Jonne G. ter Braake

Background: Integrated care initiatives for socioeconomically vulnerable cardiometabolic risk groups can deliver pro-active care, improve health outcomes, and foster greater equity within the healthcare system. However, implementation of these initiatives into standard care is often not achieved. Therefore, insights into implementation determinants are needed to identify opportunities for implementation support. Building on previous results, one of the focus points of this research are stakeholder perspectives on how to pay for group consultations. Approach: We conducted a case study on cross-domain group consultations for citizens with cardiometabolic risk factors. To identify implementation determinants, we used a qualitative design guided by the Consolidated Framework for Implementation Research (CFIR) and the Rainbow Model of Integrated Care. Semi-structured interviews and a focus group were conducted with professionals, policy makers, and people with lived experience. We used Framework analysis to identify implementation determinants and matched implementation strategies to a selection of barriers using CFIR’s Expert Recommendations of Implementation Research matching tool. Because fragmentation of funding has previously been identified as a main cause of discontinuation of cross-domain initiatives, we conducted a follow-up study aiming to identify viable strategies to mitigate this barrier. We therefore employed Q-methodology to systematically identify different perspectives on how to pay for group consultations, to identify widely supported solutions. During October and November 2025, data is being collected, including at least 25 participants. The primary care provider who initiated the group consultations, together with other participating professionals, contributed to data collection, interpretation, and the dissemination of findings to a broader group of stakeholders and the lay audience. Results: We conducted 28 interviews and one focus group (n=16) to identify implementation determinants. Key facilitators were 1) the widespread enthusiasm for the concept of group consultations, 2) a sense of urgency for change, and 3) the adaptability of the initiative to the local context. Key barriers included 1) insufficient involvement of citizens in the design of the group consultations, which can be overcome by involving experts by experience. 2) A lack of embedding in the current healthcare and social support systems, which can be mitigated by obtaining formal commitments. 3) Inadequate evaluation, which could be improved by capturing and sharing local knowledge and developing and organising a quality monitoring system, and 4) fragmentation of funding. Preliminary findings of perspectives on how to pay for group consultations indicate consensus among stakeholders on the importance of trust between providers and payers, structural financing, and cofinancing from the medical and social domains. Implications: Community involvement in designing an integrated care initiative is a key determinant of implementation when targeting socioeconomically vulnerable groups. Despite broad support for embedding integrated care into standard practice, its implementation is hindered by organisational and system-level barriers related to fragmentation of healthcare and social support. [Based on preliminary findings] The development of a payment structure built on trust and securing sustainable funding from both the medical and social domain seem to stimulate implementation of cross-sector initiatives.

Introduction: The incorporation of integrated care initiatives for socioeconomically vulnerable groups into standard care is rare. Insight into implementation barriers and facilitators to select strategies for further implementation and upscaling are therefore needed. Description: This study evaluated the implementation of an integrated care initiative adopting interprofessional collaborative practice of patient-centred care for citizens with prediabetes in the form of group consultations. Results: Key barriers included insufficient involvement of citizens in the design of the group consultations, which could be overcome by involving patients/consumers and family members in the design of the group consultations. Additionally, we identified a lack of embedding in the current healthcare and social support systems and fragmented financing systems as barriers. By developing a formal implementation blueprint, obtaining formal commitments, using other payment schemes, and developing resource sharing agreements, these barriers could be addressed. Finally, inadequate evaluation was identified as a barrier. This could be improved by capturing and sharing local knowledge and developing and organising a quality monitoring system. Key facilitators were the widespread enthusiasm for the concept of group consultations, a sense of urgency for change, and the adaptability of the initiative to the local context. Conclusion: Meaningful citizen involvement in the design of an integrated care initiative, such as group consultations, is a key determinant of implementation when targeting socioeconomically vulnerable groups. Although there is broad support for interprofessional collaborative practice, the organisational and governance structures required for their sustainable implementation remain underdeveloped.

