We found several important differences between the two healthcare systems that appear to influence the provision of SMS. In KP, responsibility for patient care was shared among several providers overseeing populations of patients. In contrast, DHS HCPs working in general practice viewed themselves as individual practitioners bearing sole responsibility for the care of individual patients and with limited resources to provide SMS. Furthermore, differing perceptions of boundaries between clinics and patients’ homes seemed to influence SMS. DHS HCPs typically did not contact patients at home. The contractual agreement between the GPs and the Health Insurance Fund has traditionally not reimbursed DHS GPs for initiating contacts with patients. Even though they currently receive payment for contacting patients for preventive reasons, we believe this historical narrative limits the ability of clinics to provide SMS outreach.
Additionally, an evidence-based approach at KP (e.g. motivational counseling and ongoing follow up) enhanced provider satisfaction with and belief in the value of providing SMS. Other elements influencing SMS provision at KP included: (1) HCPs specially trained to educate and support patients’ self-management and ongoing competence development; (2): strong leadership supporting the HCPs in providing SMS; (3) quality goals and aligned financial incentives; and (4) an integrated organization. In contrast, the fragmented organization of the DHS, with incompatible financial incentives, many stakeholders, and weak leadership, seemed to present a challenge to evidence-based chronic care management and SMS provision. In line with this, a study focusing on the use of lipid-lowering drugs as primary prevention in the DHS concluded that there is room for improvement for treatment guidelines to be met [16
In both systems, HIT played an important role in supporting HCPs in providing SMS. However, the HIT system is fully implemented throughout KP, whereas only a few providers in the DHS had implemented similar systems.
Distrust between providers may have limited the level of SMS provided in the DHS. The KP organizational structure and HIT system appeared to strengthen provider collaboration and, ultimately, SMS. Additionally, our results suggest that the typical DHS view of SMS as a burden – versus the KP investment view – was a barrier to implementation. This is consistent with prior studies in the DHS demonstrating that SMS is often viewed as an add-on at the end of visits and rarely integrated into the medical care provided to the patients [17
]. As an approach to chronic conditions management, SMS has existed for many years in KP, whereas the approach is rather new in the DHS. The understanding of SMS and approach to providing it was much more institutionalized in KP than was the case in the DHS, which is reflected in our results.
Our results are consistent with change management theories focusing on essential steps for a successful implementation process [19–21
]. These theories emphasize the importance of strong and engaged leadership; aligned goals/visions; support for the desired change, including changing other structures, procedures, and policies in order to remove barriers; belief in having the ability to change (self-efficacy); and symbolic activities.
Study strengths include the comparative approach that made it possible to study differences between systems and to identify elements that might have remained obscure if we had studied only one system. We focused on the macro- and meso-levels of the organizations, as the micro-level has been studied elsewhere [22–24
Limitations include the fact that HCPs with a special engagement and/or interest in providing diabetes care were selected for interviews. As a consequence, we described the social organization of SMS in settings where there was high interest in its provision. There may be elements in play in other settings that we have not identified. Interviewing patients in the two systems could also have illuminated other elements of importance for the provision of SMS.
The researcher conducting the interviews was also involved in a larger research project comparing KP and the DHS that included collecting quantitative data. The quantitative data were analyzed before the qualitative data. Thus, the analysis reported here was conducted with the awareness that the results from the quantitative data suggested that KP provides self-management to a greater extent than the DHS. However, as the aim of the study was to investigate elements important to the implementation of SMS – and not just whether SMS was provided or not – we do not believe this knowledge significantly influenced our interpretation of the empirical material.
The interview guide was based on an English-language interview guide and then translated to Danish and adopted to the Danish context. Thus, some of the questions may have been more appropriate for the American informants. On the other hand, some questions may have been formulated more clearly in the Danish setting as the interviewer is Danish. In both systems, informants were encouraged to ask for clarification if they did not understand the questions.
Our data included only qualitative interviews. Including participant observation methods of the consultations would have allowed us to identify important elements in the interactions between healthcare provider and patients.
As our results were consistent with findings from other studies conducted in Australia and in other healthcare settings in the US [25–27
], we believe that the elements identified as being essential for the provision of SMS can be applied to other Western healthcare systems.
Our study emphasizes the importance of understanding how elements in the social context of care provision are perceived when implementing SMS. Different provider perceptions of SMS, the capability and responsibility of healthcare systems, and themselves and their roles in the entire healthcare organization influenced the provision of SMS.
SMS represents an important but under-supported area of care for persons with diabetes. Disease management programs are currently being implemented in the DHS. However, a number of initiatives should be undertaken to strengthen the provision of SMS. These include supporting collaboration and integration between providers, ongoing training of HCPs, and improved infrastructures for GPs. Specific examples include implementation of an integrated HIT system, aligned financial incentives, and a national education program for nurses working in general practice. Additional research is needed to assess effective approaches for delivering SMS and the link between SMS and health outcomes.