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Quality of type 2 diabetes management in general practice is associated with involvement of general practice nurses
Abstract
To assess whether involvement of general practice nurses in type 2 diabetes care in Danish general practice is associated with improved adherence to national guidelines on regular type 2 diabetes monitoring, and with lower HbA1c and cholesterol levels in the type 2 diabetes population.
The study was an observational study soliciting questionnaire data from 193 Danish general practices and register data on 12,960 patients with type 2 diabetes (age range 40-80 years) from a diabetes database and a laboratory database. Clustering was addressed in the analyses.
Practices with well-implemented nurse-led type 2 diabetes consultations and practices with no nurse(s) employed differed according to the mean proportions of patients whose HbA1c was measured (6.4%-points: 95% CI: 1.5 to 11.4), and the mean proportions of patients whose HbA1c was ≥ 8% (-3.7%-points: 95% CI: -6.7 to -0.6). Small non-significant differences were found in the cholesterol analyses.
Compared with practices with no nurse(s) employed, the quality of diabetes management was generally higher in terms of that HbA1c was measured according to the guidelines in a larger proportion of the diabetes population and the proportion of patients with an HbA1c level ≥ 8% was lower in practices with well-implemented nurse-led type 2 diabetes consultations.
... Among the 56 studies assessed as observational study designs, 19 were cross-sectional, of which seven had high risk of bias [52][53][54][55][56][57][58], four had a moderate risk of bias [59][60][61][62] and eight had low risk of bias [63][64][65][66][67][68][69][70]. 15 were cohort studies; one study had a high risk of bias [71], five had a medium risk of bias [72][73][74][75][76][77], and eight had low risk of bias [78][79][80][81][82][83][84][85]. ...
... The burden of diabetes in Kuwait is high, and it has a serious impact on morbidity and mortality." [112] Brief "Like in many other countries, chronic care tasks are increasingly being delegated from general practitioners (GPs) to nurses in Danish general practices" [67] "in the United States alone the total financial cost attributable to diabetes was estimated at $132 billion" [31] Health reported that the intervention group achieved reductions in HbA1c with fewer physician visits compared to patients receiving usual care [33]. A cohort study in the United States reported a lower mean HbA1c among those in an out- patient programme involving face-to-face pharmacist consults (p = 0.024), and significantly reduced from baseline [76]. ...
... A Cameroo- nian pre-post study [99] found a significant reduction in mean fasting blood glucose (FBG) in non-insulin-dependent patients' following a nurse care empowerment scheme. A Danish cross-sectional study [67] found that the proportion of patients with HbA1c !8% significantly decreased in general practices with well-implemented nurse-led diabetes consultations, com- pared to practices without. ...
Background
Type 2 Diabetes Mellitus (T2DM) is reported to affect one in 11 adults worldwide, with over 80% of T2DM patients residing in low-to-middle-income countries. Health systems play an integral role in responding to this increasing global prevalence, and are key to ensuring effective diabetes management. We conducted a systematic review to examine the health system-level factors influencing T2DM awareness, treatment, adherence, and control.
Methods and findings
A protocol for this study was published on the PROSPERO international prospective register of systematic reviews (PROSPERO 2016: CRD42016048185). Studies included in this review reported the effects of health systems factors, interventions, policies, or programmes on T2DM control, awareness, treatment, and adherence. The following databases were searched on 22 February 2017: Medline, Embase, Global health, LILACS, Africa-Wide, IMSEAR, IMEMR, and WPRIM. There were no restrictions on date, language, or study designs. Two reviewers independently screened studies for eligibility, extracted the data, and screened for risk of bias. Thereafter, we performed a narrative synthesis. A meta-analysis was not conducted due to methodological heterogeneity across different aspects of included studies. 93 studies were included for qualitative synthesis; 7 were conducted in LMICs. Through this review, we found two key health system barriers to effective T2DM care and management: financial constraints faced by the patient and limited access to health services and medication. We also found three health system factors that facilitate effective T2DM care and management: the use of innovative care models, increased pharmacist involvement in care delivery, and education programmes led by healthcare professionals.
Conclusions
This review points to the importance of reducing, or possibly eliminating, out-of-pocket costs for diabetes medication and self-monitoring supplies. It also points to the potential of adopting more innovative and integrated models of care, and the value of task-sharing of care with pharmacists. More studies which identify the effect of health system arrangements on various outcomes, particularly awareness, are needed.
... The high burden of diabetes disease in the two countries indicates a need for intensifying treatment, care and preventive measures to address the challenge. It has been suggested that empowering nurses who attend to diabetes patients can greatly contribute to the general management of diabetes and to improve patient' outcomes [11]. ...
... Increasingly, healthcare systems are adopting nurseled models that appear to be patient centred compared with the traditional physician-led approach that reflects a medically -oriented model of care. It has been reported that when nurses are effectively trained and well guided, they can adequately undertake some roles in the management of specific diseases [11]. Currently, trends in healthcare suggest a task shift where nurses increasingly engage in roles previously performed by physicians [14]. ...
Background: The management of diabetes requires new models of care, of which nurses have been identified as key players. It
is observed that adequate preparation and proper guidance of nurses with knowledge and skills in diabetes care is important
for their care role. It is also essential that nurses use evidence to inform their care role towards diabetes patients, which can be
achieved through using up-to-date guidelines on diabetes care and treatment. However, it is not clear how guidelines inform
the nursing diabetes care role and to what extent nurses use the guidelines in diabetes care. This article reports findings from
a review of guidelines on the role of nurses in diabetes care, and how nurses adopt these guidelines in patient care.
Methods: The study adopted a case study approach, in which two cases (the United Kingdom and Kuwait) were involved.
We reviewed local, national and international guidelines that inform the role of nurses in diabetes care. Following analysis of
the findings from the guidelines, we compared the prescribed roles of nurses in diabetes care as informed by the guidelines
against those performed in practice.
Findings: In total, eight guidelines were reviewed, four from each case. The findings revealed a number of roles that guide
diabetes nursing care including: patient assessment, patient education, providing patient-centred care, promoting self-care,
prescription role, team work, and adapting diabetes care to local needs. The findings showed that nurses utilise the guidelines
to guide their work of nursing diabetes patients and while doing this, they take into consideration the individual needs of their
patients.
Conclusions: The study concluded that guidelines on diabetes care are essential in the provision of patient focused care,
hence the need for their adoption in all healthcare settings. It is important that the guidelines provide specific roles for the
different practitioners, and be flexible to adequately address the needs of the patients. Further research is essential to assess
the application of international, national, and local guidelines and how their application influence diabetes care delivery.
... Medicare beneficiaries (≥ 65 years), 37,[39][40][41][42] or patients with type 2 diabetes. 37,[43][44][45][46][47][48][49][50][51][52][53][54] Most studies involved a mix of private/public centres 41,49,50,[55][56][57][58][59][60] and academic/non-academic 43,58 and teaching/non-teaching practices. 44,54,[61][62][63][64][65][66][67] Included studies examined individual (n = 41), composite (n = 24) or both (n = 11) quality measures. ...
