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Cited by 289Diabetes Management and EducationDiabetes Treatment and ManagementPrimary Care and Health Outcomes

Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

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Rushforth, Bruno, McCrorie, Carolyn, Glidewell, Liz, Midgley, Eleanor, Foy, Robbie·2016·British Journal of General Practice
DOI 10.3399/bjgp16x683509PMC PMC4723210
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Abstract

BACKGROUND: Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals. AIM: To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians' and nurses' perceived influences on care. DESIGN AND SETTING: Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework. METHOD: Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians' or nurses' perceived influences on treatment goals for type 2 diabetes. RESULTS: A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification. CONCLUSION: Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than 'one size fits all' approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians' skills and emotions around treatment intensification and facilitation of patient behaviour change.

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  • Mindfulness-based interventions have been reported to improve adoption and maintenance of diabetes-related treatments.

    “Further to the direct effect on mental health, MBIs have also been reported to improve adoption and maintenance of diabetes‐related treatments, which is often challenging (Rushforth 2016).”

    From Mindfulness-based interventions for adults with type 2 diabetes mellitus (2021) · cites this paper as Rushforth 2016

    The General section describes difficulty maintaining discipline for diabetes control and non-compliance with diet or treatment; the Discussion Summary also reports clinicians’ frustrations with treatment compliance. These passages support the sentence’s point that diabetes-related treatment can be challenging, but they do not report that mindfulness-based interventions improve treatment adoption or maintenance. Page numbers are unavailable in our copy. (LLM, conf=0.86)

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References 76 · Cited by 289

