Translational Research and Evidence

This article discusses the challenges in managing diabetes in primary care settings and provides evidence-based strategies for improvement. It also highlights the barriers to implementing these changes and suggests evaluation methods.

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Introduction
Diabetes is a chronic illness that has become a major worldwide epidemic with more than
415 millions of people suffering from the disease (Lau et al., 2015). The number will grow to
about 642 million by 2040. As per the reports published by American Diabetes Association,
diabetes has been found to be effecting 29.1 millions of Americans. The management of diabetes
in the primary care setting presents with several challenges. 20 % of individuals affected with
diabetes remain undiagnosed (Geiss et al., 2014). Apart from the clinical impact of the disease,
the economic impact is also great. The cost of diagnosed diabetes has been found to be about
∼$245 billion in 2013 that represents only a 41 % increase in the previous 5 years (Geiss et al.,
2014). The costs involves prescriptions, inpatient care and medical resources for the management
of the disease, physicians visit, hospital stay and nursing care. All these data and several studies
have confirmed that there is a lack of proper screening measures and interventions required for a
management of the diabetes. All these factors calls for a specific problem statement description
given below:
Problem statement: The widespread prevalence of diabetes, absence of proper screening
techniques and education, plus high cost incurred in the management of the diseases calls for
proper interventions to be taken in the primary care sectors. There is a need for modifications in
the current diabetic management protocols in the primary care sectors.
However, this paper would put forward with a review regarding the improvement of
primary care services in the management of diabetes, supported by evidence based literatures,
with some possible, valid and reliable recommendations.

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Literature Review
According to Messina et al., (2017), restricted knowledge and abilities among the
patients restrict or delay the attainment of glycemic control. Physicians often find it hard
to keep up with the achievement of diabetes. The clinicians present in the primary care
centers do not provide enough education to the patients. Again, there are a wide range of
factors at the organization level that affects the type of care provided, like the availability
of information technology for designing the diabetes care, lack personal continuity of
care and limiting the education occasions for health care professionals. Roles of the
nurses and the physicians in the primary care sector have evolved as the diabetic care has
been integrated in the primary care sector. The nurses play a central role in providing
various elements of care to the patients across primary and secondary care. The nurses
often becomes frustrated at the compliance of the patient. Rushforth et al., (2016) have
stated that, in remote populations, the distance to the nearest primary care facility
equipped to manage with diabetes, are far. Again, the cost of the conveyance and the cost
of the missing work restricts the patient from getting enough care.
The primary care settings often does not possess enough equipment or health care
workers to screen for the diabetes (Armstrong, Herbert & Brewster, 2016). The cost of the blood
glucose meter is greater than the day of earnings for most of the patients belonging to low
economic status that delays the screening process, till the symptoms become more serious.
Again, the prior clinical manifestations of diabetes like recurrent urination and thirst might act
like as insignificant symptoms to the patients who do not have any knowledge about diabetes and

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hence does not find any justification as why they would seek medical care. Rushforth et al.,
(2016) have stated that there is a need for proper screening tests even at the slightest signs of
diabetes. The primary care facilities should have appropriate diagnostic equipment as most of the
primary care facilities do not have the resources for the proper screening procedure.
Lau et al., (2015) have considered that the goals of the Healthy People 2010 is to enhance
the education regarding diabetes from 40 % to 60 %. Education regarding diabetes self-
management is considered to be a vital element in diabetic care and the number of clients
receiving education for diabetes is less. Inaccessibility to health literacy, has been proposed as a
potential obstacles for reaching people suffering from diabetes, chiefly in the societies where the
primary care services are far away.
Action plan to implement the changes
Some of the strategies that are directed at the organization includes revising the
professional roles, such as appointing a diabetic educator to offer support apart from the general
primary care services. Another strategy involves adoption of the improved guidelines in a variety
of clinical area, focusing on improvement at the system level associated with chronic
management of disease. Kalra et al., (2015) have stated that financial strategies have moderate
positive impact on the betterment of a primary care settings. Funding for buying equipment and
appointing specialists is one of the important strategy. Multifaceted interventions has been found
to be effective the single strategies for improving the primary care services in the management of
disease like diabetes. A benchmark review by Amin et al., (2016) have stated that initiatives like
audit and feedback and educational outreach can be helpful in improving the primary health care
services for diabetes management. In relation to this Ahola and Groop, (2013) have referred to a

