All but four of the GPs confirmed the importance of improved adherence to the evidence-based guidelines. The four GPs who did not experience improved adherence belonged to a stratum with a stronger baseline performance, and three of them also belonged to the stratum with weaker improvement during the project. Three of them revealed that they had previously followed an intensive course on diabetes management. The fourth GP is still collaborating with the medical faculty of the university. Most interviewees also reported improvements in follow-up procedures, evidence-based drug prescription practices, and referral rates. The more frequent follow-up visits included regular blood monitoring and general screening for complications. Several GPs mentioned better recordkeeping.
Implementation of evidence-based treatment was evident in more timely adjustments in therapy if target criteria fell short, and in greater attention to cardiovascular risk factors, above and beyond conventional glycemic control. Finally, more patients were treated with insulin.
Some interviewees reorganized their practices to better comply with the guidelines. Others instituted regularly scheduled office visits, and some split the visits into two parts: one part dedicated to routine follow-up and the other to discussions of treatment and lifestyle. The interviewees noted better medication compliance and improved adherence to follow-up schedules by the patients.
Barriers to high-quality diabetes care and factors facilitating change
Our analysis showed that a first barrier to successful diabetes care was GPs inadequate knowledge how to manage insulin therapy and cardiovascular risk.
'My attitude about insulin therapy onset has changed. Before the start of the project, I tried too long oral anti diabetics, but the courses have changed my attitude. I became confident in starting insulin therapy, whereas before I would never initiate insulin therapy. (12-S3)
A second barrier was the GPs' lack of awareness of their own performance because of 'blind spots'.
'Such a project with follow-up is important because it obliges you to question yourself. I thought my patients were reasonably well controlled, but the QIP – especially the feedback – makes you confront your problems and weaknesses.' (3, S1)
Several interviewees also affirmed that before the start of the project they did not truly understand the importance of attaining clinical targets and regular follow-ups.
'The constant support and the organized courses made the difference. The protocol map, which has become a reference work, also contributed a lot. Because of the feedback, I became aware that my performance on lipid-lowering therapy was not good. This, together with information on vascular pathology as a major problem in diabetes, made me change my attitude. I have begun to prescribe more statins.' (10-S3)
A third barrier, expressed by several interviewees, was the presence of skepticism about evidence-based treatment and of collaborative care, and their concerns about losing control and sanctions that may result from diabetes care improvement plans.
'I do everything myself. I find it difficult to work in a team, and I am rather skeptical about the 'soft sector' (psychologists, educators...)' (11-S3)
'Policymakers should use such programs for positive motivation. They should not connect results with negative implications (e.g., loss of accreditation).' (15-S3)
Some GPs considered evidence-based medicine (EBM) only as background information describing the ideal situation to strive for, but not as a stringent, compulsory framework.
'Paper is no reality. EBM is only a supportsupport tool, but can never be an impsosed framework.' (3-S1)
One GP admitted that he had worked according to a fundamentally different paradigm closer to alternative medicine. From this viewpoint he disagreed with the guideline on many aspects, such as the importance that was given to lipid control.
'Evidence-based medicine is a relative term...something might be evidence-based, but I have in mind other parameters that are much more important. In my alternative point of view, I do not care a lot about cholesterol, for example.' (7-S2)
Some GPs admitted being lax and several indicated that lack of time – because of suboptimal practice management – prevented them from providing good quality care.
'I admit that I was lax before, but have changed during the project. Some patients were incredibly surprised that finally they were getting good care.' (7-S2)
'I didn't observe major behavioral changes in most patients, but this may be associated with my own passive attitude. I made no changes in my organization of care and I did not spend enough time at it.' (16-S4)
Several GPs also questioned the feasibility and desirability of implementing these guidelines in an older diabetes population.
'Many of my patients are older than 80. I will not forbid them to eat a piece of cake. Indeed, my own attitude towards elderly people is a little bit more loose.' (4-S2)
'The recommendations on weight loss and physical activity are useless for a lot of elderly people who are too ill or immobile to follow them.' (3-S1)
Factors conducive to good care were also discussed. The consensus was that transparent treatment protocols and tailored post-graduate courses would go a long way in overcoming knowledge gaps. Benchmarking feedback confronted the GPs with their blind spots and weaknesses, and increased their awareness of shortcomings in their case management habits. Case coaching was identified as an important innovation in improving 'knowledge on the spot', especially in initiating and adapting insulin therapy.
'The extra coaching was unique to this project and functioned like clockwork. You only had to make a phone call – that is very comforting to a GP.' (12-S3)
Several GPs confirmed that the three-month data collection exercise encouraged regular recordkeeping and a structured approach to patient follow-up.
'The imposed recordkeeping of patient data put me under some pressure. Imposing a structure helps you handle your job more systematically. Since the project has stopped, this disciplined approach is beginning to wane again.' (1-S2)
Many GPs also felt that care was compromised by the patients' insufficient understanding of diabetes, lack of awareness of serious complications, and of the importance lifestyle changes. Fear of insulin therapy ('fear of the needle') was also mentioned. However, these barriers were perceived as something that could be overcome by education, especially when provided by well-trained nurse educators.
