Effectiveness of different interprofessional collaborative processes to optimize type-2 diabetes prevention in routine Primary Care: the PREDIAPS implementation trial

Abstract

Introduction: Effectiveness of different strategies to engage healthcare professionals in collaborative processes that seek to optimize practice is unknown. The PREDIAPS project aims to assess the effect of different engagement procedures in the creation of a facilitated interprofessional collaborative process to optimize type-2 diabetes (T2D) prevention in routine Primary Care (PHC). Theory/Methods: Randomized cluster implementation trial in which nine PHC centers from Osakidetza were allocated to two different procedures to engage family physicians and nurses. All centers received training on effective healthy lifestyles interventions for T2D prevention. Headed by a local leader and an external facilitator, centers conducted a collaborative structured process to model and adapt the intervention and its implementation to their specific context. One of the groups applied this strategy globally, promoting the cooperation of all health professionals from the beginning. The other performed it sequentially, centered first on nurses, who lately obtained the pragmatic cooperation of physicians. All patients without diabetes aged =30 years old at high risk of developing T2D who attended collaborating centers during the study period were eligible for program inclusion. Main outcome measures focus on changes in T2D prevention practice indicators after 24 months. The present study presents the short-term results. Results: After 4 months of trial fieldwork, 38966 patients aged =30 years old attended at least once to their family physician, of whom 2845 (7.3%) were eligible for program inclusion as having an abnormal glucose level (=110-125 mg/dl) previous to any of their visits. Of those, 272 (10.6%) have been addressed by assessing their healthy lifestyles in both comparison groups. The proportion of attending patients at risk of T2D receiving a personalized prescription of a healthy lifestyle change (N=130) was slightly higher in the Global (5.5%; range 7.3%-4.6%) than in the Sequential group (4.5%; range 6.4%-2.2%). When considering program spreading, 239 additional at risk patients recruited by nurses or others without T2D risk have also received a lifestyle prescription. Discussion: Preliminary results showed that the short-term reach of the implanted intervention programs is still limited. Results at 6 and 9 months (in process) will provide more precise data on the most effective procedure to change healthy lifestyle promotion practice. Conclusions and lessons learned: The PEDIAPS implementation strategy is feasible and the exposition of professionals in both groups has been high. Center's organizational context has determined the impact of the implementation strategies: work overload, multiple corporative initiatives, staff movement, etc. Professional commitment is a key factor for both the process of implementation and its results. Limitations: The limited number of centers may affect the generalizability of results. Lack of motivation of patients may affect actual reach of the intervention programs. At center's level, maintaining the commitment of professionals throughout the project and personnel movement are the major threats. Suggestions for future research: An adequate fit between "fidelity" of the strategy and the necessary "adaptability" to the local context of centers remains to be a big challenge. The time necessary for the achievement of relevant changes in clinical practice is certainly unknown.