Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice
Barriers to, and facilitators in, introducing integrated diabetes care in Ireland: a qualitative study of views in general practice
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DOI：
10.1136/bmjopen-2013-003217
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发表时间：
2013-01-01
期刊：
影响因子：
2.9
通讯作者：
Bradley, Colin
中科院分区：
文献类型：
--
作者：
Mc Hugh, Sheena;O'Mullane, Monica;Bradley, Colin
目的：在爱尔兰实施综合护理模式之前，从全科医生的角度研究改善糖尿病管理的障碍和促进因素。设计：采用半结构化访谈进行定性分析。背景：爱尔兰共和国的初级保健。参与者：目的样本为29名全科医生和2名执业护士。方法：采用框架法对数据进行分析。结果：主要障碍和促进因素发生在卫生系统层面，但在组织、专业和患者层面产生了连锁反应。爱尔兰卫生系统对糖尿病管理缺乏有针对性的报酬，这在一般实践中造成了冷漠，并被认为表明卫生系统对慢性病管理缺乏价值。全科医生中有一小部分人受到“职业”激励（如职业责任感）的驱使；然而，这还不足以推动广泛的改进。医院服务被视为初级保健管理的基本支持，尽管一些参与者提到了环境之间出现的紧张关系。初级和二级界面缺乏协调导致了本可避免的重复，以及“在此期间”不确定患者何时会被专家服务呼叫或召回。促进因素包括护理支持的可用性和偶然获得的服务。社区资源的缺乏被认为与将常规管理转变为全科实践的政策不一致，后者正迅速达到饱和。结论：目前，内在动机正在推动爱尔兰糖尿病护理的改善。这不足以实施拟议的改革，包括全国综合护理模式。政策制定者需要评估和准备不同水平的兴趣和基础设施在爱尔兰的初级保健，以支持这一变化。
Objective: To examine the barriers to, and facilitators in, improving diabetes management from the general practice perspective, in advance of the implementation of an integrated model of care in Ireland.Design: Qualitative using semistructured interviews.Setting: Primary care in the Republic of Ireland.Participants: Purposive sample of 29 general practitioners (GPs) and two practice nurses.Methods: Data were analysed using a framework approach.Results: The main barriers and facilitators occurred at the level of the health system but had a ripple effect at an organisational, professional and patient level. The lack of targeted remuneration for diabetes management in the Irish health system created apathy in general practice and was perceived to be indicative of the lack of value placed on chronic disease management in the health system. There were 'pockets of interest' among GPs motivated by 'vocational' incentives such as a sense of professional duty; however, this was not sufficient to drive widespread improvement. The hospital service was seen as an essential support for primary care management, although some participants referred to emerging tension between settings. The lack of coordination at the primary-secondary interface resulted in avoidable duplication and an 'in the meantime' period of uncertainty around when patients would be called or recalled by specialist services. Facilitators included the availability of nursing support and serendipitous access to services. The lack of resources in the community was considered to be at odds with policy to shift routine management to general practice, which is fast reaching saturation.Conclusions: At present, intrinsic motivation is driving the improvement of diabetes care in Ireland. This will not be sufficient to implement the proposed reform including a national model of integrated care. Policymakers need to assess and prepare for the disparate levels of interest and infrastructure in primary care in Ireland to support this change.