Perceived barriers to the implementation of diabetes guidelines in hospitals in The Netherlands

doi:10.1016/S0300-2977(99)00123-0

The Netherlands Journal of Medicine

Volume 56, Issue 3, March 2000, Pages 80-85

The Netherlands Jour...

https://doi.org/10.1016/S0300-2977(99)00123-0 Get rights and content

Abstract

Objective: To determine the organisational and personal barriers to the implementation of diabetes guidelines in hospitals in The Netherlands and relate them to structural factors of diabetes care.

Method: In a written survey internists specialised (or with a specific interest) in diabetes in all general hospitals in The Netherlands (n=120) were asked to indicate the perceived organisational and personal barriers to adherence to the diabetes guidelines. In the same questionnaire their activities related to diabetes care and the working hours of the additional personnel involved were measured.

Results: There was at least one specialised diabetes nurse employed in all hospitals, although the extent of the appointment varied widely from 0.2 to 6.9 full-time equivalent (average 1.5). In most hospitals (90%) a diabetes care team had been established, while podiatrists were working in only 72% of the hospitals. Furthermore, 65–80% of the hospitals organised special consultation hours for diabetic patients, had a protocol for diabetes treatment, or patient held administration booklets. The most frequently mentioned barriers to the implementation of diabetes guidelines were high workload, no adequate financial compensation, and a shortage of necessary personnel.

Conclusion: A number of preconditions for structured diabetes care, like the presence of a diabetes team and a specialised diabetes nurse, were in place. However, large differences between the hospitals in the organisation of diabetes care and the availability of staff, together with the related perceived barriers to the implementation of the guidelines showed that there are still many opportunities for improvements.

Introduction

The credibility of guidelines is based on their scientific value; adherence to guidelines is determined by the extent to which they are accepted within the target group and their feasibility in daily practice [1]. The degree of adherence to diabetes guidelines in Netherlands hospitals is as yet not clear. Research shows that in general adherence to diabetes guidelines is moderate [2], [3], [4], especially with respect to ophthalmic examinations [5], [6], [7], or examination of the feet [7], [8], [9]. A lack of structured care is in part capable of explaining this lack of adherence. Diabetes is a complex multi-systemic chronic disease and is difficult to fit into a health care delivery system designed to deal with acute and episodic illness [10]. The Saint Vincent Declaration, named after the town where the International Diabetes Federation and the World Health Organisation met in 1989, resolved to achieve a drastic reduction of diabetes related complications. The target was to reduce by at least one third the incidence of diabetes related blindness and end-stage renal failure, and to halve the rate of lower limb amputation within the next 5 years [11]. The Dutch Diabetes Federation gives priority to structured care in multidisciplinary teams and adherence to diabetes guidelines concerning treatment [12].

In October 1998 the Dutch Diabetes Federation, in collaboration with the National Organisation for Quality Assurance in Hospitals (CBO), published four guidelines. They comprised updated versions of the guidelines Diabetic Foot and Diabetic Retinopathy and new guidelines for Diabetic Nephropathy and Cardiovascular Complications in Diabetes [13]. These guidelines promote a multidisciplinary approach. The internist and the specialised diabetes nurse should see all diabetic patients regularly; requirements for referral to an ophthalmologist are specified. A special foot clinic is proposed where a podiatrist takes charge of the screening and initial treatment of patients with diabetes [13]. The Dutch Diabetes Federation further proposes diabetes care teams which include, in addition to the disciplines listed above, a dietician, (vascular) surgeon, ophthalmologist, gynaecologist, neurologist, psychologist, a social worker, and a person with diabetes, without discerning key players from disciplines that should be available on request.

Anticipating the effect of the publication of the guidelines for diabetes care, an inventory has been drawn up of the perceived organisational and personal barriers to implement the guidelines in Netherlands hospitals. Furthermore, the relationship between these barriers and the preconditions for structured diabetes care has been studied.

Section snippets

Methods

A questionnaire with open and closed questions was sent to all general hospitals in the Netherlands (n=120), addressed to the internist with specific interest in diabetes. Non-responders were reminded twice. The objectives were to

1.
ascertain the presence of a diabetes care team, list the disciplines of the team members, ascertain the availability of a diabetes nurse and podiatrist
2.
ascertain the specific activities with regards to diabetes care: the number of meetings of the diabetes care team,

Results

From the 120 questionnaires 106 were returned (88%). Responding and non-responding hospitals did not differ in terms of region or number of beds. An overview of the most important characteristics of organisation of diabetes care is given in Table 1.

Discussion

In many Netherlands hospitals several preconditions for programmed diabetes care indicate that health professionals consider that the treatment of diabetes needs a special approach. Two-thirds of the internists indicate that they certainly anticipate a number of barriers if the guidelines are implemented. The barriers most frequently mentioned were a high workload, lack of necessary personnel, and lack of appropriate compensation. However, it should be noted that perceived barriers can differ

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Original articlePerceived barriers to the implementation of diabetes guidelines in hospitals in The Netherlands

Abstract

Introduction

Section snippets

Methods

Results

Discussion

Beliefs and evidence in changing clinical practice

Br Med J

Lukt het werken volgens de NHG-standaard Diabetes mellitus type II?

Huisarts en Wet

Patient and physician perspectives regarding treatment of diabetes: compliance with practice guidelines

J Fam Pract

Variation in office-based quality. A claims-based profile of care provided to Medicare patients with diabetes

J Am Med Assoc

Ophthalmic examination among adults with diagnosed diabetes mellitus

J Am Med Assoc

Diabetes care policies and practices in Michigan nursing homes, 1991

Diabetes Care

Met benchmarking de diabeteszorg verbeteren

Medisch Contact

Potential barriers to diabetes care

Diabetes Care

Barriers to care in non-insulin-dependent diabetes mellitus. The Michigan experience

Ann Intern Med

Diabet Med

Original article
Perceived barriers to the implementation of diabetes guidelines in hospitals in The Netherlands