... Other practice factors identified (≥ 5 studies) were practice deprivation, 38,54,64,67,68,70,71,86,103,117,118 diabetes prevalence 38,47,64,67,68,71,86,87,103,117 or volume, 45,51,69,73,84,116,119 number of patients in a practice 38,47,50,64,68,71,76,86,95,103,120,121 , number of GPs, 37,54,56,61,64,69,70,80,95,102,103 or nurses, 64,66,68,71,95,102,103 nurse or physician assistant involvement, 39,43,45,47,52,59,65,73,[121][122][123] and use of a register/recall system. 43,46,64,66,72,78,103 The relationship of these factors with quality was inconsistent. ...
Background
Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources.
Methods
We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis.
Results
In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05–1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11–1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care.
Discussion
Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.
... One such initiative is to empower those nurses who are involved in diabetes care so that they can take over some of the tasks currently carried out by physicians. Improved outcomes among patients with diabetes have been empirically linked to the empowerment of nurses in diabetes care [2]. ...
... Although evidence regarding the significant role a nurse plays in patient care has been presented in this literature review, there is little literature about: a) Exploring the role in detail and b) How the different elements of that role contribute to the quality of nursing care [2,45]. Nurses might wish to provide care befitting a patient's perceptions about the quality of nursing care that is consistent with the nursing philosophy of the patient-centred model [46,47]. ...
The role of nurses in diabetes care in Kuwait has changed remarkably as a result of the increase of the care burden caused by the incidence of long-term diabetic patients. Nurses working in diabetes care play significant roles that are comparable to other health care providers working in diabetes clinics and centres in Kuwait. While nurses’ roles in diabetes have been clearly established in other parts of the world, nurses’ role in Kuwait are neither fully recognised nor professionally acknowledged. The nurses caring for such patients do not have a special identifying title, or a clear job description that specifies their critical role in diabetes care. This review investigated the
Kuwait nurses’ roles in diabetes care and how the performance of their duties affects the perceived quality of the nursing care provided to their diabetic patients.The significance of this review is that it provides an insight into the possibility of developing a new system of diabetes patient care that could result in patients accessing good quality care. By investigating patients' and nurses' perspectives, this study seeks to provide an in-depth understanding of the influence of the quality of nursing care in managing diabetic patients in Kuwait.
... Three randomized controlled trials (Odnoletkova et al., 2016a;Shea et al., 2006;Taylor et al., 2003) and one historical control trial (Harris and Cracknell, 2005) found statistically significant improvements in HbA1c in favour of the nurse-led interventions. Two cluster randomized trials (Blackberry et al., 2013;Jansink et al., 2013), two randomized pragmatic trials (Houweling et al., 2011;Juul et al., 2012) and three randomized controlled trials (Denver et al., 2003;Edelman et al., 2015;Hiss et al., 2007) found no significant differences between groups. The nurse-led telecoaching intervention (Odnoletkova et al., 2016a) recruited 287 patients with type-2 diabetes to that intervention and 287 to usual care. ...
... The three open-label studies which were all nurse-led selfmanagement interventions found statistically significant improvements in HbA1c levels (Biernacki et al., 2015;Chan et al., 2006;Moran et al., 2011;Vrijhoef et al., 2002). The audit identified that following implementation of a nurse-led model more HbA1c levels were measured according to national guidelines and more patients had lower HbA1c levels (Juul et al., 2012). ...
Objectives:
To determine the clinical effectiveness (glycemic control, other biological measures, cost-effectiveness and patient satisfaction) of primary care nurse-led interventions for diabetes.
Design:
A systematic review following methods described for complex interventions and using PRISMA guidelines for reporting was undertaken. Nurse-led care for diabetes can be regarded as a complex intervention requiring the measurement of more than one outcome and for this reason we chose a range of outcomes clinical (symptoms), patient-centred (experiences) and organisational (cost-effectiveness).
Data sources:
An extensive literature search using MEDLINE (PubMed) EMBASE, and CINAHL was conducted.
Review methods:
Primary studies with adults in primary care with both quantitative (comparison with physician-led care and cost-effectiveness) and qualitative (patient experiences of nurse-led care) methodologies from 2003 until June 2018. All studies were appraised using the Cochrane Collaboration's tool for assessing risk of bias. The appraisal involved evaluation of the degree of risk of bias in selection, performance, detection, attrition and reporting. Because of the complexity of multiple outcomes (quantitative and qualitative) a narrative synthesis was undertaken.
Results:
The search generated 18 published studies that met our eligibility criteria. Three randomized controlled trials and one historical control trial found statistically significant differences in glycemic levels in favour of the nurse-led interventions. Two cluster randomized trials, two randomized pragmatic trials and two randomized controlled trials found no differences between groups. The three open-label studies found statistically significant improvements in HbA1c levels. The audit identified that more patients had lower HbA1c levels after the initiation of a nurse-led intervention. Three randomized controlled trials found significant improvements in biological outcomes and one did not. The four studies measuring cost-effectiveness found the nurse-led intervention was associated with less costs. Four studies examined patient satisfaction with nurse-led care and found this was very good.
Conclusion:
This review which incorporated a broad range of studies to capture the complexity of nurse-led interventions has identified that there is evolving evidence that nurse-led interventions for community treatment of diabetes may be more clinically effective than usual physician-led care.
... In Danish healthcare, as in many other countries, type 2 diabetes care is provided by general practice in the framework of one annual 30 minute -and three quarterly 15 minutes consultations. In 2009, a growing share of the diabetes care was delegated from general practitioners to nurses employed in the practices (GP nurses) [5]. We therefore established a training course aiming to improve the contents in the nurse-led diabetes consultations within the framework of current type 2 diabetes care and for the benefits of the patients with type 2 diabetes. ...
... Our recruitment strategy of the general practices was a realistic scenario for future training courses. A previous study showed that the eligible practices for the present trial were associated with a higher quality of diabetes management when compared with practices with no nurse(s) employed and also when compared with practices that did not respond to that survey [5]. This indicates less room for improvement and a higher level of engagement in diabetes management in the included practices. ...
Type 2 diabetes is a common metabolic disease with the potential for prevention of complications. The prevention requires a high level of lasting actions from the patients, which may be burdensome. The aim of this trial was to evaluate the effectiveness of a training course for general practice nurses in motivation support at 18 months follow-up in the affiliated type 2 diabetes population.
Forty general practices with nurse-led diabetes consultations from the area of Aarhus, Denmark were randomised 1∶1 to either intervention or usual practice. Intervention practices were offered a 16-hour Self-determination theory - based course including communication training for general practice nurses delivered over 10 months. The affiliated diabetes populations (aged 40-74 years) were identified from registers (intervention n = 2,005; usual n = 2,029). Primary outcomes were register-based glycated haemoglobin (HbA1c) -, total cholesterol levels, and well-being measured by the Problem Areas In Diabetes scale (PAID) and the mental component summary score, SF12 (SF12, mcs). Intention-to-treat analyses were performed. Predefined subgroups analyses were performed.
