Nursing essay on Barriers to Diabetes Treatment in a Community Primary Care Clinic (Solved)

Introduction: Diabetes mellitus is a chronic condition affecting both developed and resource-limited countries. The disease causes a considerable burden to countries by increasing mortality and morbidity alongside inside healthcare costs (Lin et al., 2020). The effective management of diabetes mellitus involves various aspects like pharmacological treatment, education, psychosocial support, and behavioral diabetes care. There should be clear definitions of these services nationally and locally to ensure patients access diabetes management services including treatment (Khan et al., 2020). Despite the availability of various support mechanisms for patients, diabetes is still a problem for many people. Inadequate control of diabetes continues to challenge the healthcare system despite advances in technology, diagnosis, and treatment.

Barriers to diabetes management exist both in individuals with the disease and healthcare providers. Most of the research conducted has focused on barriers that impede self-management of the disease with a few discussing outside forces. Self-management of the disease is observed to be affected by factors like the lack of knowledge, communication difficulties with healthcare providers, and not recognizing the importance of self-management (Adhikari et al., 2021). Apart from these barriers, primary care centers may face challenges like financial constraints that make it difficult to provide the required care. Additionally, healthcare providers in these centers may be faced with issues of staffing, lack of support from organizations, and gaps in education making it difficult to manage diabetes.

Addressing barriers to diabetes treatment in primary care centers can be an important step toward reducing the burden of the disease in the country. Approximately 21.9 million Americans are affected by the disease with almost 27.8% of the people with the disease remaining undiagnosed (Blasco-Blasco et al., 2020). According to research, one of the most important parameters that dictate the effective management of diabetes is glycemic control (Rodríguez-Gutiérrez et al., 2016). Tight glycemic control of hemoglobin A1c (HbA1c) levels is observed to prevent the slow progression of complications like neuropathy, retinopathy, and nephropathy in patients with diabetes. To effectively manage diabetes, HbA1c levels should be maintained below 7% or 53 mmol/mol (Rodríguez-Gutiérrez et al., 2016). Identifying barriers in primary care centers will help in ensuring glycemic control is easily achieved.

The care of patients with diabetes encompasses new and more efficacious strategies to reduce the burden of the disease in society. Discovering the barriers limiting treatment and prevention of the disease in primary care can ensure the deployed measures are more effective. This research can help primary care providers to utilize available treatment and prevention measures across all populations to manage diabetes. Secondly, identifying barriers to diabetes treatment can help primary care providers and other key players to design strategies that can improve the quality of life of affected individuals. Healthcare systems can be able to address the issue of cost that is becoming more every day to manage the disease by understanding barriers to patient treatment.

Overview of the Problem

Diabetes is a chronic disease that occurs when the pancreas does not produce enough insulin or when the body fails to effectively use the produced insulin (World Health Organization (WHO), 2021). Type 2 diabetes is the most common metabolic disease that involves the inability of the body to utilize produced insulin. During the management of the disease, emphasis is put on lifestyle changes that can prevent the onset of the disease like healthy eating and physical activity. The most important aspect of diabetes treatment is the control of glucose levels below the minimum value. Hemoglobin A1c (HbA1c) levels are a test that is closely monitored by healthcare providers to determine if diabetes is under control (Rodríguez-Gutiérrez et al., 2016). Certain barriers that can be related to individuals or the healthcare system affect the achievement of these goals leading to increased mortality and morbidity.

There is a significant burden of diabetes on the family, community, and the entire nation. Each year, the disease costs the US healthcare system a lot of capital with the healthcare costs of the disease for affected patients being 2.3 times higher than unaffected individuals (Blasco-Blasco et al., 2020). Diabetes is one of the largest global health concerns that pose a burden to the health and socio-economic development of countries. The International Diabetes Federation (IDF) estimates that about 451 million people are affected worldwide and it is projected that 693 million will have the disease by 2045 (Lin et al., 2020). In the United States, the population of people aged 18 years and above with diabetes quadrupled from 5.5 million in 1980 to 21.9 million in 2014 (Lin et al., 2018). There are various reasons to explain these changes including lifestyle changes and challenges with healthcare access. To combat the increasing prevalence of the disease, addressing barriers to healthcare access is among the key strategies.