There have been mixed findings on whether mortality is socially patterned among people with diabetes. We compared all-cause mortality trends by socioeconomic position (SEP) among people with and without diabetes for 2004–21 in four high-income countries. We conducted open cohort studies in Australia, Denmark, the Netherlands, and Scotland and included national or regional populations aged 35–69 years. We used the European standard population in 2013 to calculate age-standardized mortality rates (ASMRs) by calendar year, SEP quintile, diabetes status, and sex. SEP quintiles were defined using standardized disposable household income in Denmark and the Netherlands, and area-based indices in Australia and Scotland. We calculated the age-standardized slope index of inequality and age-adjusted relative index of inequality using Poisson regression as absolute and relative measures of socioeconomic inequality, respectively across the study populations stratified by calendar year, diabetes status, and sex. About 208 011 deaths occurred during 17 million person years (py) of follow-up among 35- to 69-year olds with diabetes, and 1.1 million deaths during 298 million py of follow-up among people without diabetes. ASMRs generally increased with increasing deprivation and varied between 1.3 (95% CI: 1.2–1.4) deaths per 1000 py to 29.4 (95% CI: 26.0–32.8) deaths per 1000 py. We found absolute and relative mortality inequality that increased during the follow-up period among adults without diabetes. Measures of absolute and relative inequality among adults with diabetes widened in some populations by country and sex. To conclude, disparities in mortality by SEP increased during follow-up in most countries. Strategies are needed to reduce excess mortality associated with low SEP and diabetes and related socioeconomic inequality.

Background: There have been mixed findings on whether mortality is socially patterned among people with diabetes. We compared all-cause mortality trends by socioeconomic position (SEP) among people with and without diabetes for 2004-2021 in four high-income countries. Methods: We conducted open cohort studies in Australia, Denmark, the Netherlands, and Scotland and included national or regional populations aged 35-69 years. We used the European standard population in 2013 to calculate age-standardised mortality rates (ASMRs) by calendar year, SEP quintile, diabetes status, and sex. SEP quintiles were defined using standardised disposable household income in Denmark and the Netherlands, and area-based indices in Australia and Scotland. We calculated the age-standardised slope index of inequality (SII) and age-adjusted relative index of inequality (RII) using Poisson regression as absolute and relative measures of socioeconomic inequality respectively across the study populations stratified by calendar year, diabetes status, and sex. Results: 208,011 deaths occurred during 17 million person years (py) of follow-up among 35-69 year olds with diabetes, and 1.1 million deaths during 298 million py of follow-up among people without diabetes. ASMRs generally increased with increasing deprivation and varied between 1.3 (95% CI: 1.2-1.4) deaths per 1000 py to 29.4 (95% CI: 26.0-32.8) deaths per 1000 py. We found absolute and relative mortality inequality among those with and without diabetes, both generally increased during the follow-up period. Conclusion: Disparities in mortality by SEP increased during follow-up in most countries. Strategies are needed to reduce excess mortality associated with low SEP and diabetes and related socioeconomic inequality.

Aims/hypothesis: The aim of this study was to compare cardiovascular risk management among people with type 2 diabetes according to severe mental illness (SMI) status. Methods: We used linked electronic data to perform a retrospective cohort study of adults diagnosed with type 2 diabetes in Scotland between 2004 and 2020, ascertaining their history of SMI from hospital admission records. We compared total cholesterol, systolic BP and HbA_1c target level achievement 1 year after diabetes diagnosis, and receipt of a statin prescription at diagnosis and 1 year thereafter, by SMI status using logistic regression, adjusting for sociodemographic factors and clinical history. Results: We included 291,644 individuals with type 2 diabetes, of whom 1.0% had schizophrenia, 0.5% had bipolar disorder and 3.3% had major depression. People with SMI were less likely to achieve cholesterol targets, although this difference did not reach statistical significance for all disorders. However, people with SMI were more likely to achieve systolic BP targets compared to those without SMI, with effect estimates being largest for schizophrenia (men: adjusted OR 1.72; 95% CI 1.49, 1.98; women: OR 1.64; 95% CI 1.38, 1.96). HbA_1c target achievement differed by SMI disorder and sex. Among people without previous CVD, statin prescribing was similar or better in those with vs those without SMI at diabetes diagnosis and 1 year later. In people with prior CVD, SMI was associated with lower odds of statin prescribing at diabetes diagnosis (schizophrenia: OR 0.54; 95% CI 0.43, 0.68, bipolar disorder: OR 0.75; 95% CI 0.56, 1.01, major depression: OR 0.92; 95% CI 0.83, 1.01), with this difference generally persisting 1 year later. Conclusions/interpretation: We found disparities in cholesterol target achievement and statin prescribing by SMI status. This reinforces the importance of clinical review of statin prescribing for secondary prevention of CVD, particularly among people with SMI. Graphical