Barriers to effective management of type 2 diabetes in primary care: qualitative systematic review

Background: Despite the availability of evidence-based guidance many patients with type 2 diabetes mellitus do not achieve treatment goals. Aim: To guide quality improvement strategies for type 2 diabetes by synthesising qualitative evidence on primary care physicians’ and nurses’ perceived influences on care. Design and Setting: Systematic review of qualitative studies with findings organised using the Theoretical Domains Framework. Methods: Sources were Medline, Embase, CINAHL, PsycInfo and ASSIA from 1980 until March 2014. We selected English language qualitative studies in primary care of physician or nurse perceived influences on treatment goals for type 2 diabetes. Results: We included 32 studies; 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 adherence 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 clinician skills and emotions around treatment intensification and facilitation of patient behaviour change.