The differences between the intervention- and the control practices' mean HbA1c and total cholesterol at follow-up adjusted for baseline values and clustering were respectively: -0.02%-points (95% CI: -0.11 to 0.07; p: 0.67); 0.08 mmol/l (95% CI: 0.01 to 0.15; p: 0.02). Differences in median scores adjusted for clustering were for PAID: 1.25; p = 0.31 and SF12, mcs: 0.99; p = 0.15. Women in intervention practices differed from women in usual practices on mean HbA1c: -0.12%-points (-0.23 to -0.02; p = 0.02) and SF12, mcs: 2.6; p = 0.01.
Offering a training course for general practice nurses in applying the Self-determination theory in current type 2 diabetes care had no effect compared with usual practice measured by HbA1c and total cholesterol levels and the well-being at 18 months of follow-up in a comprehensive register-based diabetes population. Subgroup analyses suggested a possible effect in women, which deserves further attention.
ClinicalTrials.gov (Identifier NCT01187069).
... The 34 selected articles involved 34 separate studies, with a total of 369 930 participants, undertaken across 15 countries from five continents. Five of the 34 studies focused on rural and remote populations and/or localities (Jessee & Rutledge, 2012;Lew et al., 2017;McDermott et al., 2015;McIlhenny et al., 2011;Price et al., 2011), and nine studies involved non-randomized controlled designs (Jessee & Rutledge, 2012;Juul et al., 2012;Lew et al., 2017;Melaku-Abbera & Smith, 2017;Mills, 2014;Murrells et al., 2015;Parker et al., 2016;Price et al., 2011). Of the 34 studies, two included diabetes of both Types 1 and 2 (Mills, 2014;Murrells et al., 2015), with the other 32 studies exclusively considering Type 2 diabetes. ...
Background
Type 1 and 2 diabetes care, especially within primary health‐care settings, has traditionally involved doctor‐led clinics. However, with increasing chronic disease burden, there is scope for nurses to expand their role in assisting diabetes self‐management.
Aims
This study aimed to determine the effectiveness of nurse‐led care in reducing glycated haemoglobin in adults with Type 1 or 2 diabetes.
Methods
Methodology from the Joanna Briggs Institute Method for Systematic Review Research and the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines were followed, including identifying publications, assessing study quality, summarizing evidence and interpreting findings. The search strategy involved using the Medical Subject Headings and keyword variations when searching MEDLINE (Ovid), Scopus, PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Inclusion criteria were samples with Type 1 or 2 diabetes, mean age of ≥18 years, English language studies and publication date of January 2011–December 2021.
Results
Overall, 34 articles from 16 countries met inclusion criteria. Though not always clinically significant, results indicated that nurse‐led care had beneficial impacts on glycated haemoglobin values, with reductions from 0.03% to 2.0%. This was evident when nurses received formal training, used treatment algorithms, had limited medical support, utilized technology and offered defined culturally sensitive and appropriate diabetes care.
Conclusions
Findings support nurse‐led Type 1 and 2 diabetes care. Although further research is required, changes may necessitate increased recognition of nurse‐led care and funding. Nurse‐led care models should differ according to health‐care settings.
... Evidence from developed and developing countries alike illustrates that nurses play a central role in managing diabetes [25][26][27][28][29][30][31][32][33]. The registered general nurse (RGN) education in Zimbabwe is primarily a 3year diploma administered through the Ministry of Health and Child Care health facilities. ...
Introduction
Due to the increasing incidence of diabetes in Zimbabwe, complications such as diabetic foot (DF) are anticipated. Establishing local gaps and needs in DF healthcare is paramount for tailoring management strategies.
Aims
To determine the status of DF services in the healthcare system and explore awareness of DF management and practices among registered general nurses (RGNs) in Zimbabwe.
Methods
A mixed-methods approach was applied. Thirty-one RGNs from 16 public health facilities in Harare, Zimbabwe attending a DF workshop were administered with a cross-sectional survey instrument and a semi-structured questionnaire. Data collected included presence/absence of DF services and podiatrists in healthcare facilities, healthcare system approaches in DF care and availability of DF training/education programs for RGNs. Analysis was performed using Stata and Nvivo software.
Results
No respondents reported availability of podiatrists. Only 1 (3%) of RGNs reported DF screening in primary care. Sixty percent (18) did not know or had never screened for DF. The RGNs reported inadequate DF educational programs/modules in primary care settings.
Conclusion
This data highlights a need to improve DF education for RGNs at the frontline of managing PLWD. Understanding the needs for DF services may guide interventions to improve education and awareness programs that are appropriately tailored to local constraints in the health system. The non-communicable diseases director is encouraged to develop DF educational programmes for frontline health care workers.
... Increasingly, healthcare systems are adopting nurse-led models that are believed to be patient centred, as opposed to the more traditional physician-led model that focuses on medical treatment and cure. Empowering nurses with more independent roles in diabetes care has been suggested as a possible initiative to improve the outcomes of patients with diabetes [5]. When comparing a nurse-led model with traditional care, Li and colleagues [6] demonstrated that the nurses led model was more effective in improving glycemic control and reducing diabetes distress. ...
Purpose: Nurses are key players in the care of diabetes patients. It is not clear how nurses experience the diabetes care role within a multidisciplinary care context. This article reports the perspectives of nurses working in one Na�tional Health Service trust in the United Kingdom, about their role in di�abetes care. Methods: The study employed a descriptive qualitative approach. Participants were nurses who worked in two diabetes clinics in one National Health Service trust in the United Kingdom. The study included 10 female participants, who provided nursing care to patients with diabetes. Data were collected between May and September 2017. Results: Three themes were generated in relation to the role of nurse in diabetes care: 1) Nurses’ per�formed role: the role performed by nurses in diabetes care was regarded as complex and one that required appropriate preparation and support; 2) Im�plications of the nurses’ performance: nurses engaged in multiple activities that aimed at providing holistic and patient centred care, and 3) Challenges facing nurses in diabetes care: nurses reported facing significant challenges that interfered with their care role and which could negatively affect patient outcomes. Conclusions: Nurses play a critical role in the care of diabetes
patients and require significant support to undertake their role.
... Studies from the UK, Germany and Denmark suggest that involving nurses in diabetes care is associated with improved quality of diabetes management and significant GP time saving with no adverse effects [37,38]. However, these studies do not provide insights into the ways in which nurses seek to increase care quality when working together with GPs. ...
Objective: To explore the experiences of general practitioners (GPs), nurses and medical secretaries in providing multi-professional diabetes care and their perceptions of professional roles.
Design, setting and subjects: Semi-structured interviews were conducted with six GPs, three nurses and two medical secretaries from five purposively sampled diabetes teams. Interviews were analysed thematically.
Main outcome measures: Healthcare professionals’ (HCPs’) experiences of multi-professional diabetes care in general practice.
Results: The involvement of nurses and medical secretaries (collaborating health care professionals) was mainly motivated by GPs’ time pressure and their perception of diabetes care as easy to standardize. GPs reported that diabetes care had become more structured and continuous after the involvement of collaborating health care professionals (cHCPs). cHCPs defined their role differently from GPs, emphasizing that their approach included acknowledging patients’ need for diabetes education, listening to their stories and meeting their need for emotional support. GPs appeared less involved in patients’ emotional concerns and more focused on the biomedical aspects of illness. There was little emphasis on teamwork among GPs and cHCPs, and none of the practices used care plans to involve patients in decisions or unify treatment among professionals. Participants stated that institutional structures including a discriminatory remuneration system, lack of role descriptions and missing procedures for collaborative approaches were an obstacle to MPC.
