Abstract
The high prevalence and incidence of diabetes mellitus and its complications have led to a serious growth in the demand for diabetes-related health care in the Netherlands. Since self-management by the patient is a cornerstone of the treatment plan, self-management education has become an important part of diabetes care. One
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aspect of self-management education is self-monitoring of blood glucose (SMBG). SMBG is a technique that enables patients to monitor and react to changes in their blood glucose levels, allowing them to integrate their diabetes into the life style they prefer. Furthermore, it allows physicians to gather data for clinical decision-making.
However, SMBG is a relatively complex process that requires specialised equipment, counselling and follow-up. National and international pharmacy practice guidelines advocate that one of the community pharmacists' roles in diabetes care is to support patients with SMBG. Since most patients regularly visit their pharmacy, pharmacies are ideally placed to support patients managing their own diabetes. Still, to what extent these guidelines are actually implemented in daily routine is unknown.
The aim of this thesis is to assess the level and the variation in the services that Dutch community pharmacies provide to patients performing blood glucose self-monitoring. Furthermore, it describes the key determinants of these self-monitoring services.
The studies reveal a significant variation in the services provided by community pharmacies. This variation is the result of many factors: differences in patient characteristics between community pharmacies, pharmacy-related determinants (for example the pharmacy team's competence and the pharmacist's perceptions of SMBG) and supra-pharmacy determinants (regional differences in for example collaboration, competition and remuneration). Although these determinants have received much attention in medical care and quality assessment, few comparable studies have been performed in pharmacy practice research, especially on diabetes care.
Based on the results of this thesis, changes in the implementation strategy of community pharmacy services are recommended. Tailor-made implementation plans and coaching of community pharmacists may be needed, since the presence of key determinants on many different levels requires an intervention must attuned to fit the local situation.
As long as community pharmacies are not reimbursed for self-monitoring services, most pharmacists will continue to prefer providing services in which they experience less competition, as for example medication surveillance and patient counselling on inhalers. At present, this makes the supra-pharmacy determinants of SMBG the most relevant barrier that limit the adoption of self-monitoring services.
Finally, this thesis signals the need for more research into the process of community pharmacy services and its 'building blocks'. A careful consideration of the definition of the care process is required in pharmacy practice research. Furthermore, knowledge of the association between the structure of care and the process of care is essential in developing quality indicators and quality improvement.
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