Facilitators and barriers to adhering to clinical

practice guidelines for the management of

children and youth with type 1 diabetes:
the health care providers perspective
Karine Khatchadourian1, Shazhan Amed2
1 University
2

of Ottawa/Childrens Hospital of Eastern Ontario, Ottawa, Canada

University of British Columbia/BC Childrens Hospital, Vancouver, Canada

Disclosure
Nothing to disclose.

Introduction
Adherence to diabetes clinical practice guidelines
(CPGs) is sub-optimal
In USA: 68% received A1C tests and 66% received eye
examinations in accordance with ADA guidelines
In BC, Canada: 54% of children with T1D receiving < 2
diabetes-related physician visits and A1C tests per year

Waitzfelder B et al, Pediatrics 2011

Amed S et al, J Pediatr 2013

Introduction
Adherence to CPGs is linked to better outcomes
Glycemic control was better in patients seen 3-4 times
per year vs 1-2 times per year (A1C 8.3% vs 9.1%)
Patients with irregular follow-up had worse glycemic
control compared to those with continuous follow-up
(12.2% vs 10.8%)
Kaufman et al, Pediatrics 1999
Jacobson et al, Pediatrics1997

Objective
To identify factors perceived as facilitators and
barriers to adhering to the Canadian Diabetes
Association CPGs for the treatment of childhood
type 1 diabetes among pediatric health care
providers (HCPs)

Methods
Online survey to pediatric and diabetes HCPs (N=260)
Physicians (pediatric endocrinologists, pediatricians)
Diabetes Educators (nurses, dieticians)

Theoretical Model
Theoretical Domains Framework
Cabana et als Framework of barriers to physician adherence to
CPGs

3 categories: knowledge, attitudes, and behaviour

Descriptive statistics
Cabana MD et al, JAMA 1999

French SD et al, Implement Sci 2012

Results

Response rate (all HCPs)

37%

(95/260)

Response rate (intensity sample)

61%

(71/116)

22.0%

8.5%

19.5%
14.6%

17.1%

Vancouver (PHSA)

18.3%

Results
Role distribution of the Health Care Professionals
(N=90)
Pediatrician

34.4%

Nurse

28.9%

Dietitian

22.2%

Pediatric Endocrinologist

7.8%

Social Worker
Other
Family Doctor
Psychologist

3.3%
2.2%
1.1%
0%

1. Knowledge
Almost all HCPs were aware of and familiar with
the CDA CPGs

Awareness of CDA CPGs

Familiarity with CDA CPGs

%
92
77

N
88
81

2. Attitudes
Most HCPs agreed or strongly agreed with
recommended glycaemic targets
Agreement with the recommended glycemic
targets for each age group
age < 6
(N=85, =4.00 0.7)

2,4%

14,1%

6 age 12
(N=85, =3.99 0.6)

1,2%

16,5%

13 age 18
(N=86, =3.83 1.0)

3,5% 8,1%

1=Strongly disagree

64,7%

18,8%

64,7%

12,8%

2=Disagree

17,6%

53,5%
3=Neither Agree or Disagree

22,1%
4=Agree

5=Strongly Agree

2. Attitudes
Most HCPs agreed or strongly agreed with
recommended complications screening schedule
Agreement with recommended screening schedule for
complications
hypertension
1,3%
(N=77, =4.00 0.7)
hyperlipidemia
(N=77, =3.95 0.7)

14,3%

2,6%

18,2%

neuropathy
1,3%
(N=77, =3.97 0.6)

16,9%

retinopathy
0,0%
(N=76, =4.03 0.6)

19,7%

nephropathy
0,0%
(N=77, =4.08 0.6)

11,6%

1/2=(Strongly) Disagree

66,2%

18,2%

61,0%

18,2%

64,9%

16,9%

57,9%

22,4%

63,6%
3=Neither Agree or Disagree

22,1%
4=Agree

5=Strongly Agree

3. Behaviour - Perceived barriers to

achieving recommended glycemic targets
(65 respondents; 92 responses)

Survey Response

(N)

I do not have enough time to counsel on glycemic targets

5.4

(5)

I do not feel comfortable in making glycemic recommendations

3.3

(3)

Most parents/patients prefer higher glycemic targets and I feel

making these recommendations will not lead to better outcome

18.5 (17)

