Interdisciplinary Teamwork in Diabetes Care: A Review of the Literature

Introduction

The Nursing and Midwifery Council (NMC,2010) specified quite clearly in the Competency Framework for undergraduate students that all nurses should be able to understand, appreciate and use in practice available evidence and research findings in order to ensure delivery of excellent patient care. Nursing students are then required to undertake extended pieces of research work that provide opportunities to develop critical thinking in order to cultivate a thorough comprehension of research and evidence to enhance clinical practice (Williamson & Whittaker, 2017). One example of such research work is a literature review, a summary and critical appraisal of available literature designed to present current state of evidence or to determine need for future research (Polit & Beck, 2018). In line with the NMC thrust, this assignment therefore aims to use a literature review format in order to review available evidence regarding the subject of interdisciplinary teamworking (IDT) in diabetes care.

Diabetes is one of the most common non-communicable diseases, with its global prevalence estimated at 422 million in 2014, and is responsible for 3.7 million deaths in 2012 (World Health Organization (WHO), 2016). It is considered a chronic metabolic disorder characterised by hyperglycaemia as a consequence of insufficient insulin production in the pancreas, or the body’s inability to effectively utilise insulin (WHO, 2017). In the UK, there are currently 3.7 million people diagnosed with diabetes aged 17 and over, majority of those are in England with 3.1 million and 200,000 from Wales (Diabetes UK, 2017). These staggering figures are projected to rise as the population is living longer, with recent population statistics showing a steady rise of those aged 65 and over at 18% in 2016 with a growth projection of 25% in 30 years (Office for National Statistics, 2017).

The ageing population and diabetes are closely linked as the latter is one of the most common chronic conditions affecting older people (Williams, 2016). Since diabetes causes serious micro- and macrovascular conditions such as neuropathy, retinopathy, nephropathy and cardiovascular complications (WHO, 2017), its management poses a huge challenge to both patients and the healthcare system. As a consequence, the UK’s current ageing population is at a greater risk than previous decades for having multiple chronic conditions and comorbidities due ironically in part to better health provisions (Parker, Moran, Roberts, Calvert, & McCahon, 2014). This therefore presents a tremendous amount of pressure to healthcare workers especially nurses who are widely accepted to be at the forefront of most healthcare situations, particularly chronic disease management such as diabetes (Young, Eley, Patterson, & Turner, 2016).

But given the complex nature of diabetes and its comorbidities, General Practitioners (GPs) and nurses are not the only ones responsible for diabetic patients (National Health Service (NHS) Wales, 2016). In fact, several research papers have shown that an interdisciplinary team approach is ideal for its effective management and positive healthcare outcome (Gucciardi, Espin, Morganti, & Dorado, 2016;Reeves, Pelone, Harrison, Goldman, & Zwarenstein, 2017). This assignment therefore aims to critically review available literature that depict a team working approach in diabetes management and to be able to identify its benefits, limitations and possible areas for improvement. It will also focus on how the interdisciplinary team works in diabetes care in the primary care setting, with particular focus on the themes of patient education and medication adherence as related to the field of adult nursing. For the purpose of this assignment, the term “patient education” will pertain to the self-management education for diabetic patients as it is closely related to medication adherence (Powers, et al., 2015).

This subject area was chosen because of diabetes’ impact on the patient’s quality of life and the economic burden of £10 billion a year that it incurs in the already beleaguered NHS (Diabetes UK, 2014). Another reason for the topic choice is that despite the multi-system complications of diabetes, it has been found to be controllable and if managed optimally, those complications can be avoided (Schwartz, et al., 2017). It was also deemed as a suitable topic for nursing research as nurses play a pivotal role in diabetes management, either in primary or secondary care setting (Royal College of Nursing, 2018). This literature review could then hopefully add to the discussion about how to best address diabetes care through interdisciplinary team working.

This assignment adheres to the confidentiality clause in the Nurses and Midwifery Council (NMC,2015) Code wherein patient confidentiality is maintained wherever applicable. Some seminal literature and articles that are older than five years will also be included to enhance the discussion by illustrating the contribution given by previous studies and highlighting the changes that transpired.