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conceptual framework that should be used to implement particular clinical guidelines in the
primary care settings. One important concept can be leaders setting a clear goals the staff to
empower, involving the health care workers to contribute towards practice improvement ,
improving the communication system to reinforce the goals for caring for the patient, developing
the team for enabling the staffs to contribute towards improvement in practice, taking small steps
, encouraging practices tests for involving small changes in the practice , assimilation of the
electronic medical records for maximizing the clinical effectiveness, enhancing the use of
electronic tools for measuring and keeping the records and provision of feedbacks within a
culture , causing an interactive cycle of goal settings by the leaders (Kalra et al., 2015).
Investing in a collaborative team development of the clinicians and the staffs enabling the
clinical settings to be more adaptive to modifications and improvements. According to Kalra et
al., (2015)it has been found that there is a requirement to blend several systems in the sector of
therapeutics and screening. With the accessibility of the glucometers at the primary care centers,
the urine sugar testing at the sub-center level cab be reduced (Stellefson, Dipnarine & Stopka,
2013). With the availability of the glucometer and the testing strips, health care workers will be
able to diagnose all the pregnant women having blood sugar in the initial trimester to contract
gestational diabetes. A continuous track should be present to check the availability of glucose
lowering drugs present in the pharmacy that comes along with the local dispensary. Useful drugs
such as alpha-glucosidase inhibitor should be stocked in the primary health care centers. Fixed
combinations of doses should be made accessible at different care standards. It should be noted
that the specific regimes should only be provided with life style interventions. Kalra et al.,
(2015) have stated that, the most important feature of a health care system is human resources
and shortage of the health care workers are mostly felt in the primary care setting. Availability of

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a medicine physician is often a constraint, due to which, diagnosis, initiation of treatment and
surveillance are often done by the nurses (Kalra et al., 2015). The obstetricians might have to
manage diabetes without any help from physician. Again, for educating the patients about
diabetes, communication material resources like diet charts and education resources in
vernacular language should be provided (Kalra et al., 2015).
Barriers to implement changes in primary care settings
There are few barriers to execute changes in primary care settings. Again, if the primary
health care workers do not have proper training, they will not have enough knowledge about the
screening, handling of the glucometer, educating the patients and managing diabetes (Rushforth
et al., 2016). There can be limitations in the capability of the workers for a systematic
improvement. Again factors like motivation of the stakeholders, external motivators and
opportunities for change plays and important role in implementing desired change in an
organization. The low levels of the awareness of the patients and insufficient training of the
health care workers can be considered to an important barrier to change.
Again in a primary care setting, prioritizing one condition over the other can be a bit
problematic. Again, there is lack of alignment with the incentives that affect the engagement of
the workers in the organization. Different types of health care workers are present in a primary
cares settings that increases the chance of creating conflicts.
Evaluation
Evaluation of positive changes can be done by using validated tools, such as maintaining
a systematic follow-up and tracing system using a patient registry. An evidence based stepped

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care approach, including prevention of the relapse has been recorded (Peek, Cohen & deGruy
2014). A practice based care manager can be kept educate and monitor and assist the primary
care clinicians. Audits and feedback seeking can be useful. Current number of visits in the
primary care settings has to be tallied with the baseline data and previous data.
Conclusion
In conclusion, it can be said that there is a need for proper and accessible diagnosis for
diabetes. Approaches for improving diabetic care includes training the health care staffs,
recruiting health care staffs, designing affordable tools for screening diabetes, using electronic
health records and proper monitoring of the health care services.

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