Research works printed but not linked: 51

  1. Goldney RD, Phillips PJ, Fisher LJ, Wilson DH. Diabetes, depression, and quality of life: a population study. Diabetes Care 2004; 27(5): 1066-1070.
  2. Carney RM, Freedland KE, Miller GE, Jaffe AS. Depression as a risk factor for cardiac mortality and morbidity: a review of potential mechanisms. J Psychosom Res 2002; 53(4): 897-902.
  3. Hex N, Bartlett C, Wright D, et al. Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabet Med 2012; 29(7): 855-862.
  4. Smith S, Bury G, O'Leary M, et al. The North Dublin randomized controlled trial of structured diabetes shared care. Fam Pract 2004; 21(1): 39-45.
  5. Grol R. Personal paper. Beliefs and evidence in changing clinical practice. BMJ 1997; 315(7105): 418-421.
  6. Dietrich UC. Factors influencing the attitudes held by women with type II diabetes: a qualitative study. Patient Educ Couns 1996; 29(1): 13-23.
  7. Holmström IM, Rosenqvist U. Misunderstandings about illness and treatment among patients with type 2 diabetes. J Adv Nurs 2005; 49(2): 146-154.
  8. Hunt LM, Valenzuela MA, Pugh JA. NIDDM patients' fears and hopes about insulin therapy. The basis of patient reluctance. Diabetes Care 1997; 20(3): 292-298.
  9. Lai WA, Lew-Ting CY, Chie WC. How diabetic patients think about and manage their illness in Taiwan. Diabet Med 2005; 22(3): 286-292.
  10. Lawton J, Peel E, Parry O, et al. Lay perceptions of type 2 diabetes in Scotland: bringing health services back in. Soc Sci Med 2005; 60(7): 1423-1435.
  11. Shaw RL, Booth A, Sutton AJ, et al. Finding qualitative research: an evaluation of search strategies. BMC Med Res Methodol 2004; 4: 5.
  12. Tavender EJ, Bosch M, Gruen RL, et al. Understanding practice: the factors that influence management of mild traumatic brain injury in the emergency department -a qualitative study using the Theoretical Domains Framework. Implement Sci 2014; 9: 8.
  13. Lee YK, Lee PY, Ng CJ. A qualitative study on healthcare professionals' perceived barriers to insulin initiation in a multi-ethnic population. BMC Fam Pract 2012; 13: 28.
  14. Lee PY, Lee YK, Khoo EM, Ng CJ. How do health care professionals assess patients when initiating insulin therapy? A qualitative study. Prim Care Diabetes 2014; 8(1): 49-55.
  15. Noor Abdulhadi NM, Al-Shafaee MA, Wahlström R, Hjelm K. Doctors' and nurses' views on patient care for type 2 diabetes: an interview study in primary health care in Oman. Prim Health Care Res Dev 2013; 14(3): 258-269.
  16. Agarwal G, Nair K, Cosby J, et al. GPs' approach to insulin prescribing in older patients: a qualitative study. Br J Gen Pract 2008; 58(553): 569-575.
  17. Pooley CG, Gerrard C, Hollis S, et al. 'Oh it's a wonderful practice … you can talk to them': a qualitative study of patients' and health professionals' views on the management of type 2 diabetes. Health Soc Care Community 2001; 9(5): 318-326.
  18. Stewart J, Dyas J, Brown K, Kendrick D. Achieving blood pressure targets: lessons from a study with practice nurses. J Diabetes Nurs 2006; 10(5): 186-193.
  19. Howard JA, Bower K, Putnam W. Factors influencing the management of hypertension in type 2 diabetes. Can J Diabetes 2006; 30(1): 38-45.
  20. Crosson JC, Heisler M, Subramanian U, et al. Physicians' perceptions of barriers to cardiovascular disease risk factor control among patients with diabetes: results from the translating research into action for diabetes (TRIAD) study. J Am Board Fam Med 2010; 23(2): 171-178.
  21. Ab E, Denig P, van Vliet T, Dekker JH. Reasons of general practitioners for not prescribing lipid-lowering medication to patients with diabetes: a qualitative study. BMC Fam Pract 2009; 10: 24.
  22. Haque M, Emerson SH, Dennison CR, et al. Barriers to initiating insulin therapy in patients with type 2 diabetes mellitus in public-sector primary health care centres in Cape Town. S Afr Med J 2005; 95(10): 798-802.
  23. Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes: barriers to guideline implementation. Diabetes Care 1998; 21(9): 1391-1396.
  24. Abbott S, Burns J, Gleadell A, Gunnell C. Community nurses and self- management of blood glucose. Br J Community Nurs 2007; 12(1): 6-11.
  25. Jeavons D, Hungin AP, Cornford CS. Patients with poorly controlled diabetes in primary care: healthcare clinicians' beliefs and attitudes. Postgrad Med J 2006; 82(967): 347-350.
  26. Greaves CJ, Brown P, Terry RT, et al. Converting to insulin in primary care: an exploration of the needs of practice nurses. J Adv Nurs 2003; 42(5): 487-496.
  27. Burden ML, Burden AC. Attitudes to starting insulin in primary care. Practical Diabetes International 2007; 24(7): 346-350.
  28. Wens J, Vermeire E, Van Royen P, et al. GPs' perspectives of type 2 diabetes patients' adherence to treatment: a qualitative analysis of barriers and solutions. BMC Fam Pract 2005; 6(1): 20.
  29. Fhärm E, Rolandsson O, Johansson EE. 'Aiming for the stars': GPs' dilemmas in the prevention of cardiovascular disease in type 2 diabetes patients: focus group interviews. Fam Pract 2009; 26(2): 109-114.
  30. Brown JB, Harris SB, Webster-Bogaert S, et al. The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus. Fam Pract 2002; 19(4): 344-349.
  31. Daniels A, Biesma R, Otten J, et al. Ambivalence of primary health care professionals towards the South African guidelines for hypertension and diabetes. S Afr Med J 2000; 90(12): 1206-1211.
  32. Alberti H, Boudriga N, Nabli M. Primary care management of diabetes in a low/middle income country: a multi-method, qualitative study of barriers and facilitators to care. BMC Fam Pract 2007; 8: 63.
  33. Grant RW, Lutfey KE, Gerstenberger E, et al. The decision to intensify therapy in patients with type 2 diabetes: results from an experiment using a clinical case vignette. J Am Board Fam Med 2009; 22(5): 513-520.
  34. Raaijmakers LG, Hamers FJ, Martens MK, et al. Perceived facilitators and barriers in diabetes care: a qualitative study among health care professionals in the Netherlands. BMC Fam Pract 2013; 14: 114.
  35. Kern DH, Mainous AG 3rd. Disease management for diabetes among family physicians and general internists: opportunism or planned care? Fam Med 2001; 33(8): 621-625.
  36. Elliott DJ, Robinson EJ, Sanford M, et al. Systemic barriers to diabetes management in primary care: a qualitative analysis of Delaware physicians. Am J Med Qual 2011; 26(4): 284-290.
  37. O'Connor R, Mannix M, Mullen J, et al. Structured care of diabetes in general practice: a qualitative study of the barriers and facilitators. Ir Med J 2013; 106(3): 77-80.
  38. McHugh S, O'Mullane M, Perry IJ, Bradley C. Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice. BMJ Open 2013; 3(8): e003217.
  39. Trewin VF, Veitch GB, Lawrence CJ. Influences on GP prescribing habits: any hypoglycaemic for the elderly? Pharm J 1999; 262(7039): 482-484.
  40. Tan AM, Muthusamy L, Ng CC, et al. Initiation of insulin for type 2 diabetes mellitus patients: what are the issues? A qualitative study. Singapore Med J 2011; 52(11): 801-809.
  41. Furler J, Spitzer O, Young D, Best J. Insulin in general practice: barriers and enablers for timely initiation. Aust Fam Physician 2011; 40(8): 617-621.
  42. Halifax NV, Cafazzo JA, Irvine MJ, et al. Telemanagement of hypertension: a qualitative assessment of patient and physician preferences. Can J Cardiol 2007; 23(7): 591-594.
  43. Loewe R, Freeman J. Interpreting diabetes mellitus: differences between patient and provider models of disease and their implications for clinical practice. Cult Med Psychiatry 2000; 24(4): 379-401.
  44. Kirsh S, Hein M, Pogach L, et al. Improving outpatient diabetes care. Am J Med Qual 2012; 27(3): 233-240.
  45. van Bokhoven MA, Kok G, van der Weijden T. Designing a quality improvement intervention: a systematic approach. Qual Saf Health Care 2003; 12(3): 215-220.
  46. von Arx LB, Kjaer T. The patient perspective of diabetes care: a systematic review of stated preference research. Patient 2014; 7(3): 283-300.
  47. Ferlie EB, Shortell SM. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q 2001; 79(2): 281-315.
  48. Khunti K, Gray LJ, Skinner T, et al. Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. BMJ 2012; 344: e2333.
  49. McSherry LA, Dombrowski SU, Francis JJ, et al. 'It's a can of worms': understanding primary care practitioners' behaviours in relation to HPV using the Theoretical Domains Framework. Implement Sci 2012; 7: 73.
  50. Lugtenberg M, Zegers-van Schaick JM, Westert GP, Burgers JS. Why don't physicians adhere to guideline recommendations in practice? An analysis of barriers among Dutch general practitioners. Implement Sci 2009; 4: 54.
  51. Presseau J, Ivers NM, Newham JJ, et al. Using a behaviour change techniques taxonomy to identify active ingredients within trials of implementation interventions for diabetes care. Implement Sci 2015; 10: 55.

