Intercountry Consensus Building: Lessons From Developing a Chronic-Conditions Self-Management Support Framework.

Self-management support initiatives that aim to improve the self-care of chronic conditions are considered a key part of a health promotion strategy for addressing the impacts of long-term illness. Given the growth of these activities and still evolving evidence base, thoughtful intercountry collaborations with subject matter experts can be an effective way to expedite building self-management support capacity, promoting the advancement of evidence, and developing effective policies and programs. The challenge is to find an effective consensus building process that promotes linkages between researchers and health promotion decisions makers across vast geographical boundaries and limited resources. This paper describes the international, multistage, face-to-face, and online process that was used for developing an international framework for self-management support by researchers, educators, health care providers, policy makers, program managers/directors, program planners, consultants, patient group representatives, and consumers in 16 countries. We reflect on key lessons from this international initiative and discuss how this type of process may be useful for other health promotion groups trying to exchange knowledge and build consensus on how to move a field of research, policy, and/or practice forward, and advance the evidence-base of practice and the relevance of research.

How Attending Physician Preceptors Negotiate Their Complex Work Environment: A Collective Ethnography.

PURPOSE: To generate an empiric, detailed, and updated view of the attending physician preceptor role and its interface with the complex work environment. METHOD: In 2013, the authors conducted a modified collective ethnography with observations of internal medicine medical teaching unit preceptors from two university hospitals in Canada. Eleven observers conducted 32 observations (99.5 hours) of 26 preceptors (30 observations [93.5 hours] of 24 preceptors were included in the analysis). An inductive thematic approach was used to analyze the data with further axial coding to identify connections between themes. Four individuals coded the main data set; differences were addressed through discussion to achieve consensus. RESULTS: Three elements or major themes of the preceptor role were identified: (1) competence or the execution of traditional physician competencies, (2) context or the extended medical teaching unit environment, and (3) conduct or the manner of acting or behaviors and attitudes in the role. Multiple connections between the elements emerged. The preceptor role appeared to depend on the execution of professional skills (competence) but also was vulnerable to contextual factors (context) independent of these skills, many of which were unpredictable. This vulnerability appeared to be tempered by preceptors' use of adaptive behaviors and attitudes (conduct), such as creativity, interpersonal skills, and wellness behaviors. CONCLUSIONS: Preceptors not only possess traditional competencies but also enlist additional behaviors and attitudes to deal with context-driven tensions and to negotiate their complex work environment. These skills could be incorporated into role training, orientation, and mentorship.

Toward consensus on self-management support: the international chronic condition self-management support framework.

Self-management support (SMS) initiatives have been hampered by insufficient attention to underserved and disadvantaged populations, a lack of integration between health, personal and social domains, over emphasis on individual responsibility and insufficient attention to ethical issues. This paper describes a SMS framework that provides guidance in developing comprehensive and coordinated approaches to SMS that may address these gaps and provides direction for decision makers in developing and implementing SMS initiatives in key areas at local levels. The framework was developed by researchers, policy-makers, practitioners and consumers from 5 English-speaking countries and reviewed by 203 individuals in 16 countries using an e-survey process. While developments in SMS will inevitably reflect local and regional contexts and needs, the strategic framework provides an emerging consensus on how we need to move SMS conceptualization, planning and development forward. The framework provides definitions of self-management (SM) and SMS, a collective vision, eight guiding principles and seven strategic directions. The framework combines important and relevant SM issues into a strategic document that provides potential value to the SMS field by helping decision-makers plan SMS initiatives that reflect local and regional needs and by catalyzing and expanding our thinking about the SMS field in relation to system thinking; shared responsibility; health equity and ethical issues. The framework was developed with the understanding that our knowledge and experience of SMS is continually evolving and that it should be modified and adapted as more evidence is available, and approaches in SMS advance.

Clinical and medication profiles stratified by household income in patients referred for diabetes care.

