Disease management program in patients with type 2 diabetes
Despite the fact that Denmark has a universal and predominantly tax-financed healthcare system providing free access to treatment and care, persistent socioeconomic (SEP) inequalities exist in the development of type 2 diabetes complications . The Danish welfare state was founded in the period 1950–73 in parallel to the other Nordic welfare states. It is tax-financed and provides universal social security formulated as social rights including free and equal access to health services based on needs . In Denmark, there has been a tendency to assume that equality in health could be secured through the universal access to generous health services combined with support for behavioral changes at the individual level such as smoking cessation courses . However, during the past two decades, researchers, practitioners, and politicians have become increasingly aware, that a part of the explanation for the persisting social inequality in health lies in the fact that equality in formal access to services does not necessarily imply equality in the opportunity to benefit from universal access . Research shows that inequalities in outcomes of type 2 diabetes are influenced by differences in healthcare provider–patient interaction across socioeconomic groups; including lower engagement in preventive health and diabetes care , poorer self-care resources , and reduced social support  among individuals with lower compared to higher SEP. The patients’ ability to negotiate , level of mental resources, and complexity of health status  influence the coherence in long-term courses of treatment and care and hence cause inequality in terms of which patients are offered, receive, and complete treatment . Resourcing and delivering universal services at a scale and intensity proportionate to the degree of need seems to require proactive support and provision of health care that matches the needs and resources of individuals. Marmot refers to this paradigm of universalism as proportionate universalism . According to the guidelines for disease-management programs general practitioners (GPs) and municipalities are expected to make efforts to include vulnerable individuals in type 2 diabetes-management programs . Results from a randomized intervention study suggest that providing proportionate care may contribute to reducing the SEP inequality in delivery of diabetes care; as an intensified diabetes disease-management program in a GP-setting demonstrated an equal reduction in the overall risk of any diabetes-related endpoint across groups with different SEP . To the best of our knowledge, no study has previously assessed equity in provision of a universal and free-of-charge type 2 diabetes-management program provided by interdisciplinary primary care clinics. In Denmark, municipalities are the primary actors for providing ongoing chronic disease-management services close to the daily life of patients  and are expected to be in an appropriate position to provide personalized disease management and to overcome different needs and abilities across SEP groups . The aim of this study was to investigate how the Copenhagen type 2 diabetes disease-management program is structured, provided, and received. In particular, the impact of country of origin and SEP as determinants of the number of bookings and participation in consultation , education , conversation , and physical training sessions were studied. By examining booking and participation across socioeconomic groups, healthcare planners can better guide the allocation of resources and address the unique challenges faced by disadvantaged groups. 

