Precision health care strategies for older adults with diabetes in Indonesia: a Delphi consensus study

Satriya Pranata,1,2 Shu-Fang Vivienne Wu,1 Chun-Hua Chu,3 Khristophorus Heri Nugroho4

Background

Studies on precision health care for older adults with diabetes in Indonesia are still limited. This study was aimed to reach the experts consensus on the suitable precision health care strategies for older adults with diabetes.

 

Methods

A total of 10 experts (4 physicians, 4 nurses, and 2 dietitians) agreed to participate in the 3-round interview using Delphi technique. The experts should have at least 5 years of experience in teaching or working as health professionals in a hospital.

 

Results

Consensus was reached that precision health care consisted of eight elements: self-management, interdisciplinary collaborative practice, personalized genetic or lifestyle factors, glycemic target, patient preferences, glycemic control, patient priority-directed care, and biodata- or evidence-based practice. The strategies of precision health care for diabetes were divided into seven steps: conducting brief deducting teaching; assessing self-management level and risk of cardiovascular disease; organizing a brainstorming session among patients to exchange experiences on glycemic target and specific target behavior; making a list of patients’ needs and ranking the priorities; setting a goal and writing action; doing follow-up; and reporting the goal attempts.

 

Conclusions

The eight elements of precision health care provided the basis of precision health care strategies for diabetic older adults, which are the real and measurable strategies for precision health care implementation in clinical settings.

 

Keywords

Delphi technique, diabetes, personal health service, precision health care, precision medicine

Older adults are at high risk of developing diabetes mellitus, especially in Indonesia. According to the surveillance data, the prevalence of diabetes in Indonesian for patients aged 55–64 years represents 6.29% and 6.03% of the population aged 65–74 years.1 Moreover, diabetes in older adults has been linked to higher mortality and further complications such as heart and kidney diseases.2,3 The total health care expenditure for people with diabetes and diabetes-related complications was US$760 billion, projected to reach US$825 billion by 2030 and US$845 billion by 2045.4

Health education and self-management can prevent diabetes-related complications in older adults with diabetes.5,6 Studies showed that health education might reduce the risk of complications if managed individually (social–cognitive determinants, intention, preference, and behavior).7 Patient-centered education leads to better patient satisfaction.8

Precision health care focuses on patient care and preferences, patient-centered care, evidence-based care, and self-management.9–12 It is a health care delivery model that relies on data, analytics, and personal information;10,13 and it provides integrated care through interprofessional collaborative practice based on personalized information on patients’ genetic and lifestyles to improve self-management.9,14,15 Although the concept of precision health care has been developed, studies on its implementation strategy for diabetic older adults in clinical settings are limited, especially in Indonesia. Thus, this study was aimed to reach the experts consensus regarding precision health care strategies for older adults with diabetes using Delphi method.

 

 

Delphi method was used to survey and collect the opinion of the experts16,17 on precision health care for older adults. This study was approved by Health Research Ethics Committee STIKES Bina Usada Bali (No: 232/EA/KEPK-BUB-2020). This study was conducted from November 28 to December 17, 2020 in referral hospitals in Surabaya, Jogjakarta, and Semarang.

 

Expert criteria

The potential experts were screened based on their expertise in diabetes management. Ten experts (4 physicians, 4 nurses, and 2 dietitians) were selected based on their competence, experience, and reputation in referral hospitals in Surabaya, Jogjakarta, and Semarang as well as reputable universities in Java, Indonesia. Selected academicians had an extensive publication on diabetes management, while practitioners had at least 5 years of work experience as health professionals in a referral hospital.

 

Data collection and analysis

An invitation e-mail was sent to the potential experts, which included an explanation of the study and participation time estimation. Participation was voluntary and confidential. The experts were asked to participate in the three-round interview using Delphi technique, which took approximately 1 hour to complete each round. Of 13 invited experts, only 10 agreed to complete the process.

The experts were blinded or did not know each other. The first round of the Delphi questionnaire consisted of open-ended questions covering the problem and procedure or strategies of the precision health care program. The objectives were conducting a brainstorming session and generating the experts’ opinions on the program. Experts were asked to describe their thinking related to precision health care in Indonesia using a semi-structured interview.

The responses of the experts (three physicians, three nurses, and a dietitian) in the first round formed the basis of the precision health care program for the second round. Furthermore, three additional experts (a nurse, physician, and dietitian) were chosen for the second round. The consensus reached in the first and second rounds was integrated into the elements and strategies of precision health care. In the third round, all experts (four physicians, four nurses, and two dietitians) were asked whether they strongly disagree or strongly agree with the results as well as providing additional comments on the specified concept areas.16,17 Data collection, analysis, and key action of each Delphi round are presented in Figure 1.

