ObjectivesPoorly controlled type 2 diabetes mellitus (T2DM) is a major international health problem. Our aim was to assess the effectiveness of healthcare interventions, specifically targeting patients with poorly controlled T2DM, which seek to improve glycaemic control and cardiovascular risk in primary care settings.DesignSystematic review.SettingPrimary care and community settings.Included studiesRandomised controlled trials (RCTs) targeting patients with poor glycaemic control were identified from Pubmed, Embase, Web of Science, Cochrane Library and SCOPUS. Poor glycaemic control was defined as HbA1c over 59 mmol/mol (7.5%).InterventionsInterventions were classified as organisational, patient-oriented, professional, financial or regulatory.OutcomesPrimary outcomes were HbA1c, blood pressure and lipid control. Two reviewers independently assessed studies for eligibility, extracted data and assessed study quality. Meta-analyses were undertaken where appropriate using random-effects models. Subgroup analysis explored the effects of intervention type, baseline HbA1c, study quality and study duration. Meta-regression analyses were undertaken to investigate identified heterogeneity.ResultsForty-two RCTs were identified, including 11 250 patients, with most undertaken in USA. In general, studies had low risk of bias. The main intervention types were patient-directed (48%) and organisational (48%). Overall, interventions reduced HbA1c by −0.34% (95% CI −0.46% to −0.22%), but meta-analyses had high statistical heterogeneity. Subgroup analyses suggested that organisational interventions and interventions on those with baseline HbA1c over 9.5% had better improvements in HbA1c. Meta-regression analyses suggested that only interventions on those with population HbA1c over 9.5% were more effective. Interventions had a modest improvement of blood pressure and lipids, although baseline levels of control were generally good.ConclusionsThis review suggests that interventions for T2DM, in primary care, are better targeted at individuals with very poor glycaemic control and that organisational interventions may be more effective.
Background: 'Implementation interventions' refer to methods used to enhance the adoption and implementation of clinical interventions such as diabetic retinopathy screening (DRS). DRS is effective, yet uptake is often suboptimal. Despite most routine management taking place in primary care and the central role of health care professionals (HCP) in referring to DRS, few interventions have been developed for primary care. We aimed to develop a multifaceted intervention targeting both professionals and patients to improve DRS uptake as an example of a systematic development process combining theory, stakeholder involvement, and evidence. Methods: First, we identified target behaviours through an audit in primary care of screening attendance. Second, we interviewed patients (n = 47) and HCP (n = 30), to identify determinants of uptake using the Theoretical Domains Framework, mapping these to behaviour change techniques (BCTs) to develop intervention content. Thirdly, we conducted semi-structured consensus groups with stakeholders, specifically users of the intervention, i.e. patients (n = 15) and HCPs (n = 16), regarding the feasibility, acceptability, and local relevance of selected BCTs and potential delivery modes. We consulted representatives from the national DRS programme to check intervention 'fit' with existing processes. We applied the APEASE criteria (affordability, practicability, effectiveness, acceptability, side effects, and equity) to select the final intervention components, drawing on findings from the previous steps, and a rapid evidence review of operationalised BCT effectiveness. Results: We identified potentially modifiable target behaviours at the patient (consent, attendance) and professional (registration) level. Patient barriers to consent/attendance included confusion between screening and routine eye checks, and fear of a negative result. Enablers included a recommendation from friends/family or professionals and recognising screening importance. Professional barriers to registration included the time to register patients and a lack of readily available information on uptake in their local area/practice. Most operationalised BCTs were acceptable to patients and HCPs while the response to feasibility varied. After considering APEASE, the core intervention, incorporating a range of BCTs, involved audit/feedback, electronic prompts targeting professionals, HCP-endorsed reminders (face-to-face, by phone and letter), and an information leaflet for patients.
The clinical experiences and opinions of the respondents suggest that the current legal availability of abortion in Ireland is insufficient to guide best clinical practice and does not represent the views of those that provide obstetric care.
Background:The asymptomatic general check-up (AGCU) is a common consultation in primary care. Detractors of the AGCU cite a lack of evidence and the harm of over-investigation. Proponents cite the opportunity for the GP to engage in health promotion and explore hidden concerns of the patient. Objectives: To research Irish GP experiences with the AGCU, including their approach to the consultation and to assess their attitudes towards the AGCU. Methods: In 2013, a cross-sectional postal-survey of 136 GPs in the Northwest of Ireland was performed. This was a mixed-method study which underwent both quantitative and qualitative analysis. Results: The response rate was 79/136 (57%). Over 6% of reported consultations were for an AGCU. Large diff erences existed amongst GPs in their approach to the AGCU. Cardiovascular risk assessment and blood investigations were deemed the most important. GPs had concerns about the AGCU relating to patients being falsely reassured, about the workload and over-diagnosis. Still, 63% of responding GPs felt that the AGCU was clinically useful. Seventy per cent did not agree with private companies off ering an AGCU. Conclusion:Despite the lack of evidence for its use and frustrations expressed by GPs, the AGCU is a frequent consultation. GPs took very diff erent approaches to the consultation when a patient presented for a check-up. Most responding GPs think it can have some clinical benefi t. There is a need for GPs to appropriately challenge mistaken health beliefs pertaining to the AGCU.
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