Abstract Diabetes is a growing endemic and places a significant financial burden on the NHS. NICE guidelines recommend using a patient centred approach and individualised management plan. Annual review appointments with a doctor or a diabetic nurse are an ideal opportunity to address various factors, but the impact can be limited due to time constraints and need to achieve QOF targets. This study looked at the impact of having a questionnaire completed by the patients prior to the appointment to identify topics and queries that need answering and to improve the patient involvement in goal setting. It was conducted at a large, city centre GP surgery with an ethnically diverse population and relatively a relatively standard prevalence of diabetes as in the rest of the UK. It identified common concerns that were related directly to diabetes such as weight and blood sugar levels and areas patients frequently overlook such as retinal screening, foot care, smoking and sick days advice. The patients were able to highlight recent improvements and concerns in their health and used the form to propose future goals and identify their current motivation levels. The patients surveyed found it useful to think and write down their queries prior to the appointment. The clinicians reported better and more time efficient consultations and noted improved patient engagement in setting future goals and motivating them to achieve it. Both clinicians and patients felt the process would have been better if the questionnaire had been sent to the patient in advance to provide more time to adequately complete it prior to the appointment. In summary, this questionnaire can be a helpful tool to improve consultations along with patient engagement and compliance. It should be considered for use by clinicians for all diabetic appointments in primary and secondary care. However, the outcomes could be improved by providing the patients this questionnaire in advance and encouraging them to fully complete it before their appointment.

INTRODUCTION

All diabetic patients are offered an annual review appointment at their local GP surgeries with a doctor or diabetic nurse. The objective of these appointments is to assess the ongoing diabetic control along with the associated cardiovascular risk factors such as smoking, cholesterol and blood pressure control and to ensure that annual checks such as screening for eye and kidney disease have been completed. It is also an opportunity for the clinician to offer dietary and lifestyle advice to the patients.

The National Institute for Health and Care Excellence (NICE) guideline updated in 2017 continues to emphasise the need for individualised care considering patient’s medical background along with an assessment of their needs and circumstances at each review appointment.  Shortus

et al.

(2007) conducted a retrospective audit in Australia and showed that diabetic patients with care plans achieved better outcomes in terms of improved metabolic control and cardiovascular risk. Roland

et al.

(2012) and Reeves

et al.

(2014) looked at the use of care plans in all long-term conditions in the UK and were able to highlight the variation in usage, quality of plans and its impact on the chronic conditions. To-date there is no published data looking at the impact of care plan for diabetic patients in the NHS. There is also a lack of data regarding patient and clinician experience of using a standardised care plan.

This study aims to look at the benefits of having a pre-filled questionnaire and its impact on the discussion between the clinician and the patient at these review appointments. It aims to provide an insight into the concerns that the patients have before attending the appointment and to assess whether these issues have been adequately addressed during their appointment.  The study will also offer an opportunity to assess patient and clinician satisfaction of using the care plan.

BACKGROUND

Diabetes is increasingly becoming a burden on healthcare systems around the world. Hex

et al.

(2012) estimated that the NHS was spending more than a million pounds every hour on the direct and indirect effects of diabetes on patients. Hence there is an increased stress for physicians to focus on optimising diabetes care and to minimise the risk of developing complications.

Diabetes is a lifelong condition and needs clinicians and patients working in a partnership. Funnell and Anderson (2002) showed that patients who were not motivated to follow the nurse practitioners’ recommendations led to poor outcomes. Collins

et al.

(2009) conducted a qualitative exploratory study looking at the various self-care coping strategies adopted by diabetic patients. It found that the patients were reluctant to follow the clinician’s self-care recommendation when it was deemed to be too demanding and the compliance improved when the self-care protocol was tailored to suit the patient type.

Grund and Stomberg (2012) ran a prospective pilot study in Sweden using a qualitative method to analyse the expectations of patients regarding health advice discussion with the diabetic nurse. It showed that whilst patients were keen to discuss their test results, their main health concerns revolved around other topics such as accessibility to the diabetic nurse along with access to group activities and knowledge of self-care.

Having a pre-appointment questionnaire would provide all the required patient queries and concerns along with a platform for patients and clinicians to document their discussion. This would improve communication and help the clinician adequately address patient’s ideas, concerns and expectations. The overall benefits are likely to be three-fold

1. Patients would benefit with identifying their areas of concern prior to their appointment and ensure they have an opportunity to discuss them with the clinician.
2. The clinicians doing the reviews are more likely to understand the common concerns patients have and they can then tailor the consultation to address these issues and formulate a management plan that incorporates the patient’s needs.
3. It is likely to be helpful and provide useful feedback to other clinicians at the practice and in primary and secondary care, in general. It is anticipated that there will be certain patterns or frequent topics of concern identified during the study that can be better addressed and discussed more frequently during every review appointment. If the results are favourable, the idea of using a care plan could be standardised to all diabetes review appointments.