Conclusions: cHCPs worked independently under delegated leadership of the GPs. Although cHCPs had a complementary role, HCPs in general practice may not take full advantage of the potential of sharing patient responsibility and learning with, from and about each other. Contextual barriers for team-based care approaches should be addressed in future research.
• KEY POINTS
• It has been suggested that multi-professional approaches improve quality of care in people with long-term conditions.
• In this study, nurses and medical secretaries perceived to have a complementary role to general practitioners (GPs) in diabetes care, focusing on patient education, building trusting relationships and providing patients with emotional support.
• As multi-professional collaboration was minimal, GPs, nurses and medical secretaries in the included practices may not take full advantage of the potential of sharing care responsibility and learning with, from and about each other.
... For instance, spirometry testing has previously been associated with the presence of a practice nurse and delegation of clinical tasks to the staff [10]. In line with this, one study showed that delegating the treatment of patients with severe hypertension to nurses improved patients' blood pressure [11], and another study showed an increase of the quality of type 2 diabetes management in general practice [12]. A potential explanation for these findings is that nurses follow guidelines more precisely than physicians and that it influences the quality of care positively. ...
Background:
The healthcare systems in the western world have in recent years faced major challenges caused by demographic changes and altered patterns of diseases as well as political decisions influencing the organisation of healthcare provisions. General practitioners are encouraged to delegate more clinical tasks to their staff in order to respond to the changing circumstances. Nevertheless, the degree of task delegation varies substantially between general practices, and how these different degrees affect the quality of care for the patients is currently not known. Using chronic obstructive pulmonary disease (COPD) as our case scenario, the aim of the study was to investigate associations between degrees of task delegation in general practice and spirometry testing as a measure of quality of care.
Methods:
We carried out a cross-sectional study comprising all general practices in Denmark and patients suffering from chronic obstructive pulmonary disease. General practitioners (GPs) were invited to participate in a survey investigating degrees of task delegation in their clinics. Data were linked to national registers on spirometry testing among patients with COPD. We investigated associations using multilevel mixed-effects logit models and adjusted for practice and patient characteristics.
Results:
GPs from 895 practices with staff managing COPD-related tasks responded, and 61,223 COPD patients were linked to these practices. Hereof, 24,685 (40.3%) had a spirometry performed within a year. Patients had a statistically significant higher odds ratio (OR) of having an annual spirometry performed in practices with medium or maximal degrees of task delegation compared to practices with a minimal degree (OR = 1.27 and OR = 1.33, respectively).
Conclusion:
Delegating more complex tasks to practice staff implies that COPD-patients are more likely to be treated according to evidence-based recommendations on spirometry testing.
... Si bien en Chile se garantiza el acceso a la atención en salud de personas con DM 2, persisten elementos como la alta descompensación (10, 11), que hacen del sistema y de las estrategias sanitarias medidas e intervenciones que no garantizan efectividad. Por esta razón, es fundamental comprender el cuidado de enfermería en este contexto, no solo para describirlo, sino también para intervenir en los factores o elementos clave, pues la evidencia científica muestra el importante rol de enfermería en el control metabólico de la DM 2 (12)(13)(14). En esta vía, la Teoría de la Atención Burocrática de Marilyn Anne Ray permite una comprensión del cuidado en un escenario complejo como lo es un centro de salud familiar, donde surge un orden implícito (el todo) y un orden explícito (la parte), representados en la interconexión del cuidado espiritual y ético con la estructura social de la organización (15). El cuidado está influenciado por la estructura social de la organización, donde intervienen elementos burocráticos como factores educativos, físicos, socioculturales, legales, tecnológicos, económicos y políticos. ...
Objetivo:
describir las características de la práctica de enfermería en el cuidado de personas con diabetes mellitus tipo 2 en la atención primaria de salud, según la Teoría de la Atención Burocrática.
Material y método:
investigación cualitativa que exploró la práctica de enfermería en el cuidado del paciente con diabetes mellitus tipo 2, por medio de la observación no participante; se realizó durante tres semanas en dos centros de salud familiar en la región de Atacama, Chile; se utilizaron notas de campo y se analizó la información por medio de comparación constante, según el referente filosófico seleccionado.
Resultados:
el cuidado de enfermería en personas con diabetes mellitus tipo 2 en los centros de salud familiar se encuentra vinculado a todos los factores señalados en la Teoría de la Atención Burocrática, es decir, factores educativos, físicos, socioculturales, legales, tecnológicos, económicos y políticos.
Conclusiones:
por medio de la Teoría de la Atención Burocrática es posible describir la práctica del cuidado de enfermería en personas con diabetes mellitus tipo 2. Enfermería debe considerar los factores propios a la burocracia de toda organización, especialmente al momento de gestionar el cuidado en este tipo de pacientes.
... This work has identified that POC HbA 1c testing within nurse consultations may operate better than GP consultations. In Denmark, GP practices with nurse-led diabetes care were found to have a lower proportion of patients with HbA 1c > 8% and patient monitoring was more likely to have taken place within guidelines [34]. A meta-analysis of trials of adults with type 2 diabetes mellitus managed in general practice found significant improvements in blood pressure and cholesterol in those who received nurse care compared with GP care [35]. ...
Aims:
Point-of-care (POC) HbA1c testing gives a rapid result, allowing testing and treatment decisions to take place in a single appointment. Trials of POC testing have not been shown to improve HbA1c, possibly because of how testing was implemented. This study aimed to identify key components of POC HbA1c testing and determine strategies to optimise implementation in UK primary care.
Methods:
This cohort feasibility study recruited thirty patients with type 2 diabetes and HbA1c>7.5% (58mmol/mol) into three primary care clinics. Patients' clinical care included two POC HbA1c tests over six months. Data were collected on appointment duration, clinical decisions, technical performance and patient behaviour.
Results:
Fifty-three POC HbA1c consultations took place during the study; clinical decisions were made in 30 consultations. Five POC consultations with a family doctor lasted on average 11min and 48 consultations with nurses took on average 24min. Five POC study visits did not take place in one clinic. POC results were uploaded to hospital records from two clinics. In total, sixty-three POC tests were performed, and there were 11 cartridge failures. No changes in HbA1c or patient behaviour were observed.
Conclusions:
HbA1c measurement with POC devices can be effectively implemented in primary care. This work has identified when these technologies might work best, as well as potential challenges. The findings can be used to inform the design of a pragmatic trial to implement POC HbA1c testing.
... evidence has demonstrated the important role that nursing has in the metabolic control of DM2(12)(13)(14)(15) .The Explicit Guarantees Regime and the list of specific benefits are mainly oriented towards pharmacological aspects and medical care, limiting the participation of nurses to consultation or control by a nurse, midwife or nutritionist, to confirm the diagnosis and/or perform the initial evaluation of the patient with manner, which may require that the list of health benefits be expanded. At the same time, it is necessary to encourage the active participation of professionals such as nurses in solving these problems, knowing that the insufficiency of human resources becomes an obstacle to achieve the universal coverage(25) . ...