Primary care providers including nurses and doctors are the most frequent individuals interacting with diabetes patients. In addition, primary care centers attend to more patients with diabetes compared to community hospitals. Identifying barriers to diabetes treatment in these centers can help to address the increased mortality and morbidity due to diabetes. This project impacts the nursing profession by ensuring that clinical nurses understand how they can modify the patient environment to effectively manage diabetes. Identifying barriers to diabetes treatment in primary care can help to address the issue of cost in healthcare. Recent analysis shows that the cost of diabetes management increased from 11% in 2012 to 13% per individual in 2013 (Riddle & Herman, 2018). In the US, the cost of diabetes management in 2017 was $237 billion with 1 in 4 US dollars spent on managing the disease (Riddle & Herman, 2018). Nurses can help bridge this gap by ensuring that perceived barriers to patient treatment are addressed.

Project Purpose Statement

The purpose of this project is to identify barriers to improving care for individuals with diabetes in community primary care clinics. The findings from this research will be important in ensuring diabetic patients receive care that meets evidence-based standards as in other practice settings.

Background and Significance

Effective management of diabetes is multifactorial and involves coordination between patients, healthcare providers, and healthcare systems. Patients have a role in ensuring they adhere to self-management interventions to reduce the impact of the disease as healthcare providers work to improve their quality of life. Many countries have developed universal health insurance programs that are mainly observed to deal with rehabilitation and treatment (Lin et al., 2020). Important aspects like prevention of the disease and addressing the phases of diagnosis appropriately have been left out. Strengthening the primary care system for improved secondary and tertiary management of the disease is imperative to the control of diabetes across all countries. Primary healthcare centers need to look beyond the treatment of the disease and apply evidence-based strategies to reach those individuals that are at risk.

Despite the development of new therapies indicated for the treatment of diabetes, suboptimal A1c control rates persist. Apart from barriers like poor patient adherence to medication, certain healthcare barriers make it difficult for the effective delivery of care to patients (Adhikari et al., 2021). The innovative approach to this project is based on the need to develop new ways of providing care to patients through practice evaluation. This project focuses on the healthcare system’s role in diabetes management and strives to identify barriers in primary care centers that make it difficult to deliver appropriate care to diabetes patients. Healthcare innovation is all about doing things differently to achieve large gains in performance. This project uses a different approach to identifying challenges to diabetes management by shifting focus from the patient factors.

The potential impact of this project is that it will improve access to healthcare services and create an avenue for addressing barriers in primary care centers that impair diabetes control. Poor glycemic control as the key indicator of diabetes control is reflected by both the failure in diabetes self-management and inadequate interventions by clinicians (Riddle & Herman, 2018). This research will identify how primary care providers utilize available technologies like electronic health records to manage diabetes and technological barriers that can be addressed to improve diabetes care. This research will provide insight on factors outside the patient’s control that are observed to hinder their treatment and strategies that can be used to improve them.

PICOT Formatted Clinical Project Question

Among patients with diabetes (P), what is the effectiveness of identifying barriers to treatment in primary care clinics (I), compared to identifying barriers to self-management (C), in achieving diabetes control (O) within 6 months?

Literature Review

Key Words: Diabetes, Diabetes management, Healthcare challenges, Primary care clinic

The global burden of diabetes has increased over the years and is expected to increase in the coming years (Blasco-Blasco et al., 2020). While most of the factors associated with the global increase in diabetes are individual-centered, the healthcare system is observed to play part in poor management of the disease. A study was conducted in the Latin America and Caribbean region to identify barriers to diabetes management. Using the systematic review method, the researchers identified both individual and system factors that hinder the effective treatment of diabetes. It was observed that challenges with getting adequate resources and the clinicians’ paternalistic attitudes and lack of proper attention to patients made it difficult to manage diabetes (Blasco-Blasco et al., 2020). It was recommended that the use of a patient-centered approach and addressing healthcare access issues could be important in redesigning primary care management of diabetes.

