Tailoring integrated care through interdisciplinary collaborative practice among patients, nurses, and physicians based on the patient’s genetics or lifestyle, glycemic target, biodata- or evidence-based practice, patient preferences, and priority for improving patient self-management to achieve glycemic control.
1. Introduction
Diabetes is a chronic disease and a major health concern in modern society. diabetes is typically characterized by an abnormal increase in glucose levels caused by one or two mechanisms: inadequate insulin production by the pancreas or inadequate cell sensitivity to the action of insulin caused by the reduced function of insulin receptors. In 2019, an estimated 463 million patients had diabetes. By 2045, this number is predicted to increase to 700.2 million
[1].
Other data indicate that people with diabetes have a greater risk of experiencing various complications than other individuals. People with diabetes are 2–3 times more likely to develop cardiovascular diseases and up to 10 times more likely to develop end-stage renal disease and part or complete amputation of a lower limb; further, an amputation is performed somewhere in the world every 30 s. In 2019, the total health care expenditures on diabetes for people aged 20–79 years were an estimated US$760 billion, such expenditure may reach US$825 billion in 2030 and US$845 in 2045
[1][2].
Hospital- and community-based interventions to avoid diabetes-related complications have been based on evidence-based practice and guidelines for diabetes care. A guideline typically provides a set of recommendations along with eligibility criteria that restrict their applicability to a specific group of patients for disseminating such knowledge and standardizing care to ensure the highest quality of care
[3]. Furthermore, interventions based on hospital guidelines involve the promotion of self-efficacy, health education, self-management, and health coaching
[4][5]. Guidelines and evidence-based practice are crucial for defining the quality of care. Nevertheless, in certain situations, deviating from such guidelines and practice is desirable and helps address the needs and peculiarities of patients with diabetes. Specifically, with the availability of health data related to patients with diabetes, precise identification based on treatment demands and targets can be executed, posing challenges on diabetes care to clinical guideline recommendations. However, studies related to preference regarding integrated individualized health care in diabetes are limited.
Research efforts in this direction are termed “precision medicine”. The vision of precision medicine is that this medication is predictive, preventive, personalized, and participatory
[6][7]. Moreover, doctors and researchers adopt treatment and prevention strategies more accurately through precision medicine and consider differences between individuals rather than the one-size-fits-all approach
[8]. As an individual’s experience of both health and disease is unique at the molecular, cellular, and organ levels, treating the causes rather than the symptoms of diseases is achievable
[9]. The precision medicine approach is becoming a trend in clinical settings, especially after former US President Obama’s launch of the Precision Medicine Initiative in early 2015. The primary aim of precision medicine is to improve clinical outcomes for individual patients through precise treatment targeting by leveraging genetic, biomarker, phenotypic, or psychosocial characteristics that distinguish a given patient from others with similar clinical presentations
[3].
In addition, the terminologies defined above can be applied to other approaches in the form of precision health care (PHC). PHC involves patient care preferences, patient-oriented care, evidence-based care, and self-management
[10][11][12]. PHC is a care delivery model that relies heavily on data, analytics, and personal information
[11][13].
2. Discovery of the Elements and Their Concept Description
We discovered the PHC elements for diabetes through the literature study and discussed the concept description of eight elements. We identified the concepts by extracting the data in each article, comparable definitions used in precision medicine and health then integrated the results. Therefore, we reached a final consensus after discussion with the research team. The concept description and strategy of each element can be seen in and are explained below.
Table 21. Elements, Concept Descriptions, and Clinical Strategies on PHC for Diabetes.
No |
Elements |
Concept Description |
Clinical Strategies |
1. |
Personalized genetic or lifestyle |
- Genetic or lifestyle analysis; genomic test screening for diabetes autoantibodies that remain after a drug or insulin dose, gene encoding glucokinase, presence of HNF1A and HNF4A that are associated with forms of diabetes onset; C-peptide is a biomarker that can be used as a guide to treatment choice (insulin deficiency); single-nucleotide polymorphisms provide information regarding drug toxicity |
- Assessment of risk of complication by using risk prediction charts, genotype, or electronic health records |
2. |
Biodata-or evidence-based |
- Genetic examination to detect various potential health problems, cardiovascular disease, a person’s metabolic ability to a nutrient, and HbA1c target |
- Electronic health records and ADA guidelines |
3. |
Glycemic target |
- Based on ADA guidelines, target and therapy differ based on the features and responses of each individual (including HbA1c, blood pressure, and cholesterol) |
- Shared decision-making assessment tool |
4. |
Patient preferences |
- Identification of whether the patient needs additional medication and their concern regarding hyper/hypoglycemia, further expressing their decision |
- Shared decision-making assessment tool |
5. |
Glycemic control |
- Supporting the use of a potent drug to achieve a reduction in HbA1c to <6.5%. |
- HbA1c based on ADA guidelines |
6. |
Interdisciplinary collaboration practice |
- Teamwork entails discussion of the most appropriate treatment for patients |
- Shared decision-making among patients, nurses, physicians, etc. |
7. |
Self-management |
- Individualizing therapy so that patients can effectively self-manage their disease through increasing self-efficacy |
- Diabetes SM education, self-efficacy enhancing intervention program |
8. |
Patient priority direct care |
- Assess the individual as a whole including the complex interplay of comorbid conditions, psychosocial, functional status, and individual need |
- Shared decision-making assessment tool |