Susan M Smith

Peer support in type 2 diabetes: a randomised controlled trial in primary care with parallel economic and qualitative analyses: pilot study and protocol

BackgroundDiabetes is a chronic illness, which requires the individual to assume responsibility for their own care with the aim of maintaining glucose and blood pressure levels as close to normal as possible. Traditionally self-management training for diabetes has been delivered in a didactic manner. In recent times alternatives to the traditional delivery of diabetes care have been investigated, for example, the concept of peer support which emphasises patient rather than professional domination. This paper describes the pilot study and protocol for a study that aims to evaluate the effectiveness of a peer support intervention for people with type 2 diabetes in a primary care setting.Methods/DesignA pilot study was conducted to access the feasibility of a randomized controlled trial of a peer support intervention. We used the MRC Framework for the evaluation of complex interventions. Elements of the intervention were defined and the study protocol was finalized. In this cluster randomised controlled trial twenty general practices are assigned to control and intervention groups. Each practice compiles a diabetes register and randomly selects 21 patients. All practices implement a standardised diabetes care system. In the intervention group all practices recruit three peer supporters. The peer supporters are trained to conduct nine group meetings in their general practice over a period of two years. Each meeting has a structured component. The primary outcomes are blood pressure, total cholesterol, HBA1c and the Diabetes Well-being score. In addition to biophysical, psychosocial, economic and health service utilization data peer supporter activity and qualitative data are collected.DiscussionPeer support is a complex intervention and evaluating such an intervention presents challenges to researchers. This study will evaluate whether a peer support programme for patients with type 2 diabetes improves biophysical and psychosocial outcomes and whether it is an acceptable, cost effective intervention in the primary care setting.Trial registrationCurrent Controlled Trials ISRCTN42541690

Development of a complex intervention to test the effectiveness of peer support in type 2 diabetes

BackgroundDiabetes is a chronic illness which requires the individual to assume responsibility for their own care with the aim of maintaining glucose and blood pressure levels as close to normal as possible. Traditionally self management training for diabetes has been delivered in a didactic setting. In recent times alternatives to the traditional delivery of diabetes care have been investigated, for example, the concept of peer support which emphasises patient rather than professional domination. The aim of this paper is to describe the development of a complex intervention of peer support in type 2 diabetes for a randomised control trial in a primary care setting.MethodsThe Medical Research Council (MRC) framework for the development and evaluation of complex interventions for randomised control trials (RCT) was used as a theoretical guide to designing the intervention.The first three phases (Preclinical Phase, Phase 1, Phase 2) of this framework were examined in depth. The Preclinical Phase included a review of the literature relating to type 2 diabetes and peer support. In Phase 1 the theoretical background and qualitative data from 4 focus groups were combined to define the main components of the intervention. The preliminary intervention was conducted in Phase 2. This was a pilot study conducted in two general practices and amongst 24 patients and 4 peer supporters. Focus groups and semi structured interviews were conducted to collect additional qualitative data to inform the development of the intervention.ResultsThe four components of the intervention were identified from the Preclinical Phase and Phase 1. They are: 1. Peer supporters; 2. Peer supporter training; 3. Retention and support for peer supporters; 4.Peer support meetings. The preliminary intervention was implemented in the Phase 2. Findings from this phase allowed further modeling of the intervention, to produce the definitive intervention.ConclusionThe MRC framework was instrumental in the development of a robust intervention of peer support of type 2 diabetes in primary care.Trial registrationCurrent Controlled Trials ISRCTN42541690

Managing patients with multimorbidity : systematic review of interventions in primary care and community settings