Objective:
determine the prevalence of Effective Universal Coverage of Diabetes Mellitus Type 2 in Chile and its relation with the variables: Health Care Coverage of Diabetes Mellitus Type 2; Average of diabetics with metabolic control in 2011-2013; Mortality Rate for Diabetes Mellitus; and Percentage of nurses participating in the Cardiovascular Health Program.
Method:
cross-sectional descriptive study with ecological components that uses documentary sources of the Ministry of Health. It was established that there is correlation between the Universal Effective Coverage of Diabetes Mellitus Type 2 and the independent variables; it was applied the Pearson Coefficient, being significant at the 0.05 level.
Results:
in Chile Universal Health Care Coverage of Diabetes Mellitus Type 2 (HbA1c<7% estimated population) is less than 20%; this is related with Mortality Rate for Diabetes Mellitus and Percentage of nurses participating in the Cardiovascular Health Program, being significant at the 0.01 level.
Conclusion:
effective prevalence of Universal Health Coverage of Diabetes Mellitus Type 2 is low, even though some regions stand out in this research and in the metabolic control of patients who participate in health control program; its relation with percentage of nurses participating in the Cardiovascular Health Program represents a challenge and an opportunity for the health system.
... 15 Finally, an observational study of 193 Danish general practices and 12 960 patients with type 2 diabetes found that the proportion of patients with HbA 1c levels of 64 mmol/mol or more was lower in practices with well implemented, nurse-led type 2 diabetes consultations. 16 Having completed an ACC was the only variable that was significantly associated with glycaemic control after adjustment for patient characteristics. It is interesting that the only published study that examined the association between the completion of an ACC and health outcomes found that the physical functioning of women with diabetes who had completed an ACC was poorer than in women who had only had their HbA 1c levels measured. ...
Objectives:
To determine whether certain characteristics of general practices are associated with good glycaemic control in patients with diabetes and with completing an annual cycle of care (ACC).
Research design and methods:
Our cross-sectional analysis used baseline data from the Australian Diabetes Care Project conducted between 2011 and 2014. Practice characteristics were self-reported. Characteristics of the patients that were assessed included glycaemic control (HbA1c level ≤ 53 mmol/mol), age, sex, duration of diabetes, socio-economic disadvantage (SEIFA) score, the complexity of the patient's condition, and whether the patient had completed an ACC for diabetes in the past 18 months. Clustered logistic regression was used to establish predictors of glycaemic control and a completed ACC.
Results:
Data were available from 147 general practices and 5455 patients with established type 1 or type 2 diabetes in three Australian states. After adjustment for other patient characteristics, only the patient completing an ACC was statistically significant as a predictor of glycaemic control (P = 0.011). In a multivariate model, the practice having a chronic disease-focused practice nurse (P = 0.036) and running educational events for patients with diabetes (P = 0.004) were statistically significant predictors of the patient having complete an ACC.
Conclusions:
Patient characteristics are moderately good predictors of whether the patient is in glycaemic control, whereas practice characteristics appear to predict only the likelihood of patients completing an ACC. The ACC is an established indicator of good diabetes management. This is the first study to report a positive association between having completed an ACC and the patient being in glycaemic control.
... It is therefore acknowledged that an important part of diabetes care is providing diabetes education to patients, with the aim of improving their self-management (or self-care) activities (Gorter et al., 2010;Thoolen, de Ridder, Bensing, Gorter, & Rutten, 2008). To varying degrees across countries, treatment of T2DM occurs mainly in primary care, with general practitioners' (GPs') practice nurses increasingly providing most of that care (den Engelsen et al., 2009;Edwall et al., 2008;Houweling et al., 2011;Juul et al., 2012). Nurse consultations aim to monitor patients' health and to support patients in self-managing their diabetes through diabetes education (Gorter et al., 2010). ...
http://edepot.wur.nl/318483
... The most important limitation of guidelines is that the recommendations may be wrong at an individual level [39]. They should be used taking into account the situation of the patient, in the light of the clinical experience of the physician [40]. However, the criteria considered in this study were the fundamental checkup list that should be applied irrespective of the severity of the disease. ...
... nurses increasingly providing most of that care (den Engelsen, SoedamahMuthu, Oosterheert, Ballieux, & Rutten, 2009; Edwall, Hellström, Öhrn, & Danielson, 2008; Houweling et al., 2011; Juul, Maindal, Frydenberg, Kristensen, & Sandbaek, 2012). Nurse consultations aim to monitor patients' health and to support patients in self-managing their diabetes through diabetes education (Gorter et al., 2010). ...
Many type 2 diabetes mellitus patients have difficulties reaching optimal blood glucose control. With patients treated in primary care by nurses, nurse communication plays a pivotal role in supporting patient health. The twofold aim of the present review is to categorize common barriers to nurse-patient communication and to review potentially effective communication methods. Important communication barriers are lack of skills and self-efficacy, possibly because nurses work in a context where they have to perform biomedical examinations and then perform patient-centered counseling from a biopsychosocial approach. Training in patient-centered counseling does not seem helpful in overcoming this paradox. Rather, patient-centeredness should be regarded as a basic condition for counseling, whereby nurses and patients seek to cooperate and share responsibility based on trust. Nurses may be more successful when incorporating behavior change counseling based on psychological principles of self-regulation, for example, goal setting, incremental performance accomplishments, and action planning.
... The results underline the importance of regular communication with the patient. In many fields of medicine, e.g., in diabetes, depression or epilepsy, specialized nurses are trained to take care of the patients' education to improve care and adherence [81][82][83]. This might represent a feasible and useful approach also for patients taking oral anticoagulants. ...
Oral anticoagulation has proven to reduce mortality and morbidity of thromboembolic events. One of the most important determinants of the effectiveness and safety of anticoagulation therapy is the adherence to the prescribed therapy. Vitamin K antagonists are characterized by under-utilization, a narrow therapeutic window and multiple food and drug interactions which contribute to a variable dose-response relationship with the risk of insufficient protection and/or increased bleeding risk. The "new" direct oral anticoagulants have demonstrated equal or superior protection and reduced bleeding risks compared to warfarin and are easier to use because of fixed dosing without monitoring of anticoagulation. Controlling of adherence to the direct oral anticoagulants is difficult. Therefore, continuous and regular medication intake represents a pre-requisite for achieving optimal protection. The present review aims to give an overview about the factors that affect drug adherence in patients taking oral anticoagulation drugs and discusses strategies to improve drug adherence.
Purpose:
To investigate variability in older people's outcomes according to general practitioner (GP) and practice characteristics in New Zealand and the Netherlands.
Methods:
We used data from 2 primary care-based, cluster-randomized, controlled trials to separately fit mixed models of unplanned admission rates, functional ability, and quality of life (QOL) and examine variation according to GP- and practice-level characteristics after adjusting for participant-level characteristics. For the New Zealand sample (n = 3,755 aged 75+ years in 60 practices), we modeled 36-month unplanned admission rates, Nottingham Extended Activities of Daily Living (NEADL) scale, and QOL domain ratings from the brief version of the World Health Organization Quality of Life assessment tool. For the Netherlands sample (n = 3,141 aged 75+ years in 59 practices), we modeled 12-month unplanned admission rates, Groningen Activity Restriction Scale scores, and EuroQOL 5 dimensions (EQ-5D) summary index.