 

 

 

 

In total, 10 invited experts agreed to participate in this study. Eight important elements were found in the implementation of precision health care, which were obtained using an in-depth analysis.

 

Delphi round 1

Seven experts completed the first round, which discovered the elements of precision health care. The elements included self-management, interdisciplinary collaborative practice, personalized genetic or lifestyle factors, patient priority-directed care, glycemic target, patient preferences, glycemic control, and biodata- or evidence-based practice. Detail explanation of each element can be seen in Table 1.

 

 

 

Delphi round 2

Round 2 was conducted based on the results of the first round. Additional suggestions including patient priority-directed care, glycemic targets, and glycemic control were obtained from the experts to complete the results as shown in Table 1.

 

Delphi round 3

The strategies of precision health care implementation in clinical settings were made by integrating all information in the systematic stage after suggestions were collected. The suggestions included individual needs such as personalized genetic or lifestyle factors, biodata- or evidence-based practice, glycemic targets, patient preferences, glycemic control, interdisciplinary collaborative practice, self-management, and priority-directed care. After all the elements were integrated into precision health care strategies, the experts were asked whether they agree or disagree with the strategies. All experts agreed on the seven steps in the strategies of precision health care implementation in diabetic patients. This approach could become a model to obtain health information, improve diabetes self-management, and reduce diabetes-related complications among patients. The strategies of precision health care based on the development of each element are shown in Table 2.

 

 

 

 

A consensus was reached on the elements of precision health care, which became the basis of the 7-step strategy for precision health care implementation. Those seven strategies were: brief deducting teaching; assessing self-management level and risk of cardiovascular disease among patients; organizing a brainstorming session among patients to exchange experiences on glycemic target and specific target behavior; making a list of patients’ needs then ranking the priorities; setting a goal and writing action; doing follow-up; and reporting the goal attempts.

Brief deducting teaching is implemented based on self-management and interprofessional collaborative practice and conducted through health seminars involving various health professionals and older adults with diabetes. Health education is expected to improve self-management awareness.18,19 Self-management provides an accurate treatment for older adults with diabetes,20,21 which is one of the critical components of precision health care for diabetes. Moreover, self-management supports precise problem solving and minimizes unnecessary interventions.19,22 Verifying and clarifying this understanding are paramount for health literacy.5 Brief deducting teaching requires every health professional including medical specialists, nurses, nurse specialists, and nutritionists to implement interdisciplinary communication and cooperation models,23 thus improving the patients’ understanding of self-management plans (e.g., test, medication, procedure, and behavioral change).24–26

Furthermore, other precision health care strategies such as making a list of patients’ needs, ranking the priorities, setting goals, and writing goal-oriented actions provide exclusive health care with an accurate diagnosis, thereby improving treatment and care effectiveness.19,27,28 A patient-centered care model can improve the current model of precision health care, which covers broader medical assessments including patient glycemic target, glycemic control, biodata- or evidence-based practice, patient preferences, and patient priority-directed care.29–33 Personalized glycemic goals are based on the agreement between health professionals and patients, while the individualization target is based on the hypoglycemic episode risk among patients.27,34 Precision health care strategies are patient-centered care with personalized glycemic goals and care plans established through group care.34–38 The goals are intended to reduce intervention risks, develop interdisciplinary integration, improve patients’ outcomes and quality of life, and avoid unnecessary medical interventions.

In addition, a brainstorming session among older adults with diabetes enables knowledge exchange to solve health problems.18,39 Problem solving is an essential skill for patients to make the right, systematic, and logical decisions and various viewpoints consideration.40,41 Furthermore, brainstorming helps patients to discuss and be informed of their individual needs, especially in achieving glycemic targets and specific target behavior.36,40,41

All experts agreed that these precision health care strategies could be a new approach to improve self-management and reduce complication risks among diabetic patients. However, limitations of this study included the experts’ opinions that were limited to the condition of patients in referral hospitals with better health literacy. These precision health care strategies should be tested in a small sample population to obtain its implementation results before being tested on a large sample population through the randomized control trial method. Further studies to evaluate the impact of precision health care strategies in improving self-management and reducing the risk of diabetes complications among older adults are needed.

In conclusion, precision health care strategies are important to prevent diabetes-related complications in older adults with diabetes. Precision health care strategy is a model of health care delivery that relies heavily on personalized information genetic, preference, evidence-based, interprofessional collaborative practice, and patients' lifestyles. A personalized approach encourages patients to take personal responsibility and minimizes conflicting recommendations between clinicians and patients because the decisions come from the patients' perspectives and their specific health outcome goals. The recommended precision health care strategies are useful for the health care providers, managers, and policymakers to provide comprehensive health care services for future diabetes management.

 

 

 

 

 

 

 

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