From protocol to personalised care: improving and tailoring diabetes management in general practice

To improve primary diabetes care in the Netherlands, in 2007 a ‘care group’ system is initiated. We first studied the association between adherence to a structured diabetes protocol and patient outcomes. We then investigated what practices actually require when seeking to adjust care to patient needs. With that aim in mind, we explored the effect of dispensing with protocol and the key conditions for successful implementation of self-management interventions. Finally, we measured patient outcomes with regard to treatment satisfaction, quality of life and monitoring.A structured care protocol has added value for people with diabetes; the proportion of people having recommended monitoring increases sharply. Practices likely undergo an intensive learning process when they join a care group and appear to reach the same as experienced practice within a year. When comparing the HbA1 levels of people with recommended and incomplete monitoring, we found that the HbA1c levels in people with recommended monitoring are significantly circa 2 mmol/mol lower compared to incomplete monitoring. In other words, recommended monitoring is far more than merely an administrative procedure; it actually reflects better real-world HbA1c levels. Differences in HbA1c level between people with recommended versus incomplete monitoring were greater in vulnerable populations, to the extent of approximately 3 mmol/mol, whereas a circa 1 mmol/mol difference was found in the intermediate category. In other words, within a care group setting people in the deprived category derive the most benefit from recommended monitoring.Protocol-free care provided room for reflection concerning ‘tailored care’; varying self-management interventions were chosen Our study revealed three key conditions for successful implementation of self-management interventions. Considering that patient satisfaction and monitoring decreased, this thesis ends with a roadmap consisting of several recommendations to improve and tailor diabetes care in general practice.Sanof