I do not feel my patients with T1D and their families have

28.3 (26)
adequate support to achieve these recommended glycemic targets
I spend most of the clinic visit visit focusing on psychosocial issues 13.0 (12)
and do not have time to review glycemic targets
I do not feel it is my responsibility to make recommendations on
glycemic targets (i.e. it is another team members responsibility)

12.0 (11)

Other

19.6 (18)

3. Behaviour - Perceived barriers to

adhering to complication screening schedule
(59 respondents; 80 responses)

Survey Responses

13.8

11

I do not have enough time during a visit to take a BP

measurement

2.5

I do not feel comfortable or feel prepared in making these

recommendations to the parent/patient

2.5

Most parents/patients are given laboratory requisition forms for

tests, but tests are not completed by next visit

23.8

19

I do not feel my patients with T1D and their families have the
motivation or support to achieve the screening schedule

13.8

11

I do not feel it is my responsibility to make these recommendations 18.8

(i.e. it is another team diabetes members responsibility)

15

Other

20

I do not have enough time during a visit to confirm screening

25.0

4. Barriers - Poor access to

psychosocial support is a key barrier

Only 14% of HCPs felt it

was feasible to refer
patients for psychosocial
support

Why?
71% identify long wait times & lack
of psychosocial services

5. Facilitators
What might enhance adherence to CPGs?
Diabetes clinic template form with reminders on
key aspects of CPGs

28.9%

Web-based information for parents and patients

23.0%

Printed information such as pamphlets

19.6%

Questionnaires for families to complete in

physicians office to facilitate discussion

22.5%

Conclusions
Almost all pediatric diabetes HCPs in British Columbia
are aware of and agree with the CDA Clinical Practice
Guidelines

Major barriers to adhering to CPGs include:

Lack of support for parents/patients
Insufficient access to a mental health professional or social
worker
Parental preference for higher glycemic targets
Parental/patient non-compliance

Limitations
Survey method and survey response rate lower
(37% vs 63%) than similar survey study in UK
Gosden C et al, Arch Dis Child 2010

Biases
Phenomenon of social desirability
Selection bias

Next Steps
Improved access to mental health services is needed
Future research identifying patient/family perspectives on
facilitators and barriers to adhering to treatment
Innovative approaches to improving adherence
Electronic medical records offering reminders for screening
Models of care shared care, medical home, transition clinics to
improve access to care
Technology Telehealth, SMS text messaging

Acknowledgements

HCPs who completed the survey

Dr Shazhan Amed
Dr Robert Everett
Dr Jacek Kopec
Ashley McKerrow
Boris Kuzeljevic
Jen Yong

Other Responses for barriers faced in

following recommended screening schedule

Forgetfulness by HCP (n=2) or families (n=2)

Lack access to services outside Vancouver (n=2)
No barriers (n=2)
Lack proper system to flag patients (n=1)
Focus on HbA1C (n=1)
Guidelines well covered by EMR (n=1)

Other Responses for barriers faced in achieving

the recommended glycemic targets
Guilt/fear/discouragement from families trying to achieve
targets (n=2)
Care to be individualized (n=1)
Difficulty with adherence/compliance (n=3)
Availability and waiting list for mental health services too
long (n=1)
Lack motivation from parents (n=1)
Fear hypoglycemia (n=2)
Schedule visits 6-9 months apart (n=1)

Frequency of screening for complications

N=69

N=69, (=3.880.87)
53,6%

21,7%
17,4%
5,8%
1,4%
1=Never

2=Rarely

3=Sometimes

4=Often

5=Almost Always

Frequency of Visits
N=75

(N=75, =2.37 1.17)

30,7%

29,3%

26,7%

8,0%
5,3%

1=Four times or
more

2=Three times

3=Two times

4=One time

5=Other

HCP-identified barriers leading to frequency visits <2/yr

(N=90)
28,9%
23,3%
17,8%

18,9%

11,1%

0,0%
HCP believes
unnecessary

Other

Limited clinic
capacity

Patient
preference
(prefer not to
come more
often)

Shared care

Patient
compliance

HCPs Familiarity with

CPG (1=Not familiar to
5=Very familiar)

Mean

SD

81

3.94

0.91