Association of personalised care plans with monitoring and control of clinical outcomes, prescription of medication and utilisation of primary care services in patients with type 2 diabetes: an observational real-world study

Abstract

Objective To study the association of personalised care plans with monitoring and controlling clinical outcomes, prescription of cardiovascular and antihyperglycaemic medication and utilisation of primary care services in patients with type 2 diabetes (T2D). Patients Primary care T2D outpatients from the Rovaniemi Health Centre. Setting The municipal health centre, Rovaniemi, Finland. Design A cross-sectional, observational, retrospective register-based study. The patients were divided into three groups: ‘no care plan entries’ (usual care); ‘1–2 care plan entries’; and ‘3 or more care plan entries’. Main outcome measures Monitoring of clinical and biochemical measures, achievement of treatment targets, prescription of cardiovascular and antihyperglycemic medication, and use of primary care services. Results A total of 5104 patients with T2D (mean age 65.5 years (SD 12.4)), of which 67% had at least one care plan entry. Compared to usual care, the establishment of a care plan (either care plan group) was associated with better monitoring of glycosylated haemoglobin A1c, low-density-lipoprotein cholesterol, systolic blood pressure (sBP), and renal function, and there was more frequent prescription of all cardiovascular and antihyperglycemic medication. Patients in either care plan group were more likely to achieve sBP target ( p < 0.05). Patients without a care plan had more unplanned primary care physician contacts compared to patients in care plan groups ( p < 0.001). Conclusion Establishment of a care plan is associated with more intensive and focussed care of patients with T2D. The appropriate use of primary care resources is essential and personalised care plans may contribute to the treatment of patients with T2D. Key Points Care planning aims to empower patients with type 2 diabetes. This study demonstrates that personalised care planning is associated with more frequent monitoring for clinical outcomes, more frequent prescription of cardiovascular and antihyperglycemic medication and more frequent utilisation of planned diabetes consultations when compared to usual care.

What is meant by ‘integrated personalized diabetes management’: A view into the future and what success should look like

“…Adequate classification and stratification are essential for efficient and effective IPDM planning. 43 Figure 1 illustrates the various patient profiles based on their complexity and the type of care required, including self-management. 44 When primary health care is effective, it can address 90% of people's health needs.…”

“…Proper screening, diagnosis, disease management and referral routines at a primary care level will enhance the efficiency and cost‐effectiveness of the health system involved. Adequate classification and stratification are essential for efficient and effective IPDM planning 43 . Figure 1 illustrates the various patient profiles based on their complexity and the type of care required, including self‐management 44 .…”

Association of musculoskeletal pain with the achievement of treatment targets for type 2 diabetes among primary care patients

“…In turn, corresponding figures among primary care T2D patients were recorded in a large Scandinavian study, with approximately 34-53% achieving the HbA1c (< 53 mol/mmol) target, 46-70% the LDL target (< 2.5 mmol/L) and 29-40% the BP goal defined under 130/80 mmHg [40]. In Rovaniemi, all patients with T2D who are treated in primary health centres are followed up regularly by healthcare professionals, and therefore patients are likely to be exposed to regular assistance for self-care that may have favourable effects on T2D treatment balance [41], explaining at least a part of the outperforming. MS pain in any of the studied forms was not relevant in meeting the T2D treatment targets of interest in a real-world setting after adjustments.…”