Implementation of a Personalized Care Plan for Patients With Type 2 Diabetes Is Associated With Improvements in Clinical Outcomes: An Observational Real-World Study

Abstract

Objective: To analyze the clinical outcomes of patients with type 2 diabetes (T2D) before and after implementation of a personalized care plan in the primary health care setting. Design: Observational, retrospective, real-world study. Setting: All T2D patients with a care plan in Rovaniemi Health Center, Rovaniemi, Finland, for whom data were available from a baseline visit (in 2013-2015 during which the care plan was written) and from a follow-up visit, including an updated care plan by the year 2017. Subjects: In total, 447 patients were included. Mean age was 66.9 (SD 10.1) years, 58.8% were male, 15.4% were smokers, 33.1% had vascular disease, and 17.0% were receiving insulin treatment. The mean follow-up time was 14.4 months. Main Outcome Measures: Glycosylated hemoglobin A1 (HbA1c), low-density lipoprotein (LDL), blood pressure (BP), and body mass index (BMI). Clinical values were taken at both baseline and follow-up. Results: LDL decreased by 0.2 mmol/L, systolic blood pressure by 2.2 mm Hg, diastolic blood pressure by 1.5 mm Hg, and BMI by 0.5 kg/m2 ( P < .05 for each). The decrease in HbA1c was 0.8 mmol/mol ( P = .07). Conclusion: We observed statistically significant decreases in LDL, BP, and BMI. Our results indicate that, over 14 months of follow-up, implementation of a written care plan was associated with small improvements in the clinical outcomes of T2D patients in a primary health care study population in a real-world setting.

A qualitative analysis of the needs and wishes of people with type 2 diabetes and healthcare professionals for optimal diabetes care

“…However, PWD mentioned that they are not being provided with the tools and education to manage their diabetes. Collaboration for the development of personalised care plans and goals is also important to actively involve PWD in their own care 25 and is associated with better outcomes, as they have the lived experience to care for their own individual needs.…”

Randomized controlled study of the impact of a participatory patient care plan among primary care patients with common chronic diseases: a one-year follow-up study

“…One study concerned the diseases studied in our study. An observational, retrospective study of type 2 diabetes patients in primary care with mean follow-up time of 14 months showed statistical significant decrease in LDL-C, blood pressure and BMI [ 16 ]. A telephone interview study with female asthma patients after a two-year follow-up showed greater medication adherence and satisfaction with clinical care among patients having a negotiated care plan, but no significant associations between a negotiated care plan, asthma control and urgent care use [ 15 ].…”

“…Although various care plans have been used in Finland and elsewhere for decades, there is still little research on their effectiveness [8,[10][11][12][13][14][15]. Earlier Finnish care plan projects have reported a decrease in the number of health care visits in the long run and improvements in blood lipid levels, blood pressure levels and body mass index (BMI) [12,16,17]. In Australia (2009), the use of a care plan improved the treatment of depressed patients, reduced their 10-year risk of cardiovascular disease, and increased their physical activity [10,18].…”

Same goals, different challenges: A systematic review of perspectives of people with diabetes and healthcare professionals on Type 2 diabetes care

“…Additionally, shared decision making between HCP and PWD can mitigate some PWD concerns, thereby reducing resistance to pharmacotherapy. Personalised care plans in the context of primary care can also improve diabetes outcomes and actively engage PWD in their self care 43 …”