In the Danish guidelines for disease-management program for type 2 diabetes, the division of responsibilities for coordination between GPs, municipalities, specialized care, and hospitals are described . It is specified that GPs are gatekeepers for the patient and must offer referrals to all patients with newly diagnosed type 2 diabetes to specific municipal care activities. Since 2016, the Copenhagen Municipality Centre for Diabetes (CfD) has offered type 2 diabetes-specific disease management. After an electronic referral from a hospital or GP has been issued, the Centre invites the patient to take part in an introductory conversation. At the introductory conversation, the patient will, in collaboration with a primary health professional, develop a personal disease-management plan based on the patient’s needs, motivation, and preferences for activities. The CfD has developed a set of treatment guidelines, with written specification of target groups, aims, methods, form, and healthcare personnel for the introduction conversation as well as each of the activities offered . In 2019, patient-reported outcomes were added as a method, for structuring of the disease-management program and focusing on the most important endpoints for the patients. The guidelines also include descriptions of how to assist vulnerable patients in attending the program. Several tailored sessions are offered to individuals or groups with special needs or preferences, e.g. gender separated activities, evening sessions, and the healthcare staff may (with prior consent by the patient) contact patients if they do not show up at scheduled activities. Moreover, if a patient lacks social or mental competencies or has limited time, activities that would normally be carried out as group sessions, are offered as individual education/conversation. In the introductory conversation, and during program consultations, a personal plan or revision of the plan is developed as a mix of five activities in content, duration, and frequency . During the period from January 2016 to April 2021, 3326 persons with type 2 diabetes were referred to the CfD [Online (OSM) 1] and 2979 (90%) participated in the introductory conversation. Data By use of a unique personal identification number given at birth or immigration, data on disease-management activities from the CfD were linked to national register data on sex, age, measures of SEP, and country of origin. In Denmark, researchers are allowed to use register data for conducting statistical analyses of population-level outcomes, if they comply with a list of predefined ethical standards, including that the persons are anonymized for the researchers. Hence, no specific ethical approval was needed for the study. Disease-management activity, bookings, and participation Information related to each disease-management activity was: “content of activity,” “scheduled date of activity,” and “status of participation.” The variable status of participation had the following five categories “participated,” “canceled by the patient/did not show up,” “canceled by the municipality,” “missing information on participation,” and “patient was hospitalized or died.” The number of booked sessions by activity was calculated as the number of registrations in the electronic database within each activity and the number of participated sessions were calculated as the number of “participated” sessions. Socioeconomic position, country of origin, and covariates Data on education, income, and employment status were obtained from administrative registers in the year preceding enrollment in the disease-management program. Individuals’ highest recorded educational attainment was categorized according to ISCED11  into short education (primary and lower secondary education; <2 years of vocational training), medium education (upper secondary and post-secondary education; 2–4 years of vocational training) and long education (tertiary education; >4 years of education, academic degree completion). Equalized disposable income was calculated as total household income after taxation and interest, divided by the weighted sum of the number of household adult equivalents . The first adult was assigned a weight of 1.0, each subsequent resident aged >14 years was assigned a weight of 0.5 and each child under 14 years was assigned a weight of 0.3. Income was grouped into four categories: low <3.500, middle-low 3.500–4.999, mid-high 5.000–6.999, and high ≥7.000 euro per month. Employment was categorized as employed, currently not employed, and pensioned. Data on sex, age, and country of origin (categorized into Danish/Western, or other origin) and civic status (categorized into partner or single) were obtained from the Danish Central Population Register . Statistical analyses All participants who participated in the introductory conversation ( n = 2979) were included in a series of Poisson regression analyses. We assessed the association between determinants (education, income, employment, civic status, country of origin) and absolute number of booked activities (program consultation, diet education, patient education, telephone conversation, or training). On the same study population, we conducted comparable analyses, with absolute number of participated activities as outcome, as a replacement for booked activities. An assessment of interaction between sex and each of the four SEP variables showed significant differences in the number of bookings of physical training. Hence, we conducted all analyses on physical training separately for men and women. Last, in a sensitivity analysis, we assess if missing registration on participation status led to selection bias (OSM 2) by comparing results of mean number of participating sessions, with analyses where all missing registrations were excluded from the model. Data and resource availability The data of this study are available from the steering group of the Public Health Database and CfD. However, restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available. 

By use of a unique personal identification number given at birth or immigration, data on disease-management activities from the CfD were linked to national register data on sex, age, measures of SEP, and country of origin. In Denmark, researchers are allowed to use register data for conducting statistical analyses of population-level outcomes, if they comply with a list of predefined ethical standards, including that the persons are anonymized for the researchers. Hence, no specific ethical approval was needed for the study. Disease-management activity, bookings, and participation Information related to each disease-management activity was: “content of activity,” “scheduled date of activity,” and “status of participation.” The variable status of participation had the following five categories “participated,” “canceled by the patient/did not show up,” “canceled by the municipality,” “missing information on participation,” and “patient was hospitalized or died.” The number of booked sessions by activity was calculated as the number of registrations in the electronic database within each activity and the number of participated sessions were calculated as the number of “participated” sessions. Socioeconomic position, country of origin, and covariates Data on education, income, and employment status were obtained from administrative registers in the year preceding enrollment in the disease-management program. Individuals’ highest recorded educational attainment was categorized according to ISCED11  into short education (primary and lower secondary education; <2 years of vocational training), medium education (upper secondary and post-secondary education; 2–4 years of vocational training) and long education (tertiary education; >4 years of education, academic degree completion). Equalized disposable income was calculated as total household income after taxation and interest, divided by the weighted sum of the number of household adult equivalents . The first adult was assigned a weight of 1.0, each subsequent resident aged >14 years was assigned a weight of 0.5 and each child under 14 years was assigned a weight of 0.3. Income was grouped into four categories: low <3.500, middle-low 3.500–4.999, mid-high 5.000–6.999, and high ≥7.000 euro per month. Employment was categorized as employed, currently not employed, and pensioned. Data on sex, age, and country of origin (categorized into Danish/Western, or other origin) and civic status (categorized into partner or single) were obtained from the Danish Central Population Register . 

Information related to each disease-management activity was: “content of activity,” “scheduled date of activity,” and “status of participation.” The variable status of participation had the following five categories “participated,” “canceled by the patient/did not show up,” “canceled by the municipality,” “missing information on participation,” and “patient was hospitalized or died.” The number of booked sessions by activity was calculated as the number of registrations in the electronic database within each activity and the number of participated sessions were calculated as the number of “participated” sessions. 