Results:
None of the GP or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample, but we found greater rates of admission in larger practices (incidence rate ratio [IRR], 1.45; 95% CI, 1.15-1.81) and practices staffed with a practice nurse (IRR, 1.74; 95% CI, 1.20-2.52) in the Netherlands sample. In both samples, differences were consistently small where there were significant associations with function (range, -0.26 to 0.19 NEADL points in the New Zealand sample; no associations in the Netherlands sample) and QOL (range, -1.64 to 0.97 QOL points in New Zealand; -0.01 EQ-5D points in the Netherlands).
Conclusions:
In the absence of substantial differences in older people's function and QOL, it remains unclear whether intriguing GP- or practice-related variations in admission rates represent low- or high-quality practice.
Aim:
Using the methodology of the Joanna Briggs Institute, a systematic review of current research was performed to determine if the addition of management by nurses had been more effective in improving clinical outcomes of patients with type 2 diabetes attending a general practice compared with standard care.
Methods:
A three-step literature search was conducted for suitable English studies with quantitative clinical outcomes that had been published from January 1990 to May 2014. Randomised controlled trials (RCTs) were particularly sought after; however, other research designs were considered. Articles were assessed by two independent reviewers for methodological validity, prior to inclusion in the review, using standardised critical appraisal instruments from the Joanna Briggs Institute. When possible, quantitative data were pooled in statistical meta-analysis.
Results:
Seven studies were of suitable quality and relevance for the review: these included three randomised control trials; two cluster- RCTs; a cluster, nonrandomised, controlled before-after study; and a cluster observational cohort study. These studies yield evidence that nurse management in addition to standard general practitioner care leads to modest improvements in blood pressure and total cholesterol levels in adults with type 2 diabetes attending a general practice.
Conclusion:
Meta-analysis identified modest, significant improvements amongst participants in nurse management interventions (NMIs) in the following clinical outcomes: mean SBP, mean DBP and mean total cholesterol. The majority of outcomes studied did not show any advantage to adding NMIs to general practitioner care. Two studies reported significant improvements of participants with poor control in mean haemoglobin A1c. An RCT that investigates the effect of NMIs on patients, with poor control in regard to clinical outcomes and cost effectiveness, is recommended.
The study aimed to establish whether the organization for the management of type 2 diabetes mellitus at 9 diabetic units (DUs), in 5 neighboring local health authorities (LHAs), was able to (a) comply with the organizational model prescribed by specific regional standards; (b) ensure adequate clinical management of diabetic patients; (c) assess whether the relationship between primary care physicians (PCPs) and diabetologists (SDs) was instrumental to the needs of patients; (d) optimize specialist treatment at the DUs; (e) optimize drug management; and (f) check whether organizational changes led to variations in clinical results.
This 6-stage study analyzed procedures, precoded actions, and recordable processes. Stage (1) Defining clinical and organizational endpoints; (2) Drafting flowcharts to describe the actions and work procedures implemented within each LHA; (3) Comparing the flowcharts with the data obtained from related literature; (4) Establishing a protocol shared with PCPs for the management and treatment of patients with type 2 diabetes; (5) Changing the procedures at the DUs; and (6) Evaluating the results. The data were assessed before and after establishing a shared protocol for SDs and PCPs (year 2009 vs 2011).
The study shows inconsistencies in the organization of work in the 5 LHAs; however, collaboration with PCPs has guaranteed: (a) unchanged hemoglobin A1C values before and after applying the protocol; (b) a percentage increase in the number of patients with type 2 diabetes who were identified thanks to these protocols; (c) an increase in the use of biguanides compared to the preprotocol period; and (d) no change in the number of patients hospitalized because of acute complications from type 2 diabetes mellitus.
This study confirms how adequate collaboration between SDs and PCPs keeps the risk of complications stable. Nevertheless, shared protocols and clearly defined roles are required.
Background:
In Norway, most people with diabetes are treated by general practitioners. At our own general practice, we wanted to find out whether we were succeeding in following the Directorate of Health's 2009 clinical guidelines on treatment and management of diabetes.
Material and method:
All patients with the diagnosis diabetes mellitus in our electronic archive between November 2009 and October 2010 were registered. Those patients on our general practice lists in October 2010 were identified. The patient records were manually reviewed and relevant data recorded.
Results:
In all, 271 patients with diabetes attended our surgery for check-ups in October 2010. 11% had type 1 diabetes and 88% had type 2 diabetes. HbA1c was measured in 99% of the diabetes patients, blood pressure in 98% and lipids in 93%. The measurements were taken at our surgery during the past year for 96% of the patients. The treatment goals for HbA1c, systolic blood pressure and LDL cholesterol were reached in, respectively, 55%, 55% and 49% of the patients. 13% reached all three treatment goals. 82% had a check-up with an ophthalmologist. Weight and smoking habits were documented in 85% and 90% respectively. 19% of the patients for whom we had documented data, smoked. Examinations of height, feet and microalbumin were documented in 57%, 35% and 28% of the patients respectively.
Interpretation:
The guidelines are being followed on most points to a high degree, and the proportion of patients reaching the stricter treatment goals is consistent with the results of earlier Norwegian surveys. There is the potential for further improvement of these results.
Type 2 diabetes is associated with severe micro- and macro-vascular complications. Physicians' and patients' adherence to follow-up guidelines permits postponing or reducing these complications. The objectives were to assess the level of adherence to fundamental follow-up guidelines and determine patients' characteristics associated with this level of adherence in the context of Luxembourg, where no guidelines were implemented.
The exhaustive residing population treated for type 2 diabetes in Luxembourg during the 2000-2006 period (N = 21,068).
Seven fundamental criteria were extracted from international guidelines (consultation with the treating physician, HbA1c tests, electrocardiogram, retinal, dental, lipid and renal check-ups). The factors associated with the level of adherence to those criteria were identified using a partial proportional odds model.
In 2006, despite 90% of the patients consulted at least 4 times their treating physician, only 0.6% completed all criteria; 55.0% had no HbA1c test (-8.6 points since 2000) and 31.1% had a renal check-up (+21.6 points). The sex (ORmale: 0.87 [95%CI, 0.83-0.92]), the nationality (ORNonEU: 0.64 [0.52-0.78]), the type of antidiabetic treatment (ORoral: 1.48 [1.35-1.63], ORmixed: 1.35 [1.20-1.52]) and the type of treating physician (ORG-ID: 0.47 [0.42-0.53]) were the main factors associated with the level of adherence in 2006 (3 or more criteria).
A large percentage of patients were not provided with a systematic annual follow-up between 2000 and 2006. This study highlighted the necessity to promote guidelines in Luxembourg, education for physicians and to launch a national discussion on a disease management program for diabetic patients.
To assess the level of care given to people with diabetes by general practitioners and factors affecting it.
A cross-sectional study of Irish general practitioners, looking at practice characteristics and patient care over the previous 2 years; a nationally representative sample of 27 general practitioners. A total of 1030 people with diabetes were studied, of whom 201 were type 1 and 829 were type 2.