BACKGROUND: Low income individuals with diabetes are at particularly high risk for poor health outcomes. While specialized diabetes care may help reduce this risk, it is not currently known whether there are significant clinical differences across income groups at the time of referral. The objective of this study is to determine if the clinical profiles and medication use of patients referred for diabetes care differ across income quintiles. METHODS: This cross-sectional study was conducted using a Canadian, urban, Diabetes Education Centre (DEC) database. Clinical information on the 4687 patients referred to the DEC from May 2000 - January 2002 was examined. These data were merged with 2001 Canadian census data on income. Potential differences in continuous clinical parameters across income quintiles were examined using regression models. Differences in medication use were examined using Chi square analyses. RESULTS: Multivariate regression analysis indicated that income was negatively associated with BMI (p < 0.0005) and age (p = 0.023) at time of referral. The highest income quintiles were found to have lower serum triglycerides (p = 0.011) and higher HDL-c (p = 0.008) at time of referral. No significant differences were found in HBA1C, LDL-c or duration of diabetes. The Chi square analysis of medication use revealed that despite no significant differences in HBA1C, the lowest income quintiles used more metformin (p = 0.001) and sulfonylureas (p < 0.0005) than the wealthy. Use of other therapies were similar across income groups, including lipid lowering medications. High income patients were more likely to be treated with diet alone (p < 0.0005). CONCLUSION: Our findings demonstrate that low income patients present to diabetes clinic older, heavier and with a more atherogenic lipid profile than do high income patients. Overall medication use was higher among the lower income group suggesting that differences in clinical profiles are not the result of under-treatment, thus invoking lifestyle factors as potential contributors to these findings.

Association of socio-economic status with diabetes prevalence and utilization of diabetes care services.

BACKGROUND: Low income appears to be associated with a higher prevalence of diabetes and diabetes related complications, however, little is known about how income influences access to diabetes care. The objective of the present study was to determine whether income is associated with referral to a diabetes centre within a universal health care system. METHODS: Data on referral for diabetes care, diabetes prevalence and median household income were obtained from a regional Diabetes Education Centre (DEC) database, the Canadian National Diabetes Surveillance System (NDSS) and the 2001 Canadian Census respectively. Diabetes rate per capita, referral rate per capita and proportion with diabetes referred was determined for census dissemination areas. We used Chi square analyses to determine if diabetes prevalence or population rates of referral differed across income quintiles, and Poisson regression to model diabetes rate and referral rate in relation to income while controlling for education and age. RESULTS: There was a significant gradient in both diabetes prevalence (chi2 = 743.72, p < 0.0005) and population rates of referral (chi2 = 168.435, p < 0.0005) across income quintiles, with the lowest income quintiles having the highest rates of diabetes and referral to the DEC. Referral rate among those with diabetes, however, was uniform across income quintiles. Controlling for age and education, Poisson regression models confirmed a significant socio-economic gradient in diabetes prevalence and population rates of referral. CONCLUSION: Low income is associated with a higher prevalence of diabetes and a higher population rate of referral to this regional DEC. After accounting for diabetes prevalence, however, the equal proportions referred to the DEC across income groups suggest that there is no access bias based on income.

Patient profiles at a centralized, urban, diabetes education centre.

BACKGROUND: Little is known about the characteristics of patients attending diabetes education centres (DECs). To address this knowledge gap, we examined the clinical characteristics of patients referred to a centralized urban DEC. METHODS: Using a clinically detailed patient registry, we studied the profiles of 1459 patients seen in an urban DEC, and compared patients referred to the DEC by family physicians (FPs) to those referred by other physicians (usually specialists), and patients referred to the DEC for the first time to those who had been referred a number of times (multiply-referred patients). RESULTS: Among patients with a known source of referral, 73% were referred by their FP and 27% by a physician other than the FP. Eighty-seven percent of patients were being referred for the first time, and 13% had previous referrals. Blood glucose control at the time of referral was poorer for non-FP referrals and for multiply-referred patients. Patients in the former subgroup were more likely taking insulin when referred (38% v. 12%, p < 0.000), to have type 1 diabetes (19% v. 8%, p < 0.000) and to be referred for insulin initiation (12% v. 2%, p < 0.000) than were FP referrals. Meanwhile, multiply-referred patients were younger (51.9 v. 56.1 yr, p < 0.000) and were more likely to be female (59% v. 46%, p = 0.001) than were patients referred only once. INTERPRETATION: Source of referral (FP v. non-FP) and presence or absence of previous referrals define unique DEC patient subgroups. Attention to the relative size and service needs of these subgroups is relevant to the planning of diabetes services.