Data on education, income, and employment status were obtained from administrative registers in the year preceding enrollment in the disease-management program. Individuals’ highest recorded educational attainment was categorized according to ISCED11  into short education (primary and lower secondary education; <2 years of vocational training), medium education (upper secondary and post-secondary education; 2–4 years of vocational training) and long education (tertiary education; >4 years of education, academic degree completion). Equalized disposable income was calculated as total household income after taxation and interest, divided by the weighted sum of the number of household adult equivalents . The first adult was assigned a weight of 1.0, each subsequent resident aged >14 years was assigned a weight of 0.5 and each child under 14 years was assigned a weight of 0.3. Income was grouped into four categories: low <3.500, middle-low 3.500–4.999, mid-high 5.000–6.999, and high ≥7.000 euro per month. Employment was categorized as employed, currently not employed, and pensioned. Data on sex, age, and country of origin (categorized into Danish/Western, or other origin) and civic status (categorized into partner or single) were obtained from the Danish Central Population Register . 

All participants who participated in the introductory conversation ( n = 2979) were included in a series of Poisson regression analyses. We assessed the association between determinants (education, income, employment, civic status, country of origin) and absolute number of booked activities (program consultation, diet education, patient education, telephone conversation, or training). On the same study population, we conducted comparable analyses, with absolute number of participated activities as outcome, as a replacement for booked activities. An assessment of interaction between sex and each of the four SEP variables showed significant differences in the number of bookings of physical training. Hence, we conducted all analyses on physical training separately for men and women. Last, in a sensitivity analysis, we assess if missing registration on participation status led to selection bias (OSM 2) by comparing results of mean number of participating sessions, with analyses where all missing registrations were excluded from the model. 

The data of this study are available from the steering group of the Public Health Database and CfD. However, restrictions apply to the availability of these data, which were used under license for the current study and are not publicly available. 

In total, 62,901 disease-management sessions were booked among the 2979 persons participating in the introductory conversation. Among these, 91% had booked at least one program conversation, 46% had booked dietary conversation, 58% had booked dietary education, 55% had booked telephone conversation(s) and 47% had booked physical training session(s) (OSM 1). There were large variations in the total number of booked (mean = 21) and participated (mean = 10) sessions . Overall, ethnic and SEP differences in booked consultations, dietary education, patient education, and telephone conversations, were relatively small in absolute terms (<2 session difference), with an overall trend of higher number of bookings among lower SEP and persons of Danish/Western origin ; e.g. unemployed bookings of dietary education. Comparable differences in participation were likewise small, with an overall trend of equal number of bookings across SEP groups and slightly more sessions among persons of Danish/Western origin [e.g. 0.4 (22%) extra dietary education sessions among Danish/Western compared to other countries of origin]. Differences were larger for physical training among women , where women with lower compared to higher SEP and of non-Danish/Western origin had more booked and participated sessions. For example, women not currently employed had booked 5.0 (24%) additional sessions and participated in 1.5 (18%) additional sessions compared to those employed. And women of non-Danish/Western origin had booked 6.3 (32%) more sessions and participated in 2.6 (38%) more sessions than Danish/Western women. 