The response rate was 27 out of 52 (52%). HbA1c values were not related to the patient's socioeconomic status. The average HbA1c for type 1 people with diabetes was 7.81%, and for type 2 it was 7.1%. HbA1c values were measured 3.02 times for type 1 and 3.16 times for people with type 2 diabetes. This is a good standard of care, especially for type 2 disease. Computerized practices and those patients whose care was shared with the hospital achieved better control, even though HbA1c levels were checked less frequently with computerization. The use of a protocol in the practices also improved care. Those practices employing a nurse had increased frequency of measurement of HbA1c and better control on univariate but not on multivariate analysis. Possible reasons for this are discussed.
Diabetes Mellitus is treated to a good standard in Irish general practice, especially type 2 disease. This standard appears to be independent of the patient's socio-economic status, is improved by GPs being computerised, in group practices and by providing care according to a protocol. Shared care also improves control. Employing a practice nurse may also improve care.
Type 2 diabetes is an important, chronic condition notorious for its costly and disabling complications. Nowadays, enhanced cooperation is expected to improve the quality of diabetes care and reduce risks for chronically ill patients. It is, however, questionable whether this assumption is evidence based.
Using a structured literature search, we selected systematic reviews, randomised controlled trials (RCTs) and other effect evaluations regarding the sharing and allocation of diabetes care.
We selected 22 studies to include in this review. The process of care improved in all studies investigating this quality aspect. HbA1c improved in seven reviews and in five other studies. All included reviews and four RCTs were unable to demonstrate a positive effect on blood pressure. Total cholesterol improved in two reviews and five other studies.
The sharing and allocation of diabetes care leads to significant reduction in HbA1c and improves the process of care. However, this improvement has not as yet led to better cardiovascular risk management. For a number of reasons, a truly accurate estimation of the results of shared and allocated diabetes care within the Dutch diabetes care system is not possible.
Results of intervention studies in patients with type 2 diabetes have led to concerns about the safety of aiming for normal blood glucose concentrations. We assessed survival as a function of HbA(1c) in people with type 2 diabetes.
Two cohorts of patients aged 50 years and older with type 2 diabetes were generated from the UK General Practice Research Database from November 1986 to November 2008. We identified 27 965 patients whose treatment had been intensified from oral monotherapy to combination therapy with oral blood-glucose lowering agents, and 20 005 who had changed to regimens that included insulin. Those with diabetes secondary to other causes were excluded. All-cause mortality was the primary outcome. Age, sex, smoking status, cholesterol, cardiovascular risk, and general morbidity were identified as important confounding factors, and Cox survival models were adjusted for these factors accordingly.
For combined cohorts, compared with the glycated haemoglobin (HbA(1c)) decile with the lowest hazard (median HbA(1c) 7.5%, IQR 7.5-7.6%), the adjusted hazard ratio (HR) of all-cause mortality in the lowest HbA(1c) decile (6.4%, 6.1-6.6) was 1.52 (95% CI 1.32-1.76), and in the highest HbA(1c) decile (median 10.5%, IQR 10.1-11.2%) was 1.79 (95% CI 1.56-2.06). Results showed a general U-shaped association, with the lowest HR at an HbA(1c) of about 7.5%. HR for all-cause mortality in people given insulin-based regimens (2834 deaths) versus those given combination oral agents (2035) was 1.49 (95% CI 1.39-1.59).
Low and high mean HbA(1c) values were associated with increased all-cause mortality and cardiac events. If confirmed, diabetes guidelines might need revision to include a minimum HbA(1c) value.
Eli Lilly and Company.
Despite many quality improvement trials, diabetes care often remains suboptimal. Few studies in a primary care setting have investigated the 'real life' association between organizational differences and quality of diabetes care.
Observational study among ten health care centres with a total of 45 general practitioners (GP). We investigated health care organization and related this to quality of care in a total of 1849 electronic patient records.
There were large differences among health care centres in the percentage of patients receiving optimal care (range: 8-67%). The odds to receive good quality of care was higher if the health care centre had a diabetes education program (OR: 4.3; CI: 3.4-5.4), when yearly medical check-ups were done by both the GP and nurse practitioner (NP) (OR: 5.5; CI: 4.2-7.3), planned that after the patient visited the NP the patient is discussed with the GP (OR: 1.8; CI: 1.6-2.0), and had structured follow-up measures for compliance to check-ups (OR: 0.7; CI: 0.5-0.9 and OR: 0.59; CI: 0.5-0.7 for respectively one and two active measures compared to three active measures).
Also in real life, quality of care for type 2 diabetic patients is related to health care organization.
The main objective is to examine the effect of the introduction of a practice nurse (PN) on the quality of type 2 diabetes care.
Retrospective cohort study in 397 type 2 diabetes patients recruited from five general practices in the Netherlands. Measurements were performed in 2003, 2005 and 2007, to estimate the effects before (2003) and after the introduction of the PN (2005) as well as the changed diabetes guidelines (2007). Process measures indicated whether measurements of HbA(1c), systolic blood pressure, lipid profile, funduscopy, foot examination and annual check-ups were carried out. Outcome measures comprised actual levels of HbA(1c), systolic blood pressure, lipid levels and BMI.
All process measures - except performance of funduscopy - improved significantly. Mean HbA(1c) decreased from 6.8% to 6.5% (2003-2007: ns, 2005-2007: p<0.01), mean LDL-cholesterol from 3.2 to 2.7 mmol/L (p<0.0001) and mean total cholesterol/HDL-cholesterol ratio from 4.5 to 3.7 (p<0.0001). For systolic blood pressure, the number of patients reaching targets increased considerably in 2007. Analyses for both study populations at different time points as well as for patients present at all time points showed comparable results.
Delegating diabetes care to a PN leads to significant improvements in diabetes care. General practitioners should seriously consider close collaboration with PNs to delegate diabetes care tasks.
Background:
Diabetes is a common chronic disease that is increasingly managed in primary care. Different systems have been proposed to manage diabetes care.
Objectives:
To assess the effects of different interventions, targeted at health professionals or the structure in which they deliver care, on the management of patients with diabetes in primary care, outpatient and community settings.
Search strategy:
We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, the Cochrane Controlled Trials Register (Issue 4 1999), MEDLINE (1966-1999), EMBASE (1980-1999), Cinahl (1982-1999), and reference lists of articles.
Selection criteria:
Randomised trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) analyses of professional, financial and organisational strategies aimed at improving care for people with Type 1 or Type 2 diabetes. The participants were health care professionals, including physicians, nurses and pharmacists. The outcomes included objectively measured health professional performance or patient outcomes, and self-report measures with known validity and reliability.
Data collection and analysis:
Two reviewers independently extracted data and assessed study quality.
Main results:
Forty-one studies were included involving more than 200 practices and 48,000 patients. Twenty-seven studies were RCTs, 12 were CBAs, and two were ITS. The studies were heterogeneous in terms of interventions, participants, settings and outcomes. The methodological quality of the studies was often poor. In all studies the intervention strategy was multifaceted. In 12 studies the interventions were targeted at health professionals, in nine they were targeted at the organisation of care, and 20 studies targeted both. In 15 studies patient education was added to the professional and organisational interventions. A combination of professional interventions improved process outcomes. The effect on patient outcomes remained less clear as these were rarely assessed. Arrangements for follow-up (organisational intervention) also showed a favourable effect on process outcomes. Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients' health outcomes.