Objective To determine the effectiveness of interventions designed to improve outcomes in patients with multimorbidity in primary care and community settings. Design Systematic review. Data sources Medline, Embase, CINAHL, CAB Health, Cochrane central register of controlled trials, the database of abstracts of reviews of effectiveness, and the Cochrane EPOC (effective practice and organisation of care) register (searches updated in April 2011). Eligibility criteria Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses reporting on interventions to improve outcomes for people with multimorbidity in primary care and community settings. Multimorbidity was defined as two or more chronic conditions in the same individual. Outcomes included any validated measure of physical or mental health and psychosocial status, including quality of life outcomes, wellbeing, and measures of disability or functional status. Also included were measures of patient and provider behaviour, including drug adherence, utilisation of health services, acceptability of services, and costs. Data selection Two reviewers independently assessed studies for eligibility, extracted data, and assessed study quality. As meta-analysis of results was not possible owing to heterogeneity in participants and interventions, a narrative synthesis of the results from the included studies was carried out. Results 10 studies examining a range of complex interventions totalling 3407 patients with multimorbidity were identified. All were randomised controlled trials with a low risk of bias. Two studies described interventions for patients with specific comorbidities. The remaining eight studies focused on multimorbidity, generally in older patients. Consideration of the impact of socioeconomic deprivation was minimal. All studies involved complex interventions with multiple components. In six of the 10 studies the predominant component was a change to the organisation of care delivery, usually through case management or enhanced multidisciplinary team work. In the remaining four studies, intervention components were predominantly patient oriented. Overall the results were mixed, with a trend towards improved prescribing and drug adherence. The results indicated that it is difficult to improve outcomes in this population but that interventions focusing on particular risk factors in comorbid conditions or functional difficulties in multimorbidity may be more effective. No economic analyses were included, although the improvements in prescribing and risk factor management in some studies could provide potentially important cost savings. Conclusions Evidence on the care of patients with multimorbidity is limited, despite the prevalence of multimorbidity and its impact on patients and healthcare systems. Interventions to date have had mixed effects, although are likely to be more effective if targeted at risk factors or specific functional difficulties. A need exists to clearly identify patients with multimorbidity and to develop cost effective and specifically targeted interventions that can improve health outcomes.

Multimorbidity in primary care: developing the research agenda

Multimorbidity usually defined as the co-existence of two or more long-term conditions in an individual is the norm rather than the exception in primary care patients 1,2 and will become more prevalent as populations age. 3,1 Multimorbidity cuts across the vertical paradigms in which most health research and policy is envisaged, supported and carried out, reflecting not only specialist interests in particular problems and diseases, but also the tendency of research to focus on easily defined issues. ‘‘Complicated’’ patients with multimorbidity are usually excluded from such research. Although complexity is under-represented in the research literature, it is common place in general medical practice, where the challenges are ‘‘horizontal’’, integrating not only at the level of the clinical encounter, but also in the co-ordination of services to support patients with multiple problems. The challenge of carrying out research on multimorbidity is to reflect, investigate, inform and improve these aspects of generalist clinical practice. Given that multimorbidity is a challenge facing practitioners and patients alike it has attracted surprisingly little research interest. 4 The research to date has largely focussed on analysis of the impact of multimorbidity on individuals and healthcare systems, with very few studies examining interventions to improve outcomes. One of ‘multimorbidity’s many challenges’ includes setting a research agenda to systematically begin to answer important practical issues in supporting people with multimorbidity. Given the scale and complexity of the task, the first difficulty is simply knowing where to start. In order to gather views from the academic primary care community on the research agenda in multimorbidity we held workshops in Ireland (July 2008) and Scotland (January 2009) under the aegis of the Society for Academic Primary Care and the Scottish School of Primary Care respectively. The workshops were attended by approximately 50 delegates, including patient representatives, primary care professionals, and academics; both explored issues of definition, outcome measures, studies and interventions. The common themes that emerged are outlined below.

