Furler John S, Blackberry Irene D, Walker Christine, Manski-Nankervis Jo-Anne, Anderson Jenny, O'Neal David, Young Doris, Best James
Department of General Practice, University of Melbourne,
Department of General Practice, University of Melbourne.
Fam Pract. 2014 Jun;31(3):349-56. doi: 10.1093/fampra/cmt085. Epub 2014 Jan 28.
Most people with type 2 diabetes (T2D) have glycaemic levels outside of target. Insulin is effective in improving glycaemia and most people with T2D eventually need this. Despite this, transition to insulin therapy is often delayed in primary care.
To develop a model of care (Stepping Up) for insulin initiation in routine diabetes care in Australian general practice. To evaluate the model for feasibility of integration within routine general practice care.
Drawing on qualitative work and normalisation process theory, we developed a model of care that included clarification of roles, in-practice systems and simple clinical tools. The model was introduced in an educational and practice system change intervention for general practitioners (GPs) and practice nurses (PNs). Five practices (seven GPs and five PNs) and 18 patients formed the feasibility study. Evaluation at 3 and 12 months explored experiences of GPs, PNs and patients.
Fourteen patients commenced insulin, with average HbA1c falling from 8.4% (68.3 mmol/mol) to 7.5% (58.5 mmol/mol) at 3 months. Qualitative evaluation highlighted how the model of care supported integration of the technical work of insulin initiation within ongoing generalist GP care. Ensuring peer support for patients and issues of clinical accountability and flexibility, managing time and resources were highlighted as important.
The Stepping Up model allowed technical care to be embedded within generalist whole-person care, supported clinicians and practice system to overcome clinical inertia and supported patients to make the timely transition to insulin. Testing of the model's effectiveness is now underway.
大多数2型糖尿病（T2D）患者的血糖水平未达目标。胰岛素在改善血糖方面有效，大多数T2D患者最终都需要使用胰岛素。尽管如此，在初级保健中，向胰岛素治疗的转变往往会延迟。
为澳大利亚普通实践中常规糖尿病护理的胰岛素起始治疗开发一种护理模式（逐步升级模式）。评估该模式在常规普通实践护理中整合的可行性。
借鉴定性研究工作和规范化过程理论，我们开发了一种护理模式，包括明确角色、实践中的系统和简单的临床工具。该模式在针对全科医生（GPs）和执业护士（PNs）的教育及实践系统变革干预中引入。五个诊所（七名全科医生和五名执业护士）和18名患者组成了可行性研究。在3个月和12个月时进行的评估探讨了全科医生、执业护士和患者的经历。
14名患者开始使用胰岛素，3个月时平均糖化血红蛋白（HbA1c）从8.4%（68.3 mmol/mol）降至7.5%（58.5 mmol/mol）。定性评估突出了护理模式如何支持在持续的全科医生综合护理中整合胰岛素起始治疗的技术工作。确保为患者提供同伴支持以及临床问责和灵活性问题、管理时间和资源被强调为重要方面。
逐步升级模式使技术护理能够融入全科医生的整体人护理中，支持临床医生和实践系统克服临床惰性，并支持患者及时过渡到胰岛素治疗。该模式的有效性测试正在进行中。
