title: Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review.
abstract: BACKGROUND
  Despite the availability of evidence-based guidance, many patients with type 2 diabetes do not achieve treatment goals.
  
  
  OBJECTIVE
  To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians' and nurses' perceived influences on care.
  
  
  METHODS
  Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework.
  
  
  METHODS
  Databases searched were MEDLINE, Embase, CINAHL, PsycInfo, and ASSIA from 1980 until March 2014. Studies included were English-language qualitative studies in primary care of physicians' or nurses' perceived influences on treatment goals for type 2 diabetes.
  
  
  RESULTS
  A total of 32 studies were included: 17 address general diabetes care, 11 glycaemic control, three blood pressure, and one cholesterol control. Clinicians struggle to meet evolving treatment targets within limited time and resources, and are frustrated with resulting compromises. They lack confidence in knowledge of guidelines and skills, notably initiating insulin and facilitating patient behaviour change. Changing professional boundaries have resulted in uncertainty about where clinical responsibility resides. Accounts are often couched in emotional terms, especially frustrations over patient compliance and anxieties about treatment intensification.
  
  
  CONCLUSIONS
  Although resources are important, many barriers to improving care are amenable to behaviour change strategies. Improvement strategies need to account for differences between clinical targets and consider tailored rather than 'one size fits all' approaches. Training targeting knowledge is necessary but insufficient to bring about major change; approaches to improve diabetes care need to delineate roles and responsibilities, and address clinicians' skills and emotions around treatment intensification and facilitation of patient behaviour change.
authors.affiliation: Foundry Lane Surgery, Leeds.
authors.forename: Bruno
authors.initials: B
authors.lastname: Rushforth
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds.
authors.forename: Carolyn
authors.initials: C
authors.lastname: McCrorie
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds.
authors.forename: Liz
authors.initials: L
authors.lastname: Glidewell
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds.
authors.forename: Eleanor
authors.initials: E
authors.lastname: Midgley
authors.affiliation: Leeds Institute of Health Sciences, University of Leeds, Leeds.
authors.forename: Robbie
authors.initials: R
authors.lastname: Foy
mesh_terms: D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D019468:Disease Management; D006801:Humans; D010349:Patient Compliance; D011320:Primary Health Care / Q000379:methods*; D036301:Qualitative Research; D058996:Quality Improvement / Q000458:organization & administration*
keywords: diabetes mellitus, type 2; primary health care; qualitative research; quality improvement; systematic review
references.citation: J Am Board Fam Med. 2009 Sep-Oct;22(5):513-20
references.pmid: 19734397
references.citation: Fam Pract. 2009 Apr;26(2):109-14
references.pmid: 19208737
references.citation: S Afr Med J. 2005 Oct;95(10):798-802
references.pmid: 16341336
references.citation: Diabetes Care. 1998 Sep;21(9):1391-6
references.pmid: 9727882
references.citation: BMC Fam Pract. 2009 Apr 21;10:24
references.pmid: 19383116
references.citation: Am J Med Qual. 2011 Jul-Aug;26(4):284-90
references.pmid: 21393616
references.citation: Can J Cardiol. 2007 May 15;23(7):591-4
references.pmid: 17534469
references.citation: Fam Pract. 2002 Aug;19(4):344-9
references.pmid: 12110552
references.citation: BMC Fam Pract. 2007 Nov 09;8:63
references.pmid: 17996084
references.citation: Implement Sci. 2009 Aug 12;4:54
references.pmid: 19674440
references.citation: World Health Organ Tech Rep Ser. 1980;646:1-80
references.pmid: 6771926
references.citation: Fam Pract. 2004 Feb;21(1):39-45
references.pmid: 14760042
