Diabetes mellitus type 2 has become a widespread problem in many Western societies. In 2010, the global diabetes prevalence among people aged 20-79 was estimated at 6.4%, representing 285 million people 1. In the European Union, approximately thirty-three million people aged 20-79 were diagnosed with diabetes in 2010, representing more than 6% of the age group 2. Similarly, a survey conducted by the National Institute for Public Health and the Environment among the Dutch population in 2009/2010 revealed that 582,600 people aged 30-70 had diabetes, representing approximately 7% of the age group 3,4. Moreover, studies project an increase of global diabetes prevalence by 54% until 2030 and that, globally, the number of people who die due to diabetes will double between 2005 and 2030 1,5.
Integrated care has been suggested as a solution to effectively manage chronic conditions such as diabetes type 2. The World Health Organization defines integrated care as “the management and delivery of health services such that people receive a continuum of health promotion, health protection and disease prevention services, as well as diagnosis, treatment, long-term care, rehabilitation, and palliative care services through the different levels and sites of care within the health system and according to their needs” 6. While research suggests that different types of integrated care interventions can be effective for type 2 diabetes, this is not always the case and it is not clear when and why they are effective 7-12. Therefore we aim to find out how different integrated care intervention types as well as barriers and facilitators in the implementation process affect the outcomes achieved for diabetes type 2.
The purpose of our research is to gain insights into the intervention types, barriers and facilitators and outcomes of integrated care for chronic conditions, specifically for diabetes mellitus type 2.
In order to gain insights into the current evidence on the effectiveness of integrated care for people with type 2 diabetes, we conducted a systematic review of the international literature published in the period 2003-2013. We examined the types of integrated care interventions that were implemented, the barriers and facilitators encountered in the implementation process and which outcomes were achieved. We also tried to assess how the different intervention types, barriers and facilitators influenced the outcomes achieved.
As a next step, we conducted a qualitative case study at two Dutch care groups which were selected as best practices in the Netherlands. In total, we conducted 26 in depth interviews with care group managers and staff, care purchasers and health care professionals including general practitioners, practice nurses, diabetes nurse specialists, dieticians, optometrists, pharmacists, podiatrists and pedicurists. Again, we aimed to find out what the integrated care intervention consisted of (what were its components?), which barriers and facilitators affected its implementation and how these, combined, influenced the outcomes that were achieved.
Systematic Literature Review
- Regarding intervention types, most studies reported integrated care interventions which included self-management, delivery system design, decision support and clinical information system components.
- Most barriers were related to the organisational context and most facilitators to the social context.
- Most studies reported positive patient, process and health services utilisation outcomes.
- The information on costs was limited and inconsistent.
- It should be noted that the integration of diabetes care in the Netherlands is still work-in-process.
- If an intervention causes financial losses (or even only the expectation of financial losses) this can mean the end of the intervention regardless of other positive factors, especially if this is felt by a relatively powerful group.
- One should be aware that health care innovations are always introduced into an already existing health system. On the one hand this means that the interaction between the health system and the care innovation should be considered beforehand. On the other hand, it is important for the care innovation to be flexible enough to absorb changes in the existing health system.
- The importance of health IT can never be overrated or emphasised enough. Health IT should not be an afterthought or be seen as an additional feature; instead it should be treated as an integral part of the care intervention. Provider education, continuous feedback and system improvements should be part of the normal implementation cycle from the beginning and throughout the intervention.
- It is important to stay close and in continuous conversation with the health care professionals to make sure that the changes reflect their wishes and that one is not trying to solve problems that were not actually perceived as such by the health care professionals in the first place. Furthermore, it is important to give people the time to adapt to a new situation and experience its advantages and disadvantages before changing the situation again as this could lead to people becoming tired of all the changes regardless of the beneficial effects the changes might have. In this case, the innovation itself would become the barrier.