134 Battered Children: A Medical and Psychological Study

A controlled investigation of 134 battered children showed that nearly half had serious injuries and 21 died. Sixty-five had been battered more than once, 20 had permanent neurological sequelae, a quarter were low birth weight babies, and 10 had serious congenital defects. Twenty-three had been previously admitted to hospital with failure to thrive and the overlap with physical neglect was considerable. Mortality and morbidity among their siblings was also high. Difficulties with the child were attributable to interaction with neurotic mothers. The risk of battering diminishes after a childs second birthday. The establishment of specialized hospital teams to tackle the overall problem is suggested as a method of improving management. Prevention may lie in educating mothers in the basic physical and psychological requirements of children and overcoming their reluctance to avail themselves of medical care.

Managing patients with multimorbidity in primary care

#### The bottom line Multimorbidity, commonly defined as the presence of two or more chronic medical conditions in an individual,1 is associated with decreased quality of life, functional decline, and increased healthcare utilisation, including emergency admissions, particularly with higher numbers of coexisting conditions.2 3 4 5 6 The management of multimorbidity with drugs is often complex, resulting in polypharmacy with its attendant risks.7 8 9 Patients with multimorbidity have a high treatment burden in terms of understanding and self managing the conditions, attending multiple appointments, and managing complex drug regimens.10 Qualitative research highlights the “endless struggle” patients experience in trying to manage their conditions well.11 Psychological distress is common: in an Australian survey of 7620 patients in primary care, 23% of those with one chronic condition reported depression compared with 40% of those with five or more conditions.12 #### Sources and selection criteria We based this article on the authors’ experience and information from published literature. We carried out searches of PubMed and the Cochrane library using the search terms “co-morbidity” or “comorbidity” or “multimorbid” or “multimorbidity” or “multi-morbidity”. No MeSH term exists for multimorbidity. The searches were supplemented by a review of authors’ personal archives as well as relevant articles from the International Research …

Cost-effectiveness of insulin analogs.

Qualitative arterial waveform analysis has been in existence for millennia; quantitative arterial waveform analysis techniques, which can be traced back to Eulers work in the 18th century, have not been widely used by anesthesiologists and other clinicians. This is likely attributable, in part, to the widespread use of the sphygmomanometer, which allows the practitioner to assess arterial blood pressure without having to develop a sense for the higher-order characteristics of the arterial waveform. The 20-year delay in the development of devices that measure these traits is a testament to the primitiveness of our appreciation for this information. The shape of the peripheral arterial pressure waveform may indeed contain information useful to the anesthesiologist and intensivist. The maximal slope of the peripheral arterial pressure tracing seems to be related to left ventricular contractility, although the relationship may be confounded by other hemodynamic variables. The area under the peripheral arterial pressure tracing is related to stroke volume when loading conditions are stable; this finding has been used in the development of several continuous cardiac output monitors. Pulse wave velocity may be related to vascular impedance and could potentially improve the accuracy of waveform-based stroke volume estimates. Estimates of central arterial pressures (e.g., aortic) can be produced from peripheral (e.g., brachial, radial) tracings using a Generalized Transfer Function, and are incorporated into the algorithms of several continuous cardiac output monitors.OBJECTIVE To determine the effectiveness of shared care interventions designed to improve the management of chronic disease across the primary-specialty care interface. STUDY DESIGN AND METHODS Systematic review using the Cochrane Collaboration method. RESULTS Twenty studies were identified, 19 of which were randomized controlled trials. The majority of studies examined complex interventions and were of short duration. Results were mixed, with no consistent improvements in physical or mental health outcomes, psychosocial outcomes, hospital admissions, default or participation rates, recording of risk factors, and satisfaction with treatment. However, there were improvements in prescribing in the studies that considered this outcome. The methodologic quality of studies varied, with only a minority of studies of high-quality design. Cost data were limited and difficult to interpret across studies. CONCLUSIONS At present, there is insufficient evidence to support the introduction of shared care services into clinical practice. However, methodologic shortcomings, particularly inadequate length of follow-up, may account for this lack of evidence. Further research is needed to test models of collaboration across the primary-specialty care divide both in terms of effectiveness and sustainability over longer periods of time.