In the United States, diabetes is the seventh leading cause of death and many others live with complications that require close monitoring (Kutz et al., 2018). A research was conducted in the US to examine the effect of implementing a chronic care model to optimize primary care management of the disease. After observing that majority of the patients did not meet the required HbA1c levels, a chronic care model was employed in the primary care clinic. Interventions during management included A1c testing, monofilament foot examination, retinal eye examination, and blood pressure monitoring among many other interventions (Kutz et al., 2018). The implementation of the diabetes care bundle proved that primary care centers lack strict adherence to standard diabetes care guidelines which leads to poor disease management.

Another study conducted in India aimed at assessing the knowledge, attitude, and practice among nurses regarding diabetes care. The cross-sectional study examined a total of 102 nurses in the areas of knowledge regarding the etiology of diabetes, symptoms of the disease, complications, insulin role in diabetes, and general management of the disease (Gharsangi et al., 2021). The main barrier identified in the healthcare facility was that nurses lacked adequate knowledge regarding diabetes care. There were gaps in essential aspects of care like insulin administration, signs of hypoglycemia, and the pathology of the disease leading to poor disease management. A similar study conducted in a sub-district health promotion hospital in Thailand observed that barriers like the lack of essential drugs and technology impaired primary care delivery of diabetes services (Somanawat et al., 2020). The study recommended the use of collaborative approaches during care delivery and the provision of financial support to primary care centers to effectively manage diabetes.

Diabetes care should involve collaboration between various healthcare providers including financial support from the lead governments. A recent study analyzed the barriers to diabetes management during the COVID- 19 pandemic. Focusing on reports from underdeveloped countries and low-income areas, the researchers observed that financial constraints made it difficult to achieve set targets (Nouhjah & Jahanfar et al., 2020). Because of the restrictions during the pandemic, it was observed that most primary care facilities lacked adequate technological advancement to implement telehealth services (Nouhjah & Jahanfar et al., 2020). Poor communication with patients is a challenge in these facilities with most patients, especially the elderly lacking adequate knowledge and skills on the use of telehealth.

Critical Appraisal of Literature

The literature summary provided draws attention to the different factors that are barriers to primary care management of diabetes. All the articles discussed highlight challenges with finance that limit the availability of essential resources for diabetes care. For instance, the lack of adequate capital for primary care centers limits the utilization of technology that is required to manage chronic conditions today. With many healthcare centers being affected by the COVID-19 pandemic, the availability of capital can enhance the utilization of technology and ensure drugs are easily available (Nouhjah & Jahanfar et al., 2020). Apart from these aspects, there is evidence that healthcare providers lack adequate knowledge and perhaps skills on effective management of diabetes. The paternalistic attitudes and lack of standardized diabetes care in primary care centers hinder the effective treatment of patients (Blasco-Blasco et al., 2020, Gharsangi et al., 2021). Addressing the barriers in primary care diabetes management will require focusing on the aspect of healthcare access through the allocation of resources and education of staff.

The strengths of the literature review lie in the utilization of quality studies conducted using different research methodologies. For example, the literature review utilized findings from systematic reviews, mixed methods research, pilot study, and cross-sectional descriptive study. Another strength is that most articles focused their research on barriers in primary care centers from different countries. The research findings discussed indicate that primary care clinics across developed and developing countries face almost the same challenges that need to be addressed universally to optimize diabetes care. A few weaknesses can be noted in the articles discussed in the literature review summary. For example, some of the studies collected data from urban primary care facilities making the findings not applicable to other settings (Blasco-Blasco et al., 2020, Nouhjah & Jahanfar, 2020). Additionally, some articles have findings from research conducted in one primary care health system and the results cannot be generalized.

EBP Standard

The American Diabetes Association (ADA) defines diabetes as a chronic disease that requires continuous medical care with multifactorial risk-reduction strategies beyond glycemic control. The first recommended approach that can improve diabetes care in primary care clinics is the use of the bundled approach. As part of the standard care, bundling diabetic care involves measuring A1c and blood pressure levels, foot examinations, and providing nephropathy attention, which is one approach to providing systematic ongoing patient care (Kutz et al., 2018). Apart from this strategy, primary care providers can benefit from a comprehensive diabetes education program to strengthen their skills and improve attitudes toward the care of diabetes patients (Gharsangi et al., 2021). The educational approach will ensure that the individual preferences of patients are considered. For example, well-educated staff will be able to provide comprehensive education to patients and do a follow-up.