AIMS AND OBJECTIVES

1. To assess the entries of the patients in the care plan and look for recurring themes of concern or topics of discussion that patients frequently wish to have with the clinician during their annual review appointment.
2. To look at the associated risk factors that patients highlight or wish to discuss.
3. To assess if above concerns have been adequately addressed by reviewing the medical records.
4. To evaluate the benefits and satisfaction for clinicians and patients by completing a standardised questionnaire.

PROJECT APPROACH AND METHODOLOGY

The project was conducted at a large city centre practice in Derby with a practice size of over 15,000 patients. The practice has a diverse population with just over 1000 patients on the diabetes register. The care plan that is currently being used at the practice is based on the generic care plan created by NHS England and Diabetes UK (see appendix 1). This has been modified by NHS West Midlands as part of their locally adapted NICE guidelines (see Appendix 6) which underpins the use of a care plan to holistically deal with all issues relevant to diabetes. The care plan has been modified to include a section titled My current health and wellbeing for patients to write down their areas of concerns and intended topics of discussion. This study has been designed to look at this half of the care plan only and not include the agreed goals due to the limitations listed below.

Ethics approval was gained from the Warwick University Biomedical and Scientific Research Ethics Committee and the local Clinical Commissioning Group (CCG) prior to the start of the study. The diabetic nurse practitioners at the practice were counselled regarding the project and they volunteered to take part in the study. All diabetic patients who attended the practice during March 2019 were given a copy of the care plan with a covering letter (see Appendix 2) upon arrival to the surgery. This explained the aims of the study along with the assurance of confidential data collection and highlighting the fact that enrolment into the study was voluntary. The nurses were encouraged to write down the NHS number of the patient on their respective forms to identify those who had completed the forms and hence provide an opportunity to review their medical record entries later. A total of 120 care plans were handed out with 79 forms completed and returned to the clinician or the practice. The data was then imported onto a spreadsheet using non patient identifiable information and stored securely on a work computer.

Adult diabetic patients who attended appointment during March 2019 (Total = 120) Declined to complete the care plan (Total = 41) Consented to take part and completed the form (Total = 79) Illegible forms (Total = 2) Legible and completed forms included in the study (Total = 77)

Table 1: Inclusion and exclusion criteria

Quantitative analysis of the areas of concerns highlighted by the patients was conducted whilst the answers provided to the questions in the care plan were grouped into themes to look for similar patterns.

Both patient and clinician questionnaires were designed using a combination of 5-point Likert scales and free text questions to highlight the benefits of the care plan and areas for further development. A study conducted by Dawes (2008) showed that 5- and 7-point Likert scales were equally reliable and showed the same mean score when scaled to a 10-point scale. Hence, a 5-point Likert scale was adopted for the questionnaire to minimise variability given the small sample of patients and clinicians surveyed during this study.

Invites (see Appendix 3) were sent to 20 random patients who had completed the questionnaire requesting them to provide feedback on their experience of completing the form prior to the appointment. There were 7 responses received initially with a further 5 responses received after sending a reminder letter to all the patients who were initially contacted. Following this, all the diabetic nurses involved in the project were requested to complete anonymised feedback questionnaire (see Appendix 4) and their responses collated and underwent quantitative analysis and assessed for recurring themes in their responses.

RESULTS

Patient questionnaire summary

Table 2: Bar chart showing areas of patient concern

Woodcock & Kinmonth (2001) looked at patient areas of concern a year after they were diagnosed with diabetes. Their findings were similar to those from this study, wherein, the top concerns by the patients were worsening diabetic control, associated complications, symptoms of diabetes such as lethargy, dietary advice concordance and weight control. It appears from these findings that patients’ priorities revolve around areas deemed to be directly related to diabetes with less emphasis on other risk factors such as blood pressure, cholesterol and smoking.

Weight and dietary advice were the second most common concern for patients who consented to complete the care plan. A review of the medical records of the 31 patients who indicated this as a concern revealed that all these patients were obese with a body mass index (BMI) of over 30. Of the other 46 patients who did not indicate this as a concern, 28 patients (60%) were recorded as obese. Relative to this, physical activity was highlighted by a smaller number of participants as an ongoing concern. The NICE guidelines continue to emphasise the role and benefits of increased physical activity on improving glycaemic control, in patients treated with medications and those on diet control only.

It was noted during this study that patients rated eye care as a lower priority or area of concern compared to other areas such as blood pressure, cholesterol, foot care and advise during illness. The practice in Derby where this study was conducted has a high rate of deprivation with the second most deprived decile rating on the Public Health England’s National General Practice Profiles. The findings of this study are in keeping with those by Scanlon

et al.