Background

With the ageing UK population, more people are now living with chronic conditions and relying more on the NHS (Department of Health and Social Care, 2015). This rising prevalence of long-term conditions is the main challenge faced not only in the UK, but by healthcare systems globally with its enormous economic impact (Adler-Waxman, 2017). One of these conditions is diabetes which requires optimal management given its multifactorial risks and complications (National Institute for Health and Care Excellence (NICE), 2017). Extensive body of evidence has shown a number of benefits in terms of cost reduction, patient safety and positive clinical outcomes with managing chronic conditions by utilising team collaboration in healthcare (Smith, Cousins, Clyne, Allwright, & O’Dowd, 2017). Because of its complex nature, diabetes needs to be managed under a variety of health professionals such as general and specialist physicians, nurses, podiatrists, ophthalmologists, dieticians, psychologists, among others (Gucciardi et al., 2016).

Interprofessional or interdisciplinary teamworking (IDT) is a system wherein various health and social care professionals work collaboratively with the goal of achieving positive patient results (Reeves et al., 2017). The Welsh Government supports this system with its diabetes delivery plan envisioning a fully-integrated primary and specialist service aimed to optimally manage the patient’s needs and improve key outcomes (NHS Wales, 2016). It is therefore important to know what the literature is saying about IDT’s usefulness in diabetes management in order to validate its inclusion in such policies.

There are several aspects of diabetes management, but glycaemic control seemed to be the agreed primary goal as it is a major factor in the development of comorbidities (Whitehead, et al., 2016). The landmark trial called the United Kingdom Prospective Diabetes Study (UKPDS), the longest and largest study on Type 2 diabetic patients, supported the correlation of glycaemic control and diabetic complications and the benefits of pharmacological therapy in lowering blood glucose levels (UKPDS Group, 1998; Hayes, Leal, Gray, Holman, & Clarke, 2013). Several studies has since reiterated that non-adherence with pharmacological means of lowering blood glucose is associated with increased risk of diabetes-related complications (Callaghan, Little, Feldman, & Hughes, 2012). Medical adherence, on the other hand, has been found to be encouraged by patient education (Chrvala, Sherr, & Lipman, 2015). Therefore, the specific focus themes for this literature review are patient education and medication adherence with regards to diabetes management in an IDT setting.

Glycaemic control is the primary goal in diabetes management and the key factor in the development of long-term complications [1].

Living with diabetes presents many challenges, including daily choices and actions that have a direct impact on blood glucose (e.g. exercise, stress, and for many, medication management) [2].

The short-term and long-term effects of hyperglycaemia are multiple, including microvascular (e.g. retinopathy, nephropathy and neuropathy) and macrovascular (e.g. heart disease) changes.

Search strategy

A search strategy is a planned and structured means of organising the key terms of the research topic from databases (Polit & Beck, 2018).  For this literature review, relevant studies were searched electronically through a combination of databases: Medline/Pubmed, NICE Evidence Search, Cochrane Library, iFind, Cumulative Index to Nursing and Allied Health Literature (CINAHL), British Nursing Index, RCN Online library and Google Scholar.  A scan of reference lists in relevant articles and publications was also accomplished. Databases were searched for the MeSH terms: “diabetes” with the use of truncation asterisk * (diabet*), followed by the Boolean operator “AND” in searching for the terms “interdisciplinary” and “interprofessional” which are separated by the link word “OR”. Related terms were also searched with those mentioned above such as: “team”, “team work”, “collaboration/collaborative”, and “shared care”.

The search strategy was particularly challenging because the term “multidisciplinary” has a different meaning from “interdisciplinary”,  and yet it was evident that some authors were using them interchangeably when the former is combined with the word “collaboration” (Chamberlain-Salaun, Mills, & Usher, 2013). Hence, some articles mentioning “multidisciplinary” to mean “interdisciplinary” were included.