Implications

The proposed project will have an impact on nursing research, education, and practice by improving the quality of care offered to patients. Through this project, nurses will be able to understand factors within the healthcare system that impact effective diabetes treatment. Recommendations like the use bundled approach and education to address these challenges will improve the quality of care provided to patients. Regarding nursing research, this project will open doors for further research on how to breach the issue of access that impairs effective delivery of diabetes care to patients in primary care centers and rural communities. There are gaps in the utilization of technology to improve diabetes care that can be addressed through further research. Overall, a multilevel approach is needed to address barriers to diabetes treatment in primary care clinics. Further research is required to systematically identify the barriers health centers face in making system-wide changes to diabetes care.

References

Adhikari, M., Devkota, H. R., & Cesuroglu, T. (2021). Barriers to and facilitators of diabetes self-management practices in Rupandehi, Nepal-multiple stakeholders’ perspective. BMC Public Health, 21(1), 1-18. https://doi.org/10.1186/s12889-021-11308-4

Blasco-Blasco, M., Puig-García, M., Piay, N., Lumbreras, B., Hernández-Aguado, I., & Parker, L. A. (2020). Barriers and facilitators to successful management of type 2 diabetes mellitus in Latin America and the Caribbean: A systematic review. PloS One, 15(9), e0237542. https://doi.org/10.1371/journal.pone.0237542

Gharsangi, K., Himral, P., & Bhawani, R. (2021). Knowledge, attitude and practices regarding diabetes and its complications among health care workers in Medical College of North India. International Journal of Collaborative Research on Internal Medicine & Public Health, 13(6), 1-7. https://www.iomcworld.org/articles/knowledge-attitude-and-practices-regarding-diabetes-and-its-complications-among-health-care-workers-in-medical-college-of-north-in-80800.html

Khan, M., Hashim, M. J., King, J. K., Govender, R. D., Mustafa, H., & Al Kaabi, J. (2020). Epidemiology of type 2 diabetes – Global burden of disease and forecasted trends. Journal of Epidemiology and Global Health, 10(1), 107–111. https://doi.org/10.2991/jegh.k.191028.001

Kutz, T. L., Roszhart, J. M., Hale, M., Dolan, V., Suchomski, G., & Jaeger, C. (2018). Improving comprehensive care for patients with diabetes. BMJ Open Quality, 7(4), e000101. http://dx.doi.org/10.1136/bmjoq-2017-000101

Lin, J., Thompson, T. J., Cheng, Y. J., Zhuo, X., Zhang, P., Gregg, E., & Rolka, D. B. (2018). Projection of the future diabetes burden in the United States through 2060. Population Health Metrics, 16(1), 1-9. https://doi.org/10.1186/s12963-018-0166-4

Lin, X., Xu, Y., Pan, X., Xu, J., Ding, Y., Sun, X., … & Shan, P. F. (2020). Global, regional, and national burden and trend of diabetes in 195 countries and territories: An analysis from 1990 to 2025. Scientific Reports, 10(1), 1-11. https://doi.org/10.1038/s41598-020-71908-9

Nouhjah, S., & Jahanfar, S. (2020). Challenges of diabetes care management in developing countries with a high incidence of COVID-19: A brief report. Diabetes & Metabolic Syndrome, 14(5), 731–732. https://doi.org/10.1016/j.dsx.2020.05.012

Riddle, M. C., & Herman, W. H. (2018). The cost of diabetes care—an elephant in the room. Diabetes Care, 41(5), 929-932. https://doi.org/10.2337/dci18-0012

Rodríguez-Gutiérrez, R., & Montori, V. M. (2016). Glycemic control for patients with type 2 diabetes mellitus: Our evolving faith in the face of evidence. Circulation. Cardiovascular Quality and Outcomes, 9(5), 504–512. https://doi.org/10.1161/CIRCOUTCOMES.116.002901

Somanawat, J., Saramunee, K., & Chanasopon, S. (2020). Process, quality and challenges of diabetes care in primary care: A study of district health network in Thailand. Primary Health Care Research & Development, 21 (e46), 1-9. https://doi.org/10.1017/S1463423620000468

World Health Organization. (2021). Diabetes: Key facts. https://www.who.int/news-room/fact-sheets/detail/diabetes