references.citation: BMC Fam Pract. 2005 May 12;6(1):20
references.pmid: 15890071
references.citation: BMJ Open. 2013 Aug 19;3(8):e003217
references.pmid: 23959754
references.citation: BMC Fam Pract. 2012 Jul 04;13:28
references.pmid: 22469132
references.citation: Postgrad Med J. 2006 May;82(967):347-50
references.pmid: 16679475
references.citation: Diabetes Res Clin Pract. 2011 Jul;93(1):1-9
references.pmid: 21382643
references.citation: Br J Community Nurs. 2007 Jan;12(1):6-11
references.pmid: 17353805
references.citation: Implement Sci. 2006 Feb 23;1:4
references.pmid: 16722571
references.citation: BMJ. 1997 Aug 16;315(7105):418-21
references.pmid: 9277610
references.citation: Implement Sci. 2015 Apr 23;10:55
references.pmid: 25900104
references.citation: Diabet Med. 2012 Jul;29(7):855-62
references.pmid: 22537247
references.citation: Implement Sci. 2014 Jan 17;9:14
references.pmid: 24438584
references.citation: S Afr Med J. 2000 Dec;90(12):1206-11
references.pmid: 11234651
references.citation: Singapore Med J. 2011 Nov;52(11):801-9
references.pmid: 22173249
references.citation: Qual Saf Health Care. 2003 Jun;12(3):215-20
references.pmid: 12792013
references.citation: Patient Educ Couns. 1996 Oct;29(1):13-23
references.pmid: 9006218
references.citation: Cult Med Psychiatry. 2000 Dec;24(4):379-401
references.pmid: 11128624
references.citation: Am J Med Qual. 2012 May-Jun;27(3):233-40
references.pmid: 22031174
references.citation: J Adv Nurs. 2005 Jan;49(2):146-54
references.pmid: 15641947
references.citation: Prim Health Care Res Dev. 2013 Jul;14(3):258-69
references.pmid: 23259934
references.citation: Aust Fam Physician. 2011 Aug;40(8):617-21
references.pmid: 21814661
references.citation: Implement Sci. 2012 Aug 03;7:73
references.pmid: 22862968
references.citation: Milbank Q. 2001;79(2):281-315
references.pmid: 11439467
references.citation: BMC Fam Pract. 2013 Aug 10;14:114
references.pmid: 23937325
references.citation: Qual Saf Health Care. 2005 Feb;14(1):26-33
references.pmid: 15692000
references.citation: Fam Med. 2001 Sep;33(8):621-5
references.pmid: 11573720
references.citation: BMC Med Res Methodol. 2004 Mar 16;4:5
references.pmid: 15070427
references.citation: Implement Sci. 2014 Jan 13;9:8
references.pmid: 24418161
references.citation: J Psychosom Res. 2002 Oct;53(4):897-902
references.pmid: 12377300
references.citation: Diabetes Care. 2004 May;27(5):1066-70
references.pmid: 15111522
references.citation: Soc Sci Med. 2005 Apr;60(7):1423-35
references.pmid: 15652676
references.citation: Implement Sci. 2011 Apr 23;6:42
references.pmid: 21513547
references.citation: Health Soc Care Community. 2001 Sep;9(5):318-26
references.pmid: 11560747
references.citation: Prim Care Diabetes. 2014 Apr;8(1):49-55
references.pmid: 24315732
references.citation: Lancet. 2012 Jun 16;379(9833):2252-61
references.pmid: 22683130
references.citation: Cochrane Database Syst Rev. 2013 Oct 08;(10):CD010414
references.pmid: 24101553
references.citation: J Am Board Fam Med. 2010 Mar-Apr;23(2):171-8
references.pmid: 20207927
references.citation: Diabetes Care. 2014 Jan;37 Suppl 1:S14-80
references.pmid: 24357209
references.citation: Implement Sci. 2012 Apr 24;7:37
references.pmid: 22530986
references.citation: Diabet Med. 2005 Mar;22(3):286-92
references.pmid: 15717876
references.citation: JAMA. 2002 Oct 9;288(14):1775-9
references.pmid: 12365965
references.citation: BMJ. 2012 Apr 26;344:e2333
references.pmid: 22539172
references.citation: Br J Gen Pract. 2008 Aug;58(553):569-75
references.pmid: 18682013
references.citation: BMC Fam Pract. 2014 Jan 31;15:20
references.pmid: 24479762
references.citation: Patient. 2014;7(3):283-300
references.pmid: 24691766
references.citation: Ir Med J. 2013 Mar;106(3):77-80
references.pmid: 23951976
references.citation: Diabetes Care. 1997 Mar;20(3):292-8
references.pmid: 9051375
references.citation: Cochrane Database Syst Rev. 2010 Mar 17;(3):CD005470
references.pmid: 20238340
references.citation: J Adv Nurs. 2003 Jun;42(5):487-96
references.pmid: 12752869