Reviewer's conclusions:
Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes. Organisational interventions that improve regular prompted recall and review of patients (central computerised tracking systems or nurses who regularly contact the patient) can also improve diabetes management. The addition of patient-oriented interventions can lead to improved patient health outcomes. Nurses can play an important role in patient-oriented interventions, through patient education or facilitating adherence to treatment.
A solution to safeguard high quality diabetes care may be to allocate care to the nurse specialist. By using a one group pretest-posttest design with additional comparisons, this study evaluated effects on patient outcomes of a shared care model with the diabetes nurse as main care-provider for patients with type 2 diabetes in a primary care setting. The shared care model resulted in an improved glycaemic control, additional consultations and other outcomes being equivalent to diabetes care before introduction, with the general practitioner as main care-provider. Assignment of care for patients with type 2 diabetes to nurse specialists seems to be justified.
Background:
Demand for primary care services has increased in developed countries due to population ageing, rising patient expectations, and reforms that shift care from hospitals to the community. At the same time, the supply of physicians is constrained and there is increasing pressure to contain costs. Shifting care from physicians to nurses is one possible response to these challenges. The expectation is that nurse-doctor substitution will reduce cost and physician workload while maintaining quality of care.
Objectives:
Our aim was to evaluate the impact of doctor-nurse substitution in primary care on patient outcomes, process of care, and resource utilisation including cost. Patient outcomes included: morbidity; mortality; satisfaction; compliance; and preference. Process of care outcomes included: practitioner adherence to clinical guidelines; standards or quality of care; and practitioner health care activity (e.g. provision of advice). Resource utilisation was assessed by: frequency and length of consultations; return visits; prescriptions; tests and investigations; referral to other services; and direct or indirect costs.
Search strategy:
The following databases were searched for the period 1966 to 2002: Medline; Cinahl; Bids, Embase; Social Science Citation Index; British Nursing Index; HMIC; EPOC Register; and Cochrane Controlled Trial Register. Search terms specified the setting (primary care), professional (nurse), study design (randomised controlled trial, controlled before-and-after-study, interrupted time series), and subject (e.g. skill mix).
Selection criteria:
Studies were included if nurses were compared to doctors providing a similar primary health care service (excluding accident and emergency services). Primary care doctors included: general practitioners, family physicians, paediatricians, general internists or geriatricians. Primary care nurses included: practice nurses, nurse practitioners, clinical nurse specialists, or advanced practice nurses.
Data collection and analysis:
Study selection and data extraction was conducted independently by two reviewers with differences resolved through discussion. Meta-analysis was applied to outcomes for which there was adequate reporting of intervention effects from at least three randomised controlled trials. Semi-quantitative methods were used to synthesize other outcomes.
Main results:
4253 articles were screened of which 25 articles, relating to 16 studies, met our inclusion criteria. In seven studies the nurse assumed responsibility for first contact and ongoing care for all presenting patients. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost. In five studies the nurse assumed responsibility for first contact care for patients wanting urgent consultations during office hours or out-of-hours. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than did doctors. The impact on physician workload and direct cost of care was variable. In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. The outcomes investigated varied across studies so limiting the opportunity for data synthesis. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilisation or cost.
Authors' conclusions:
The findings suggest that appropriately trained nurses can produce as high quality care as primary care doctors and achieve as good health outcomes for patients. However, this conclusion should be viewed with caution given that only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less. While doctor-nurse substitution has the potential to reduce doctors' workload and direct healthcare costs, achieving such reductions depends on the particular context of care. Doctors' workload may remain unchanged either because nurses are deployed to meet previously unmet patient need or because nurses generate demand for care where previously there was none. Savings in cost depend on the magnitude of the salary differential between doctors and nurses, and may be offset by the lower productivity of nurses compared to doctors.
In 2003 the government introduced a national diabetes plan. One of the recommendations was to establish a national diabetes database targeted at monitoring the prevalence of diabetes and quality of diabetes care. The aim of this study is to validate a national algorithm for identification of known diabetes and compare the results with the results from the use of a regional algorithm.
Patients with diabetes residing in Aarhus County on 31 December 2003 were identified by data from The National Patient Registry, The National Health Insurance Service Registry, the prescription database and the laboratory database in the county.
This study identified a total of 8,802 patients with a diagnosis of diabetes which was confirmed by the patients' general practitioners (GP). This corresponds to a prevalence of 2.32% (95% CI: 2.27%2.37%). The national algorithm found 86% of this diabetes population while the regional algorithm found 96%. The sensitivity was increased to 91% by supplementing with information of dispensed prescriptions for anti-diabetics in the national algorithm. The positive predictive value was 89% for the national algorithm as well as for the regional algorithm.
The national algorithm may be used as a tool for establishing a national diabetes database. Despite a higher sensitivity, the regional algorithm cannot currently be recommended at a national level as it depends on the collection of person-related data which are not available nationally at the present time.
Prevention of lifestyle-related diseases and related complications represent an increasing part of daily work in general practice. In relation to selected doctor and patient characteristics we analyzed 1) the practice staff's current involvement in preventive measures, and 2) the doctors' wishes for increased involvement.
In total, 378 out of 381 general practitioners from ten counties participating in "Audit on prevention in general practice 2004" filled in a two-page questionnaire.
Almost all (377/378) had staff employed. More than half of the doctors stated that the staff performed tasks in connection with weight control, vaccination of adults, blood pressure checks, lung function tests, alcohol abuse treatment and dietary counselling. A total of 72% of the doctors wished for greater staff involvement within one or more areas, especially dietary counselling and smoking cessation support. The staff was more frequently involved in the tasks for doctors who had a nurse employed compared with doctors who did not. Except for skin prick tests no connection was found between the staff's participation and the doctor's sex and age, the type and size of the practice, and the extent of the regional lack of doctors.
Staff in general practice perform many preventive tasks related to the eight common chronic diseases, but most frequently in practices where there is a nurse employed. Although the participating doctors may have a special interest in the topic, there seems to be a basis for further staff involvement in this type of tasks. Further studies should, however, elucidate whether the participation of the staff substitutes the doctor's work to the extent desired and with sufficient quality.
Survival as a function of HbA(1c) in patients with type 2 diabetes: a retrospective cohort study
- C J Currie
- J R Peters
- A Tynan
C.J. Currie, J.R. Peters, A. Tynan, et al., Survival as a function of HbA(1c) in patients with type 2 diabetes: a retrospective cohort study, Lancet 375 (2010) 481–489.
Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings
- C M Renders
- G D Valk
- S Griffin
C.M. Renders, G.D. Valk, S. Griffin, et al., Interventions to
improve the management of diabetes mellitus in primary
care, outpatient and community settings. 2000, Cochrane
Database of Systematic Reviews (4) (2000),
http://dx.doi.org/10.1002/14651858.CD001481.