'The big change is the availability of the nurse educator... She really took the time to explain the problem of diabetes. People have a better understanding of what HbA1c is...people are afraid of needle sticks and this fear has decreased because of the project, thanks to the nurse educator.' (2-S2)
GPs also described the synergistic effect of several healthcare workers delivering the same message in inducing a sudden change in attitude.
'If three professionals give the same message and if, moreover, patients receive the same message by television, and then a sudden change can occur.' (8-S1)
There was consensus that patients' attitudes and lack of motivation are major barriers to implementing evidence-based treatment, especially when it involved a change in lifestyle.
'Physical activity and weight control remain the main problems. The motivation to change lifestyle habits is often completely absent. Some patients deny the problem: 'I don't eat very much'. (9-S2)
Finally, GPs felt that about one-third of the patients would be uncooperative no matter what changes were proposed, and most GPs agreed that changing entrenched lifestyle habits was difficult for most patients to achieve, whatever their initial motivation. For the most part, any such changes would be small and temporary.
'A minority – about 30% – doesn't want to hear anything. They won't even go to see the nurse educator. Another 30% are somewhat motivated, but not too much, and the remaining 30% really cooperate. The added value of the project, probably, applies only to patients who are motivated and who can get motivated.' (2-S2)
GPs also mentioned social, organizational, and legal barriers and facilitating factors. The interaction between a GP and his or her patients, especially when it concerns a long-term relationship, can itself hamper the transition to high-quality diabetes care. Several GPs described how patients were accustomed to certain situations and habits of their GPs, e.g., a limited use of drugs. They did not always understand or appreciate the sudden change in their GP's attitude; this led to tensions in some cases and loss of contact in others.
I have started prescribing lipid-lowering drugs relatively recently. Before the project, I was rather reluctant to prescribe medications and my patients were not accustomed to my new attitude. So, I had to take a gradual approach.' (10-S3)
'Previously, some patients probably consulted me because I was easygoing. Since my participation in the project, I've pushed them more and so I lost two patients. They frankly told me 'We're leaving because you exaggerate things. What's the matter with you?' But patients and physicians must evolve together, although at a moderate pace.' (7-S2)
However, the project mitigated such unfortunate instances through counseling sessions involving the GPs, patients and nurse educators. The net effect was a strengthening of the physician-patient relationship and a motivational boost to the latter.
'Diabetes patients themselves feel much more appreciated; because of that, the link between us and our patients has strengthened.' (17-S4)
Most GPs held that a lack of a clear delineation of responsibilities leads to competition between the GP and the specialist, with the latter being perceived as holding the upper hand. This competition is reinforced by the skewed reimbursement schemes in Belgium in favor of the specialist concerning patient education and home blood glucose monitoring (HBGM) kits. This skewed situation was considered as an important factor that prevents many GPs from commencing timely insulin therapy.
'Specialists gain too much control of referred patients and often exclude GPs from direct patient care. This is especially true of patients on insulin who get free instructions and monitoring kits at the diabetes centers, unlike patients in primary care. So, it's nearly impossible for GPs to hold on to patients on insulin.' (1-S2)
The QIP redefined the GP as a central 'manager' with explicit responsibilities for the care for patients with diabetes.
'To summarize this project: we started with a good protocol and established better channels of communication between primary and specialist care....The delineation of responsibilities and degree of familiarity among the partners were very important in making it easier to me to refer more patients.' (14-S1)
This was much appreciated by the interviewees. It reinforced the GPs' feeling of recognition, boosted self-esteem, promoted a greater sense of responsibility, and improved their professional relationships with specialists.
'The project did not merely create the illusion that the GP was pivotal in diabetes care, he or she actually became the central figure and this fact increased their job satisfaction....This only became possible because of an attitude change on the part of the endocrinologists. Now they say 'you GPs have to do the job, but call me when necessary.' This is a big change from the usual 'let us do our work; after all we are the specialists and you may help a little bit'. We collaborate as one team – there's mutual support! We're on the same wavelength and feel we work together toward the same objectives.' (13-S4)
Many GPs regarded the role of the nurse educator as complementary to their own and, feeling that they themselves lacked the requisite skills and time, were relieved to relinquish patient education to them.
'I prefer to have the nurse educator bring up insulin therapy before I get to it....After 30 years in general practice, I'm somewhat hesitant to get into a protracted struggle with patients to try to convince them of the need for insulin. 'If you're not interested, so be it,' I think by myself. The nurse educator is an invaluable asset in such cases.' (8-S1)
One GP felt that the Belgian fee-for-service scheme was an important impediment to the delivery of quality care, explaining that a pay-for-performance system would be a better motivator. In addition, direct payment by patients was also seen as a significant factor that discouraged patient referrals and HBGM necessary to evaluate insulin therapy.