivo 10, and analyzed using content analysis. Our results showed that TeamCare-PCN intervention components were implemented as intended but without optimal fidelity across the PCNs due to the degree of collaboration practiced, related to varying physician participation due to the existing culture (e.g., autonomy, referral practices), and limited comfort with collaborative care across team members. Despite the suboptimal fidelity, respondents identified implementation facilitators including: training; ongoing implementation support; pre-existing relationships; and professional and personal qualities of the care managers. PCN staff reported varying opinions regarding the perceived effectiveness of TeamCare-PCN; however, more PCN staff anticipated improved patient outcomes as a result of the key intervention components, including active patient follow up, specialist consultation and treat-to-target principles. TeamCare-PCN resulted in improved depression care and outcomes similar to those demonstrated in previous trials despite its suboptimal implementation in Alberta’s primary care context. However, a stronger culture of collaborative care may have yielded
S33
greater implementation fidelity possibly resulting in even better outcomes than achieved here.
85 Contextualizing the Effectiveness of a Lifestyle Intervention in Primary Care: A Qualitative Assessment LISA WOZNIAK, ALLISON SOPROVICH*, CLARK MUNDT, JEFFREY A. JOHNSON, STEVEN T. JOHNSON Edmonton, AB The Healthy Eating and Active Living for Diabetes (HEALD) proved effective in increasing physical activity among type 2 diabetes patients in 4 community-based Primary Care Networks (PCNs) in Alberta. We contextualize its effectiveness by describing implementation fidelity and PCN staff’s perceptions of effectiveness. Utilizing Glasgow’s RE-AIM framework to guide our approach, we comprehensively evaluated HEALD. The qualitative data sources, related to the dimensions of Implementation and Effectiveness, were: interviews with PCN staff (n¼24); formal reflections by researchers (n¼4) and systematic documentation (e.g., standardized checklist and field notes). Data were managed using Nvivo 10 and analyzed using content analysis. Our results suggest the HEALD intervention components were implemented as intended with adequate fidelity across PCNs. Respondents identified implementation facilitators including: appropriate human resources; training; ongoing implementation support; provision of space and simplicity of the intervention. Role satisfaction was high among exercise specialists. PCN staff reported varying opinions regarding the perceived effectiveness of HEALD in improving patient outcomes. Rationales for perceived limited effectiveness included lack of intensity or “dose” (i.e., frequency or duration) of the intervention, patients were already well managed and that the quality of usual care for people in the PCNs with diabetes was equally sufficient compared to HEALD. The demonstrated effectiveness of HEALD was a result of adequate implementation and sound intervention theory. It is possible that increasing the dose of HEALD could result in additional improvements in patient outcomes; however, the feasibility at an organization or patient level remains to be determined.
86 Postpartum Barriers for Completing the 75 g Oral Glucose Tolerance Test SUE BONK, SUSAN ORAM Markham, ON Objective: In our diabetes clinic, half of all women who had gestational diabetes mellitus (GDM) didn’t follow up with the 75 g OGTT postpartum, as recommended in the current guidelines. Barriers to completing testing were explored with an outcome to develop strategies to improving clinical practice. Method: Participants who developed GDM were referred to the adult diabetes education clinic (ADEC) by an obstetrician or midwife. They received their initial education, either a group format or individual appointment with a registered dietitian (RD) + registered nurse (RN). Ongoing appointments during the pregnancy were provided with the RD, RN and endocrinologist, during which time they received a lab requisition for the 75 g OGTT to be done between 6 weeksd6 months postpartum. A list was generated for pending postpartum 75 g OGTT and women were contacted via telephone and interviewed using a developed script.