Initial search yielded approximately 2377 articles, therefore search was further limited by excluding all data on animals, and including only humans who are not pregnant and are older than 18 of age as this is the start of adult health services provision (Social Care Institute for Excellence, 2015). A limit was also placed to include only English articles and those published within 5 years. Also in the inclusion criteria are peer-reviewed journals, reports from health-related organisations (e.g. NHS, WHO), and grey literature. Adams, Smart and Huff (2016) explained that grey literature can be used to increase the relevance, impact and currency of the review that is being conducted.

The critical appraisal tool used was the Specialist Unit for Review Evidence (SURE,2108) since it is an adapted tool that incorporated the Health Evidence Bulletins Wales checklist and the NICE Public Health Methods Manual and the Critical Appraisal Skills Programme (CASP) checklists.

Although many themes emerged since diabetes is a very complex disease, the themes that emerged in the literature search that is in line with adult nursing will be the focus of the analysis: patient education and medication adherence in the context of interdisciplinary teamworking.

Review of the literature

In order to effectively discuss the chosen themes for the review, it is important to give a general information on the umbrella topic of interdisciplinary teamworking in healthcare and in diabetes care. This will be followed by the review of available literature on medication adherence and patient education.

Interdisciplinary collaboration in chronic disease management and diabetes care

A considerable amount of literature has been published indicating that chronic disease management by interdisciplinary teams delivers positive patient outcomes and cost-effectiveness (Bookey-Bassett, Markle-Reid, McKey, & Akhtar-Danesh, 2016; Harris, et al., 2016; Katon, et al., 2012). A concept analysis by Bookey-Bassett et al. (2016) concluded that these positive outcomes are attributable to the collaborative effort of a diversed and flexible team that includes not just healthcare professionals, but also the patient and family members. This view is supported by Katon et al. (2012) who recommended that an interdisciplinary intervention should be rolled-out to primary care settings due to its cost-effectiveness.

These benefits of teamworking were partly reinforced by a Cochrane review in 2016 where Smith et al. acknowledged the importance of a multidisciplinary collaboration as a major intervention in improving outcomes in chronic diseases. However, the study also clarifies that though multidisciplinary collaboration is important, the result from studies reviewed showed only low-to-moderate certainty of evidence that teamworking was beneficial for the health system and for multimorbid conditions, therefore further studies should be conducted in the future with focus on specific multimorbidity (Smith et al., 2016).

Similarly, another review (Smith, Cousins, Clyne, Allwright, and O’Dowd,2017) dealt with shared care interventions, this time between primary and secondary care that aimed to check whether  collaborative teamworking actually improves outcomes in the management of long-term conditions. Despite the study showing IDT having moderate impact on hypertension, medical adherence and improved outcomes for patients with depression, its overall conclusion interestingly, is that shared care has minimal effect on most clinical outcomes (e.g. HBa1c, cholesterol, weight) (Smith et al.,2017).

A possible limitation of those two Cochrane reviews may probably be that other models of IDT have been developed that were not eligible for inclusion since their reviews were undertaken, hence limiting its generalisability to all kinds of collaborative care (Smith et al.,2017).  It may possibly be addressed by Hardwick, Pearson, Byng and Anderson (2013) who are currently conducting a realist review (awaiting final report) on the effectiveness of shared care.

The authors themselves were not able to identify a reason for the minimal effects of shared care, and they admittedly found it difficult to determine if genuine collaboration or teamworking has transpired in the studies they reviewed (Smith et al.,2017). West and Lyubovnikova (2013) did highlight the complexity of healthcare teams and how their characteristics and dynamics are important in driving their effectiveness across the system. Bookey-Bassett et al. (2016) who initially found that there is a lack of consensus on what constitutes interprofessional collaboration, eventually concluded that it requires a unified definition of the concept for it to work among the participants. This variation in the effect of IDT can be understood to have come due to the complex nature of interprofessional dynamics and actual practice, thus efficient and effective monitoring and evaluation should be implemented (Harris, et al., 2016).