Our results showed large variations in the total number of sessions and allocated activities between individuals, but relatively small differences between ethnic and SEP groupings. These results support the conclusions that the Copenhagen CfD healthcare workers made significant efforts in offering patient-centered treatment as outlined in the treatment guidelines. With the explicit aim to deliver proportionate care given as a higher number of sessions provided to vulnerable patients, the healthcare workers did, e.g. book more program consultations for individuals outside the workforce and booked more telephone conversations for singles. SEP inequality was induced from booking-to-participation in disease-management sessions ; in situations where the booked number of sessions was higher among lower SEP, these were largely converted to an equal level of participated sessions across groups with different SEP. One notable exception to the aforementioned conclusions relates to women of non-Western origin and women with lower SEP, who were offered substantially more training sessions than women of Danish/Western origin and higher SEP. This also resulted in a higher number of participated physical training sessions. The staff at CfD suggest that this may be explained by the blend of structures and incentives woven into the physical training program, including, e.g. group-based and gender-segregated sessions. Also, scheduled social gatherings as an explicit component of the physical training sessions may have established a foundation for interpersonal connections and support from peers and have likely contributed to the motivation for adherence to the program. Study strengths and limitations This study is to our knowledge the first of its kind to analyze systematically collected data on interdisciplinary type 2 diabetes activities. Other Danish municipalities and healthcare centers of foreign countries may differ regarding the quantity and content of program activities offered and may also differ in the education of the healthcare employees as well as differences in the accessibility of the centers. The CfD are privileged in the sense that they are in a position to develop activities for subgroups with specific needs, which are not feasible in areas with smaller patient populations. This may have increased participation rates. These are all factors that may limit the generalizability of our findings. Bearing this in mind, challenges in provision of proportionate care in Copenhagen may indicate wider problems in achieving equitable chronic care that also apply to other settings. We could not assess potential cross-municipal differences in the content and the volume of type 2 diabetes disease-management program as there exist no comprehensive database of the Danish disease-management activities. In the future, a universal national database could facilitate such analyses and would help develop more specific guidelines for best practice, implying a level of excellence or quality for municipal inspiration and benchmarking. While our study provides valuable insights into determinants of provision of public diabetes-specific disease management, several limitations should be considered. The labeling of the activities was changing largely over the years and a relatively large proportion (9%) of the data on whether the patient had participated or not was missing. A sensitivity analysis (see OSM 2) indicated that the missing registration on participation status likely underestimated the absolute mean number of participated sessions but did not change the conclusions of this study. Future analyses could help clarify to what extent the CfD delivers proportionate care. This could, e.g. be assessed by comparing associations of needed (judged by the healthcare provider), booked and participated sessions of each enrolled individual. Type 2 diabetes-specific disease-management services in Copenhagen, comprised of a comprehensive and diverse program, tailored to individuals’ needs and preferences. This, together with offering activities adapted to vulnerable patients and patients with special needs is likely to explain the relatively small differences in participation rates across SEP groups. The healthcare workers at the CfD made large efforts to include vulnerable populations in the diabetes management program by offering diverse and personalized treatment programs and by booking more sessions for vulnerable individuals. Despite efforts to provide proportionate care, approximately equal number of participated activities were achieved across socioeconomic groups. One exemption that stands out, is the results of women with lower SEP and ethnic minorities, where a higher number of booked physical training sessions, promoted these women to participate in more sessions. We encourage future studies to assess health outcomes of diabetes management programs. This can provide deeper insights into the effectiveness of selected activities in different socioeconomic strata of the population and may guide further development of disease management programs. The structure and content of the physical training program may serve as an inspiration for policy makers and health professionals in how to design equitable type 2 diabetes-specific disease-management activities. 

This study is to our knowledge the first of its kind to analyze systematically collected data on interdisciplinary type 2 diabetes activities. Other Danish municipalities and healthcare centers of foreign countries may differ regarding the quantity and content of program activities offered and may also differ in the education of the healthcare employees as well as differences in the accessibility of the centers. The CfD are privileged in the sense that they are in a position to develop activities for subgroups with specific needs, which are not feasible in areas with smaller patient populations. This may have increased participation rates. These are all factors that may limit the generalizability of our findings. Bearing this in mind, challenges in provision of proportionate care in Copenhagen may indicate wider problems in achieving equitable chronic care that also apply to other settings. We could not assess potential cross-municipal differences in the content and the volume of type 2 diabetes disease-management program as there exist no comprehensive database of the Danish disease-management activities. In the future, a universal national database could facilitate such analyses and would help develop more specific guidelines for best practice, implying a level of excellence or quality for municipal inspiration and benchmarking. While our study provides valuable insights into determinants of provision of public diabetes-specific disease management, several limitations should be considered. The labeling of the activities was changing largely over the years and a relatively large proportion (9%) of the data on whether the patient had participated or not was missing. A sensitivity analysis (see OSM 2) indicated that the missing registration on participation status likely underestimated the absolute mean number of participated sessions but did not change the conclusions of this study. Future analyses could help clarify to what extent the CfD delivers proportionate care. This could, e.g. be assessed by comparing associations of needed (judged by the healthcare provider), booked and participated sessions of each enrolled individual. Type 2 diabetes-specific disease-management services in Copenhagen, comprised of a comprehensive and diverse program, tailored to individuals’ needs and preferences. This, together with offering activities adapted to vulnerable patients and patients with special needs is likely to explain the relatively small differences in participation rates across SEP groups. The healthcare workers at the CfD made large efforts to include vulnerable populations in the diabetes management program by offering diverse and personalized treatment programs and by booking more sessions for vulnerable individuals. Despite efforts to provide proportionate care, approximately equal number of participated activities were achieved across socioeconomic groups. One exemption that stands out, is the results of women with lower SEP and ethnic minorities, where a higher number of booked physical training sessions, promoted these women to participate in more sessions. We encourage future studies to assess health outcomes of diabetes management programs. This can provide deeper insights into the effectiveness of selected activities in different socioeconomic strata of the population and may guide further development of disease management programs. The structure and content of the physical training program may serve as an inspiration for policy makers and health professionals in how to design equitable type 2 diabetes-specific disease-management activities. 

ckae155_Supplementary_Data 