(2008) who looked at the impact of deprivation on uptake of retinal screening and the subsequent increased risk of advanced retinopathy. The study found that with increasing quintile of deprivation, prevalence of retinopathy and more specifically sight-threatening retinopathy increased whilst uptake of retinal screening decreased.

Smoking was of low priority amongst those who completed the care plan. Only 2 patients highlighted this topic as an area of concern despite 42 patients (54%) being recorded as smokers in their medical records. This is disappointing given the extensive evidence available regarding increased cardiovascular risk in diabetic patients who smoke. Qin

et al.

(2013) and Pan

et al.

(2015) conducted meta-analysis and systematic review of available evidence and demonstrated a strong link between smoking in diabetic patients and increased mortality and cardiovascular events. These reviews also established that smoking cessation reduced the risk in the same cohort of patients.

Patient comments summary

When asked to highlight what is working well, 19 patient identified ongoing weight loss as a positive factor whilst 10 patients reported improved blood sugar levels in recent months. Interestingly, weight and glycaemic control were also recorded by other participants as the most common areas of ongoing concern.  Because of this, 31 patients (40%) identified weight loss as their goal along whilst 24 patients (31%) felt that increased exercises and physical activities were their priority. It was pleasing to note that 82% (63 out of 77 patients) of the respondents rated the importance of achieving their goals as 8 or more on a scale of 1 to 10 (1 = not important and 10 = important). 20 patients recognised that their planned goals would likely be long term or ongoing whilst 40 of them felt they could achieve their goals within 3 to 12 months.

The most common queries to the clinicians revolved around fluctuating blood sugar levels and advice regarding dietary and lifestyle habits. A small minority of patients were keener to discuss their general health than limit the queries to diabetes control only.

Whilst most of the care plans were filled appropriately, it was disappointing to note some of the questions left unanswered by a few of the respondents. 19 of them failed to highlight areas of concern and 13 patients did not document any ongoing positives in their general health. 31 patients were unable to identify any questions they had for the clinician and 14 others wrote down questions not related to their diabetes care. Examples of these include questions about sickness benefits, low mood, chronic backache and other medical conditions.

Questions I have Why are my blood sugar levels fluctuating? 13 Eating habits/ Healthy options/ diet 8 Blood test results?  8 How can I control my diabetes? 6 About my general health?   5	What has improved? Weight loss/maintained weight 19 Nothing has improved/No change 13 Blood sugars are better controlled   10 HBAIC has improved   7 General health improvement   6	Concerns about health Sugar levels   14 Weight    12 Pain around hip/leg when walking/running/stairs   6 Aching joints/ hip/feet/arms/shoulder/back 6 Low energy levels/getting weak    4
Future goals Lose weight/Control weight/get fit    31 More exercise/walk longer (with no pain) 24 Reduce sugar/Control sugar    16 Eat healthy/better diet    14 Control or reverse diabetes   7	Changes needed Diet control/healthy eating/reduce portions 46 Exercise/walk more 31 Review the medication/take medication/ take insulin/reduce medication 11 Follow up/ see GP/take advice from nurse 9 Lose weight   6	Time to achieve goal Long term changes/continuous   20 3-month review 13 6 to 12 months 13 6-month review 8 1 year   6

Table 3: Five most common answers to each of the questions in the care plan and the number of patients who documented this

Addressing patient concerns

The medical records of all participants and entries by the clinicians following the appointment were reviewed to assess if the concerns were appropriately addressed and documented. All 100% of the patient records had documentation of at least one area of concern mentioned in the care plan. 55 patients (71%) had all queries answered and concerns addressed appropriately whilst 16 patients (21%) were signposted to the GP for further advice or review. A small minority of 6 patients (8%) did not have documentation of all areas of concern being discussed. This could possibly be an oversight by the clinician in dealing with the issue or documenting the relevant discussion, given the limited duration of time during the appointment.

Patient feedback

Of the 12 patients who completed the feedback survey forms, 8 indicated that they had completed the care plans themselves whilst 3 patients required help from friends or family and 1 needed the help of an interpreter. All patients unanimously agreed that they found it easy to complete the form (agree = 7, strongly agree = 5) whilst 11 out of 12 patients felt it helped to document their concerns with 1 patient being equivocal about its benefit. 100% of the respondents agreed that the clinician addressed all their concerns and 83% (10 out of 12) found the overall experience of using this care plan helpful. Two other respondents neither agreed nor disagreed regarding the overall benefit of using the care plan.

When asked about the advantages of using the care plan, majority of the patients highlighted the benefit of thinking and documenting their concerns before meeting the clinician. It was felt by these people that it helped them, and the clinicians focus on the appropriate areas of care and to utilise the limited appointment time more efficiently. Some of the respondents noted that the opportunity to complete the areas of concern highlighted topics commonly overlooked by the patients during annual review appointments such as eye and foot care along with advice during sick days and travelling.