In terms of IDT in diabetes care, majority of the surveyed literature showed that interdisciplinary team care is the preferred approach. The Welsh Government encourages collaboration and integration of services between health and social care in order to provide quality care (NHS Wales, 2016), while similarly, the latest standards from the American Diabetes Association (ADA,2015) specifies that collaborative, interdisciplinary teams are beneficial in handling diabetes management delivery system in meeting patients’ needs.

The assumption that IDT is the best approach for diabetes management has been supported by earlier studies done on the subject such as the study conducted by Sieber, Newsome, & Lillie (2012) whose results demonstrated that a collaborative care model can markedly improve aspects of diabetic care such as patient self-management and laboratory tests results. More recent studies have corroborated it by showing that through IDT, there is improved glycaemic control that reduces patients’ chances of developing CV risk factors and other diabetic complications(Cauthon, Nguyen, Ramirez, Ybarra, & Parker, 2015; McGill, et al., 2017).

Medical adherence and patient education

Optimal glycaemic control remains to be the fundamental principle of diabetes management as it continues to prove its crucial contribution in preventing the onset and progression of diabetic co-morbidities (Bailey, et al., 2013;Inzucchi, et al., 2015). The association of diabetic complications and blood glucose level was confirmed with the UKPDS wherein glucose-lowering medication decreased microvascular complication rate by 25% (Hayes et al., 2013). Clinical neuropathy in both type 1 and 2 diabetes was also significantly prevented by enhanced glycaemic control(Callaghan et al.,2012). More recently, a prospective study between China and the UK has provided evidence to support the relationship between Hba1c level and subsequent cognitive decline (Zheng, Yan, Yang, Zhong, & Xie, 2018). It is therefore important that diabetic patients understand the importance of adhering to prescribed medications.

The term “adherence” is often used interchangeably with other terms pertaining to patients’ suboptimal taking of medicine such as “compliance”, “persistence” and “concordance” (Hugtenburg, Timmers, Elders, Vervloet, & van Dijk, 2013). The primary limitation in the reviewed articles is the lack of consensus on how these terms are used. Furthermore, one of the limitations of this review is that a full discourse of the differences of those terms and the surrounding controversy of their usage with medicines will not be discussed. For the purpose of this assignment, the term “adherence” will be used as it is the one followed by the latest NICE (2009) CG76 guideline on medicine adherence. The term will be used to describe the agreement between the patient and the prescriber regarding the drug recommendation and whether the patient’s actions are congruent with the recommendations (NICE, 2009).

Non-adherence with medications in type 2 diabetes is linked with poor glycaemic control, adverse clinical outcomes and higher healthcare costs, and yet a substantial number of people are still not taking their medications as prescribed (McGovern, et al., 2017). Intentional and unintentional reasons for non-adherence cited by a number of studies include: language and cognitive difficulties, polypharmacy, socio-economic issues, lack of confidence in the therapy, tolerability, fear of side effects and medicine-related factors such as complex dosing regimen (Bailey, et al., 2013; Cutler, Fernandez-Llimos, Frommer, Benrimoj, & Garcia-Cardenas, 2017; McGovern, et al., 2017).

To date, methods of improving adherence have only been partially successful due to the multifactorial nature of adherence (Garcia-Perez, Alvarez, Dilla, Gil-Guillen, & Orozco-Beltran, 2013).

Nevertheless, previous researches have indicated that various interventions had a positive impact on adherence such as simplifying the prescription regimen, educational initiatives, improved doctor–patient communication, reminder systems and reduced costs (Garcia-Cardenas, 2017; Nandyala, Nelson, Lagotte, & Osborn, 2018). Among those methods, it was found that patient-centred education that is implemented through IDT is beneficial across a variety of healthcare system and diverse cultures ranging from Europe and North America (Inzucchi, et al., 2015), Asia (Wong, et al., 2014) and the Middle East (Al Hayek, et al., 2013). In these studies, however, the benefit of IDT is merely acknowledged, and not enough data is supplied into how patient education will be delivered in a proper IDT setting. Furthermore, most studies used prescription lists to deduce medication adherence despite having various drug classes prescribed, thus limiting study comparability and heightens risk of selection bias.

