Population Health Management in Diabetes Care: Combining Clinical Audit, Risk Stratification, and Multidisciplinary Virtual Clinics in a Community Setting to Improve Diabetes Care in a Geographically Defined Population. An Integrated Diabetes Care Pilot in the North East Locality, Oxfordshire, UK.
diabetes care
health disparities
integrated care
population health
service redesign
Journal
International journal of integrated care
ISSN: 1568-4156
Titre abrégé: Int J Integr Care
Pays: England
ID NLM: 101214424
Informations de publication
Date de publication:
02 Nov 2020
02 Nov 2020
Historique:
entrez:
18
12
2020
pubmed:
19
12
2020
medline:
19
12
2020
Statut:
epublish
Résumé
Disparities in diabetes care are prevalent, with significant inequalities observed in access to, and outcomes of, healthcare. A population health approach offers a solution to improve the quality of care for all with systematic ways of assessing whole population requirements and treating and monitoring sub-groups in need of additional attention. Collaborative working between primary, secondary and community care was introduced in seven primary care practices in one locality in England, UK, caring for 3560 patients with diabetes and sharing the same community and secondary specialist diabetes care providers. Three elements of the intervention included 1) clinical audit, 2) risk stratification, and 3) the multi-disciplinary virtual clinics in the community. This paper evaluates the acceptability, feasibility and short-term impact on primary care of implementing a population approach intervention using direct observations of the clinics and surveys of participating clinicians. Eighteen virtual clinics across seven teams took place over six months between March and July 2017 with organisation, resources, policies, education and approximately 150 individuals discussed. The feedback from primary care was positive with growing knowledge and confidence managing people with complex diabetes in primary care. Taking a population health approach helped to identify groups of people in need of additional diabetes care and deliver a collaborative health intervention across traditional organisational boundaries.
Sections du résumé
BACKGROUND
BACKGROUND
Disparities in diabetes care are prevalent, with significant inequalities observed in access to, and outcomes of, healthcare. A population health approach offers a solution to improve the quality of care for all with systematic ways of assessing whole population requirements and treating and monitoring sub-groups in need of additional attention.
DESCRIPTION OF THE CARE PRACTICE
UNASSIGNED
Collaborative working between primary, secondary and community care was introduced in seven primary care practices in one locality in England, UK, caring for 3560 patients with diabetes and sharing the same community and secondary specialist diabetes care providers. Three elements of the intervention included 1) clinical audit, 2) risk stratification, and 3) the multi-disciplinary virtual clinics in the community.
METHODS
METHODS
This paper evaluates the acceptability, feasibility and short-term impact on primary care of implementing a population approach intervention using direct observations of the clinics and surveys of participating clinicians.
RESULTS AND DISCUSSION
CONCLUSIONS
Eighteen virtual clinics across seven teams took place over six months between March and July 2017 with organisation, resources, policies, education and approximately 150 individuals discussed. The feedback from primary care was positive with growing knowledge and confidence managing people with complex diabetes in primary care.
CONCLUSION
CONCLUSIONS
Taking a population health approach helped to identify groups of people in need of additional diabetes care and deliver a collaborative health intervention across traditional organisational boundaries.
Identifiants
pubmed: 33335462
doi: 10.5334/ijic.5177
pmc: PMC7716785
doi:
Types de publication
Case Reports
Langues
eng
Pagination
21Informations de copyright
Copyright: © 2020 The Author(s).
Déclaration de conflit d'intérêts
The authors have no competing interests to declare.
Références
Syst Rev. 2013 May 07;2:26
pubmed: 23647654
BMJ Open. 2018 Feb 14;8(2):e018826
pubmed: 29444781
Br J Gen Pract. 2004 Jan;54(498):50-6
pubmed: 15002420
PLoS One. 2014 Apr 15;9(4):e93964
pubmed: 24736243
Cochrane Database Syst Rev. 2012 Oct 17;10:CD004398
pubmed: 23076904
BMC Health Serv Res. 2009 Oct 07;9:179
pubmed: 19811624
BMJ. 1998 Aug 8;317(7155):390-6
pubmed: 9694757
Diabetes Care. 2016 Oct;39(10):1711-7
pubmed: 27515966
CMAJ. 2014 Oct 21;186(15):E568-78
pubmed: 25225226
Diabet Med. 2009 May;26(5):560-5
pubmed: 19646199
Trials. 2012 Sep 12;13:164
pubmed: 22971356
BMJ Open. 2017 Aug 4;7(8):e015135
pubmed: 28780542
BMJ Open. 2017 Mar 20;7(3):e013076
pubmed: 28320788
Diabetes Technol Ther. 2015 Jan;17(1):43-8
pubmed: 25296189
Curr Diab Rep. 2017 Jul;17(7):51
pubmed: 28567711
BMC Fam Pract. 2014 Sep 22;15:158
pubmed: 25245456
Ann Surg Oncol. 2012 Jun;19(6):1759-65
pubmed: 22207050
Can J Public Health. 1999 Nov-Dec;90 Suppl 1:S7-10
pubmed: 10686751
Qual Health Care. 2000 Mar;9(1):23-36
pubmed: 10848367
Br Med J. 1971 Oct 16;4(5780):161
pubmed: 5113020
Br Med J. 1973 Jun 2;2(5865):534-6
pubmed: 4714471
Health Trends. 1990;22(1):39-43
pubmed: 10106791
PLoS One. 2016 Dec 28;11(12):e0167878
pubmed: 28030547
J Telemed Telecare. 2009;15(3):150-2
pubmed: 19364901
Diabetes Educ. 2011 Nov-Dec;37(6):794-800
pubmed: 22002972
Diabetologia. 2019 Jan;62(1):41-52
pubmed: 30284015
BMC Health Serv Res. 2016 Apr 09;16:124
pubmed: 27061722
Diabet Med. 2016 Jun;33(6):768-76
pubmed: 27194175
Diabetes Technol Ther. 2016 Jun;18(6):385-90
pubmed: 27196443
JAMA. 2006 Jul 26;296(4):427-40
pubmed: 16868301
Lancet. 2012 Jun 16;379(9833):2252-61
pubmed: 22683130
J R Coll Gen Pract. 1980 Apr;30(213):199-206
pubmed: 7411509
J Clin Transl Endocrinol. 2016 Dec 09;7:21-27
pubmed: 29067246
BMJ. 1998 Aug 8;317(7155):395-6
pubmed: 9729094
Diabetes Care. 2001 Jun;24(6):1079-86
pubmed: 11375374
Implement Sci. 2013 Dec 17;8:142
pubmed: 24341511
Adv Chronic Kidney Dis. 2015 Jan;22(1):74-80
pubmed: 25573516
Curr Diab Rep. 2017 May;17(5):31
pubmed: 28364355
BMC Endocr Disord. 2008 Jul 31;8:9
pubmed: 18671870
Ann Intern Med. 2010 Feb 16;152(4):247-58
pubmed: 20157139