Whilst the overall patient feedback was positive, there was one common recurring criticism of the methodology used in this study. Most of the respondents felt that they did not have adequate time to complete the form before the appointment and they would have benefitted if the forms had been posted out to them along with the invite letter to book their annual appointment. This has also been echoed in the clinician feedback and it could be responsible for several of the questions being left unanswered or marked as “none”.

Clinician feedback

All the clinicians who completed the feedback form unanimously agreed that it was a helpful tool during the consultation and they were overall satisfied with it. They highlighted the positives of the care plan such as better ability to focus on areas of concern and as a result, it improved their time keeping during the appointments. They also felt that using this form makes patients more involved in their own care and the decision-making process. It also provides an opportunity to empower them further in setting realistic and achievable future goals. The recommendations made by the clinicians were to make the questions more specific to prevent patients documenting non diabetes related queries or concerns. The other area of feedback was to provide the patients ample time and opportunity prior to the appointment to fully complete the care plan. Like the patients, the clinicians too felt that it would have been more effective if the forms were posted out to the patient before the appointment and they were encouraged to fully complete these forms.

Some of the forms were completed by the patients and handed back to the reception rather than the clinician. It was felt that the covering letter could be worded better to explain the process to the patients and ensure that there were clear directions on completing the forms and passing it to the concerned clinician. This would avoid any miscommunication or confusion during the appointments.

LIMITATIONS

The study design required collecting patient data and a subsequent review of their medical records. Hence it could only include those patients who consented to complete the form prior to the appointment and agreed to take part in the study. There was no record kept of the patients who declined to participate and hence they could not be contacted to establish the reason for their refusal to take part in the study.  Due to the lack of consent, the study did not assess the quality of the medical record entries for these excluded patients or their satisfaction level of the consultation compared to those who agreed to take part.

Some of the questions were left unanswered by the participants which could potentially have affected the accuracy of the collected data. It is the opinion of the author, based on the patient and clinician feedback, that this maybe the result of a combination of the limited time prior to the appointment and the lack of clear instructions in the covering letter.  This could be overcome in the future by posting the forms to the patient in advance or encouraging patients to arrive at the surgery early and complete the forms whilst awaiting their appointment.

Due to time constraints, the study only looked at the health and wellbeing questionnaire aspect of the form and not the final agreed care plan between the patient and the clinician. This would have required longer term (3 to 6 months) follow up of patients to assess if the goals agreed were realistic and achievable and to identify barriers, if any, that may not have been addressed appropriately.

SUMMARY & CONCLUSION

Annual diabetic review appointments in General Practice are a golden opportunity for the clinician to address various relevant areas whilst also completing all requirements for Quality and Outcomes Framework (QOF). Trying to achieve all this in a quite limited amount of time during the appointment can be quite overwhelming for the clinician and can adversely affect the quality of the consultation. As a result, it is also possible that the clinician could overlook or fail to address patients’ ideas, concerns and expectations.

Various studies have documented the benefits of having a written care plan in other chronic conditions and patients undergoing terminal care. This leads to better communication between various multidisciplinary clinicians and between the lead clinician and the patient.

This study looked at the benefit of having a questionnaire within the care plan for patients to document areas of concern and for clinicians to focus their consultation on addressing these issues along with the other annual requirements. It highlighted the common areas of concern such as glycaemic control and weight issues as diabetic patients’ most frequent concern and helped the clinician tackle these issues appropriately. Areas such as foot care, eye care, smoking and advise during illness were noted to be of a lower priority for the patients. It could be prudent for clinicians to tailor future consultations to address these common concerns but also highlight the benefits of regular foot and eye screening and provide adequate advice regarding other topics commonly neglected by the patients.

The forms used also provided an opportunity for patients to ask questions and document future goals and timelines. It also encouraged them to consider the importance of achieving these goals giving the clinician an insight into their level of motivation. The overwhelming majority of patients and clinicians agreed that this could be an effective aid in improving the quality of the consultation and result in better patient satisfaction and engagement levels. The clinicians found it easier to focus more closely on highlighted areas of concern rather than attempt to cover all relevant areas in a short span of time. They also felt that it provided a platform to include the patient in the decision-making process and empower them to set practical and achievable goals.

Some of the drawbacks highlighted include the need for clear directions in the covering letter to the patients and a consideration to send the form to the patient well in advance. This could provide an adequate opportunity for the patients or their representatives to reflect on their ongoing needs and complete the whole form appropriately.

In summary, the study found that the care plan used could be a powerful tool in improving the quality of the consultation between the patient and the clinician and addressing adequately areas of concern important to the patient. It would also help the clinician practise a patient-centred approach and it is reasonable to assume that this would lead to better patient satisfaction levels and improved disease related outcomes.

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