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Implementing guidelines can be difficult because it requires effort and change in practices by health care personnel who may already be used to managing diabetes in their own way, and who may have time and resource constraints.

In 2009, Goderis et al evaluated the experiences of general practitioners who participated in a Quality Improvement Program with the goal of promoting adherence to international guidelines for diabetes care. The barriers to change that they found included the general practitioner’s inadequate knowledge on the management of care, their own performance in managing practices, attitudes regarding targets, medications, and skepticism about quality improvement projects. From the patient’s perspective, lack of knowledge on diet, health status, attitude and motivation, and clinic practice organization and staff were the major barriers to optimal diabetes care. More general context barriers included lack of teamwork, poor relationships between and with health care providers (including competition between specialists and general practitioners), financial concerns, and factors associated with patient aging.

Quality Improvement Program (QIP)
General practitioner responses
Barriers: knowledge, attitude, organization
Change mediated by
Education of practitioners
Team approach and participation
Consistent resource messages
Clear delineation of roles and tasks
Serial efforts to remove barriers

Changes were seen in the physician when there was education and feedback on guidelines, case coaching, and increased contact and participation in team meetings with peers and other disciplines. Patients were able to change when there was more of a team approach by health care providers, free services and materials, consistent messages from each of the resources used (general practitioner, specialist, educator, and others), and an attitude change on the part of the general practitioner. Improvement was also seen when there was a reassignment and clear delineation of roles and responsibilities along with serial efforts to remove barriers.

Successful management of diabetes depends heavily on removing barriers for optimal care experienced by both providers and patients. The authors suggested that multifaceted quality improvement programs may be better at improving management than single interventions.


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