Authors
Rushforth, B., McCrorie, C., Glidewell, L., Midgley, E., & Foy, R.
Affiliations
University of Leeds (GB)
ORCID
Venue
British Journal of General Practice
Publisher
Royal College of General Practitioners
Published
2016-01-28
Volume
66
Issue
643
Pages
e114-e127
ISSN
  • 0960-1643 (ISSN-L)
  • 1478-5242
DOI
10.3399/bjgp16x683509
PMC
PMC4723210
OpenAlex
W2233886198
Cited by
289
References
76
Citations by year
2026: 25 · 2025: 26 · 2024: 30 · 2023: 35 · 2022: 38 · 2021: 53 · 2020: 42 · 2019: 21 · 2018: 7 · 2017: 10 · 2016: 2
FWCI
1.96
Type
journal article
Language
en
Open access
Locations
  • British Journal of General Practice (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (submittedVersion)
Funders
National Institute for Health and Care Research (IPF-12-11)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Treatment and Management
  • Health Sciences › Health Professions › General Health Professions › Primary Care and Health Outcomes
Keywords
type 2 diabetes, primary care, barriers to care, glycemic control, blood pressure control, cholesterol management, treatment goals, clinician knowledge and skills, insulin initiation, patient behavior change, treatment intensification, professional boundaries, quality improvement, Theoretical Domains Framework
MeSH terms
Diabetes Mellitus, Type 2, Humans, Patient Compliance, Primary Health Care, Disease Management, Qualitative Research, Quality Improvement

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