Peer support for patients with type 2 diabetes: cluster randomised controlled trial

Objective To test the effectiveness of peer support for patients with type 2 diabetes. Design Cluster randomised controlled. Setting 20 general practices in the east of the Republic of Ireland. Participants 395 patients (192 in intervention group, 203 in control group) and 29 peer supporters with type 2 diabetes. Intervention All practices introduced a standardised diabetes care system. The peer support intervention ran over a two year period and contained four elements: the recruitment and training of peer supporters, nine group meetings led by peer supporters in participant’s own general practice, and a retention plan for the peer supporters. Main outcome measures HbA1c; cholesterol concentration; systolic blood pressure; and wellbeing score. Results There was no difference between intervention and control patients at baseline. All practices and 85% (337) of patients were followed up. At two year follow-up, there were no significant differences in HbA1c (mean difference −0.08%, 95% confidence interval −0.35% to 0.18%), systolic blood pressure (−3.9 mm Hg, −8.9 to 1.1 mm Hg), total cholesterol concentration (−0.03 mmol/L, −0.28 to 0.22 mmol/L), or wellbeing scores (−0.7, −2.3 to 0.8). While there was a trend towards decreases in the proportion of patients with poorly controlled risk factors at follow-up, particularly for systolic blood pressure (52% (87/166) >130 mm Hg in intervention v 61% (103/169) >130 mm Hg in control), these changes were not significant. The process evaluation indicated that the intervention was generally delivered as intended, though 18% (35) of patients in the intervention group never attended any group meetings. Conclusions A group based peer support intervention is feasible in general practice settings, but the intervention was not effective when targeted at all patients with type 2 diabetes. While there was a trend towards improvements of clinical outcomes, the results do not support the widespread adoption of peer support. Trial registration Current Controlled Trials ISRCTN42541690.

Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial.

Objective To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease. Design Cluster randomised controlled multicentre trial. Setting General practices in Northern Ireland and the Republic of Ireland, regions with different healthcare systems. Participants 903 patients with established coronary heart disease registered with one of 48 practices. Intervention Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care. Main outcome measures The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12). Results At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03). Conclusions Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease. Trial registration Current Controlled Trials ISRCTN24081411.

The epidemiology of malpractice claims in primary care: a systematic review

Objectives The aim of this systematic review was to examine the epidemiology of malpractice claims in primary care. Design A computerised systematic literature search was conducted. Studies were included if they reported original data (≥10 cases) pertinent to malpractice claims, were based in primary care and were published in the English language. Data were synthesised using a narrative approach. Setting Primary care. Participants Malpractice claimants. Primary outcome Malpractice claim (defined as a written demand for compensation for medical injury). We recorded: medical misadventure cited in claims, missed/delayed diagnoses cited in claims, outcome of claims, prevalence of claims and compensation awarded to claimants. Results Of the 7152 articles retrieved by electronic search, a total of 34 studies met the inclusion criteria and were included in the narrative analysis. Twenty-eight studies presented data from medical indemnity malpractice claims databases and six studies presented survey data. Fifteen studies were based in the USA, nine in the UK, seven in Australia, one in Canada and two in France. The commonest medical misadventure resulting in claims was failure to or delay in diagnosis, which represented 26–63% of all claims across included studies. Common missed or delayed diagnoses included cancer and myocardial infarction in adults and meningitis in children. Medication error represented the second commonest domain representing 5.6–20% of all claims across included studies. The prevalence of malpractice claims in primary care varied across countries. In the USA and Australia when compared with other clinical disciplines, general practice ranked in the top five specialties accounting for the most claims, representing 7.6–20% of all claims. However, the majority of claims were successfully defended. Conclusions This review of malpractice claims in primary care highlights diagnosis and medication error as areas to be prioritised in developing educational strategies and risk management systems.