Het dagelijks functioneren centraal in een diabetesconsult

Summary

Towards integrated nurseled self-management support in routine diabetes care
Anneke van Dijk-de Vries

BACKGROUND: Psychosocial problems are prevalent among patients with diabetes. They may lead to a downward spiral of poor adherence, deterioration of the condition and decline in daily functioning. In addition to medical management, systematic attention to emotional and role management tasks during routine diabetes consultations seems mandatory.
OBJECTIVE: An effective nurseled minimal psychological intervention was adjusted for implementation in the routine diabetes care by primary care nurses. The resulting Self-Management Support (SMS) programme involved early detection of patients with emotional distress and problems of daily functioning, and self-management support through problem solving and reattribution techniques. Strategies to embed SMS in daily practice included training and booster sessions for practice nurses as well as organisational and financial arrangements. The implementation process and effects of SMS were simultaneously evaluated in a hybrid effectiveness–implementation design.
METHODS: A pragmatic cluster-randomised controlled trial with a baseline measurement and follow-up measurements after 4 and 12 months was performed. Practice nurses in the intervention arm (n=19) received SMS training. Practice nurses in the control arm (n=21) provided usual care. Patients (n=264) were selected by a posted research-driven screening questionnaire measuring problems in daily functioning and emotional distress. Primary outcome measure was patients’ daily functioning. Secondary measures included emotional wellbeing, participation, autonomy and control over the disease. Quantitative and qualitative data were collected to explore facilitators and barriers regarding successful implementation of SMS.
RESULTS: Only 16 of the 117 patients in the intervention arm (14%) who were found eligible by the posted research-driven screening questionnaire were detected by the nurseled detection in routine consultations. Extra consultations for the selfmanagement support were delivered to only 11 study participants. In the control arm, 147 patients received usual care. Multilevel analyses showed no significant differences in outcomes between the intervention and control arms. Practice nurses valued the systematic approach, but felt restricted in time and expertise to fully adopt SMS in their regular care. The impact of SMS for general practitioners was limited. The organisational and financial support was not adequate. Patients seemed to support the ideal of integrated care, but did not expect a discussion about psychosocial problems in diabetes consultations.
CONCLUSIONS: SMS in its present form was not effective. The challenge is to find effective ways to identify eligible patients for the psychosocial self-management support, and to provide tailored training, support and effective financial incentives to health professionals to successfully incorporate SMS in daily practice. It also requires endeavours to make patients acquainted with the new role of the practice nurse.