Table 2 |
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Coded categories and themes |
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Perceived barriers to optimal diabetes care |
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Level |
Factor |
Item |
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Physician |
Lack of knowledge on |
- global cardiovascular treatment beyond glycemic control - insulin therapy |
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Lack of awareness regarding |
- personal practice performance ('blind spots') - need to reach treatment targets and regular follow-up |
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|
Attitude and motivation |
- laxity regarding treatment targets and timely follow-up - attitude to polypharmacy - skepticism regarding evidence-based treatment, top-down quality improvement projects and shared care collaboration |
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Patient |
Practice organization |
- lack of scheduled visits, lack of planned follow-up, lack of support staff |
|
Lack of knowledge on |
- insight regarding complications, significance of HbA1c |
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Lack of awareness regarding |
- personal dietary patterns - personal health status (HbA1c, blood pressure, cholesterol) |
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|
Attitude and motivation |
- fear of insulin treatment - lack of motivation for follow-up or to change lifestyle |
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|
Routine behavior |
- maintaining lifestyle change very difficult - adhering to planned follow-up visits is difficult |
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Context and organization |
Age and co-morbidity |
- too strict control can be dangerous in older patients - immobility hampers physical exercise and shared care referral |
|
Relationships |
- between GPs and patients (inertia to change) - competition between specialists and GPs |
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Lack of teamwork |
- Need for clear description of each provider's duties and responsibilities - Need for identical messages to the patients from all health care providers |
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Financial barriers |
- out-of-pocket payments for education, dietary advice and HBGM material - skewed reimbursement of HBGM material - fee for service: this system doesn't motivate GPs to deliver high-quality care |
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Perceived change facilitators |
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Level of impact |
Item |
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Physician |
Treatment protocol and post-graduate education; Benchmarking feedback Case coaching; Timely data collection Increased contact and communication with peers in other disciplines Participation in team meetings Attitude change on the part of specialists |
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Patient |
Nurse educator and IDCT working as a team Free services and free materials Identical messages from different sources (GP, specialist, educator, television Attitude change on the part of the GP |
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Context and organization |
Role redesign and reassignment of responsibilities Serial removal of barriers Task relief |
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HBGM = Home Blood Glucose Monitoring; IDCT = Interdisciplinary Diabetes Care Team (endocrinologist, nurse educator, dietician) installed at the primary care level |
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Goderis et al. Implementation Science 2009 4:41 doi:10.1186/1748-5908-4-41 |
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