Adoption and implementation of strategies for diabetes management in primary care practices

Background: Secondary and tertiary prevention of chronic illness is a major challenge for the United States healthcare system. Controlled studies show that interventions can enhance secondary prevention in primary care practices, but they shed little light on implementation of secondary prevention outside the experimental context. This study examines the adoption and implementation of an important set of secondary and tertiary prevention efforts-diabetes management strategies-for type 2 diabetes in the everyday clinical practice of primary care. It explores whether adoption and implementation processes differ by type of strategy or prevalence of diabetes among patients in the practice. Methods: Holistic case studies (those used to assess a single analytic unit, in this case, the physician group practice, as opposed to multiple embedded subunits) were conducted in 2001-2002 on six primary care practices in North Carolina identified from a statewide physician survey on strategies for diabetes management. Practices were selected by prevalence of diabetes and type of strategy for diabetes management-patient oriented (focused on self-management) versus biomedical (focused on secondary prevention practices). Results were derived from thematic analysis of interviews and secondary documents. Results: Adoption and implementation did not differ by diabetes prevalence or type of diabetes strategy. All practices had a routine forum for vetting new strategies, and most used traditional channels for identifying them. Implementation often required adaptation of the strategy and the organization. Sustained use of a diabetes strategy depended on favorable organizational policies and procedures (e.g., training,job redesign) and ongoing commitment of resources. Conclusions: Diabetes management strategies are often complex and require adoption and implementation processes different from those described by classic innovation diffusion models. Alternative conceptual models that consider organizational process, structure, and culture are needed.