Population stratification in type 2 diabetes mellitus: A systematic review.

AIMS: There is increasing interest in using stratification in type 2 diabetes to target resources, individualise care and improve outcomes. We aim to systematically review and collate literature that has utilised population stratification methods in the study of adults with type 2 diabetes; and to describe and compare stratification methodologies, population characteristics, variables used to stratify and outcome variables. METHODS: The MEDLINE, EMBASE, CINAHL and Cochrane databases were searched from inception to July 2020. Studies included adults with type 2 diabetes using population stratification methods. The review protocol was registered on PROSPERO (ID: CRD42020206604) and conducted in line with PRISMA guidance. Extracted data included study aims; study setting (primary or secondary care); population characteristics; stratification variables and outcomes; and methodological approach to stratification. RESULTS: Across 348 included studies, there were a total of 10,776,009 participants with a mean age of 61.0 years (SD 5.94). 6.7% of studies used data-driven methods and the rest employed expert-driven approaches using pre-defined stratification criteria. The commonest variable used to stratify populations was HbA1c (n = 57, 16.4%); few studies stratified using clinically important non-traditional variables such as health behaviours and beliefs. CONCLUSIONS: Most studies performing population stratification in type 2 diabetes used expert-driven approaches with the aim of predicting outcomes in glycaemic control, mortality and cardiovascular complications. We identified relatively few studies using data-driven approaches, which offer opportunities generate hypotheses beyond current expert knowledge. We describe important research gaps including stratification with regard to disease remission.

Integrating primary care and social services for older adults with multimorbidity: a qualitative study.

BACKGROUND: Growing demand from an increasingly ageing population with multimorbidity has resulted in complex health and social care needs requiring more integrated services. Integrating primary care with social services could utilise resources more efficiently, and improve experiences for patients, their families, and carers. There is limited evidence on progress including key barriers to and drivers of integration to inform large-scale national change. AIM: To elicit stakeholder views on drivers and barriers of integrated primary care and social services, and highlight opportunities for successful implementation. DESIGN AND SETTING: A qualitative interview study. METHOD: Semi-structured interviews with maximum variation sampling to capture stakeholder views across services and professions. RESULTS: Thirty-seven interviews were conducted across England with people including GPs, nurses, social care staff, commissioners, local government officials, voluntary and private sector workers, patients, and carers. Drivers of integration included groups of like-minded individuals supported by good leadership, expanded interface roles to bridge gaps between systems, and co-location of services. Barriers included structural and interdisciplinary tension between professions, organisational self-interest, and challenges in record sharing. CONCLUSION: Drivers and barriers to integration identified in other contexts are also present in primary care and social services. Benefits of integration are unlikely to be realised if these are not addressed in the design and execution of new initiatives. Efforts should go beyond local- and professional-level change to include wider systems- and policy-level initiatives. This will support a more systems-wide approach to integrated care reform, which is necessary to meet the complex and growing needs of an ageing multimorbid population.