Several studies and meta-analyses have shown that patient education is usually associated with improved clinical results, disease knowledge and psycho-social outcomes (Coppola, Sasso, Bagnasco, Giustina, & Gazzaruso, 2016; Nandyala et a., 2018; Zhao, Suhonen, Koskinen, & Leino-Kilpi, 2017). Patient-centred diabetes education models were also found to be highly effective as compared to usual care when delivered in an interdisciplinary setting, with most studies demonstrating statistically signicant decrease in glycaemic levels with better medication adherence (Chrvala, Sherr, & Lipman, 2015) (Hardee, et al., 2015) (Whitehead, et al., 2016). The study by Hardee et al. (2015) was actually conducted in a hospital, but it tackled how secondary care staff coordinated care with primary care healthcare team and community diabetes education providers upon the patients’s discharge. This study demonstrated that the continuation of benefits of IDT in patient education in diabetes management does not end with transfer of care.

However, research on the efficacy of patient education programs with regards to medication adherence in an IDT setting can be fraught with problems. Among them are: each study uses varied and limited types of interventions and outcomes and; themes, content and methodology are not similar therefore it is difficult to compare available studies. Coventry et. al. (2015) believe that patient education programs themselves are often poorly-matched and lack patient-centredness. Furthermore, Snow, Humprey and Sandall (2013) found that there is a need to train the interdisciplinary team on diabetic education as some professionals were ill-prepared to handle questions from patients who underwent a structured diabetic education program. Nevertheless, patient education is increasingly viewed as vital to diabetes care. More research is therefore needed on the effectiveness and impact on outcomes of patient education in an interprofessional setting.

Summary of findings

Despite its complex multi-system effects, diabetes is a manageable disease that can be controlled through comprehensive and optimal therapeutic interventions. This literature review confirms the premise that the ideal and preferred approach in managing this complex disease is through interdisciplinary team working due to improved patient outcomes and cost-effectiveness. Most studies concluded that the positive outcomes are due in part to the collaborative effort of the professionals involved and patient-centred care models implemented. However, due to the heterogeneity of the studies with varying interventions and research design, some systematic reviews found only moderate level of evidence that IDT was beneficial for social outcomes, the health system and multimorbidities associated with diabetes. Perhaps a research design specifically for determining suitable IDT model for each diabetic comorbidities could be explored for future research in order to validly compare studies.

The one outcome though that clearly benefits from IDT is medication adherence. This review found that optimal glycaemic control continues to be crucial in ensuring the progression or onset of diabetic complications, therefore medicine adherence should be at the forefront of diabetes management. A range of reasons for non-adherence was gathered from the searched articles, and the conclusion was that a patient-centred, individualized approach should be utilised to ensure adherence. Future adherence studies could be refined with a better framework for interventions, improved means of quantifying adherence and better study sampling that could derive credible conclusions.

One intervention that stood out as quite effective is patient education, with benefits encompassing a range of psycho-social and clinical outcomes. These studies also demonstrated that tailor-fitted, patient-centred framework in diabetes education combined with proper interdisciplinary team training can drive success in a number of patient outcomes including medication adherence.

Nurses are in the frontline of diabetes care; therefore, it is vital for them to understand the importance of their role in this interdisciplinary setting so as to contribute effectively in achieving the therapeutic aims. In case of limited knowledge, it is necessary for nurses to acknowledge the need for disease management and collaborative care training in order to work effectively with the team. Knowing the current research on IDT in diabetes management can help nurses in achieving positive patient outcomes through evidence-based practice.

Conclusion

Whilst there is an extensive body of evidence on the benefits of interdisciplinary team working in the healthcare system, there is not enough consistent evidence available on the specific topic of IDT in relationship with diabetes management and its social and clinical complications. More empirical studies with robust research design that focuses on diabetes and interprofessional collaboration would be beneficial in identifying better diabetes care management in the future. Therefore, it is imperative that future research focuses on how best to translate integrated, collaborative interdisciplinary team work models into real-life situations in primary care in order to achieve positive patient-centred outcomes in diabetic patients.

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