Nurse Care Manager Collaboration With Community-Based Physicians Providing Diabetes Care A Randomized Controlled Trial The cost-effectiveness of substituting physicians with diabetes nurse specialists: a randomized controlled trial with 2-year follow-up. Diabetes care from diagnosis: effects of training in patient-centred care on beliefs, attitudes and behaviour of primary care professionals. Nurse-led motivational interviewing to change the lifestyle of patients with type 2 diabetes (MILD-project): protocol for a cluster, randomized, controlled trial on implementing lifestyle recommendations Substitution model with central role for nurse specialist is justified in the care for stable type 2 diabetic outpatients. A randomised controlled clinical trial of nurse-, dietitian- and pedagogistled Group Care for the management of Type 2 diabetes Nurse Case Management To Improve Glycemic Control in Diabetic Patients in a Health Maintenance Organization An evaluation of a Diabetes Specialist Nurse prescriber on the system of delivering medicines to patients with diabetes. The use of a nurse practitioner in the management of patients with diabetes mellitus. Evaluation of a hospital diabetes specialist nursing service: a randomized controlled trial. The effectiveness of nurse‐led care in general practice on clinical outcomes in adults with type 2 diabetes Diabetes Care Processes and Outcomes in Patients Treated by Nurse Practitioners or Physicians Effect of nurse-directed diabetes care in a minority population. The Impact of an Educational Program on Improving Diabetes Knowledge and Changing Behaviors of Nurses in Long-Term Care Facilities Promoting Health in Type 2 Diabetes: Nurse-Physician Collaboration in Primary Care Shared care with task delegation to nurses for type 2 diabetes: prospective observational study. Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial.
PURPOSE The purpose of this study was to demonstrate the potential value of close collaboration at the office level of a nurse care manager with community-based primary care physicians in the care of adult patients with type 2 diabetes , particularly those physicians not affiliated with an integrated care system that some managed care organizations provide . METHODS Patients with type 2 diabetes were recruited from the general population of a large metropolitan area . Each received a comprehensive evaluation of his or her diabetes with results reported to patients and their physicians ( basic intervention ) . A r and om one-half of patients were additionally assigned to individual counseling , problem identification , care planning , and management recommendations by a nurse care manager ( individualized intervention ) . The patients receiving only the basic intervention served as the control group to those receiving the individualized intervention . Re-evaluation of all patients at 6 months after their entry into the study determined the effectiveness of the nurse-directed individualized intervention using A1C , blood pressure , and cholesterol as outcome measures . RESULTS Of 220 patients recruited , 197 had type 2 diabetes , r and omly assigned only the basic intervention ( 102 patients ) or individualized intervention ( 95 patients ) . Postintervention data were obtained on 164 patients ( 83 % ) . Significant improvement occurred in mean systolic blood pressure and A1C of all patients in the individualized but not the basic intervention only group . Patients with a systolic blood pressure > or=130 mm Hg at baseline showed improvement if they had more than 2 contacts with the study nurse but not if they had less than 2 contacts . CONCLUSIONS A nurse care manager collaborating at the office level with community-based primary care physicians can enhance the care provided to adult patients with type 2 diabetes . For those many physicians not affiliated with an integrated care system featured by some managed care organizations , this collaboration could underlie a team approach ( nurse/patient/physician ) for the ambulatory patient with diabetes that would be an essential element in a chronic disease model of care for diabetes at the community level AIMS To evaluate the cost-effectiveness of an intervention substituting physicians with nurse specialists . BACKGROUND Increasing population s of people with diabetes in most Western countries require creative solutions that give high- quality chronic care while controlling costs . Instigating nurse specialists as a substitute for physicians yields positive results in this area . Research about such interventions in a hospital-based setting is limited . METHODS This paper is a report of a study of a r and omized , non-blinded clinical trial including people with diabetes mellitus types 1 and 2 . In the intervention group  nurse specialists  were the central carers , providing care that conformed to a preset protocol . Patients were included between 2004 and 2007 .  Costs , quality of life and adverse events were measured , cost-effect ratios and incremental cost-effect ratios were calculated based on health-re source utilization rates , corresponding market prices and national tariffs from 2007 . RESULTS Health related quality of life scores did not differ significantly between the control and the intervention group . In the intervention group , fewer patients were hospitalized and fewer side effects from drugs were reported compared to controls . Nurse specialists as central care givers generated a modest reduction in costs per quality adjusted life year gained compared to usual care . CONCLUSION Nurse specialists give diabetes care that is similar to care provided by physicians in terms of quality of life and economic value . Instigating a nurse specialist as central carer yields opportunities to generate cost savings . Developing interventions which also focus on prevention of complications is recommended when aim ing for long-term organisational cost savings In a r and omised trial , general practitioners and nurses in 21 practice s were trained in patient-centred consulting and use of material s for people with Type 2 diabetes ( GPs 0.5 days ; nurses 1.5 days ; two optional follow-up half-days ) . Twenty practice s formed the comparison group . Professional beliefs , attitudes and behaviour were measured ( pre-trial , close-of-course and end-of-trial ) , supported by patient reports of  nurse behaviour ( 141 trained : 108 comparison patients , 1 year after diagnosis ) . A total of 49 practice nurses responded ( 29 trained ; 20 comparison ) . Trained nurses rated relative importance of patient-centred to professional-centred care as greater than comparison nurses . Trained nurses became less keen on the approach during the trial , and perceived time constraints persisted . Patients diagnosed later in the study were less likely to recognise intervention material s. Trained nurses rated delivery of important aspects of care and satisfaction with style of care as lower than comparison nurses , but patients were more positive about delivery of care from trained than comparison nurses . Although nurses rated patient-centred care as important , whether or not they had been trained as part of the trial , the short , generalizable training programme significantly reduced nurse perceptions of their ability to deliver it . Nonetheless , patients reported that important aspects of diabetes care were delivered more if their nurses had been trained in patient-centred consulting . This raises issues concerning measurement scales completed by trained professionals Background The diabetes of many patients is managed in general practice ; healthcare providers aim to promote healthful behaviors , such as healthful diet , adequate physical activity , and smoking cessation . These measures may decrease insulin resistance , improve glycemic control , lipid abnormalities , and hypertension . They may also prevent cardiovascular disease and complications of diabetes . However , professionals do not adhere optimally to guidelines for lifestyle counseling . Motivational interviewing to change the lifestyle of patients with type 2 diabetes is intended to improve diabetes care in accordance with the national guidelines for lifestyle counseling . Primary care nurses will be trained in motivational interviewing embedded in structured care in general practice . The aim of this paper is to describe the design and methods of a study evaluating the effects of the nurses ' training on patient outcomes . Methods / Design A cluster , r and omized , controlled trial involving 70 general practice s ( 35 practice s in the intervention arm and 35 in the control arm ) starting in March 2007 . A total of 700 patients with type 2 diabetes will be recruited . The patients in the intervention arm will receive care from the primary care nurse , who will receive training in an implementation strategy with motivational interviewing as the core component . Other components of this strategy will be adaptation of the diabetes protocol to local circumstances , introduction of a social map for lifestyle support , and educational and supportive tools for sustaining motivational interviewing . The control arm will be encouraged to maintain usual care . The effect measures will be the care process , metabolic parameters ( glycosylated hemoglobin , blood pressure and lipids ) , lifestyle ( diet , physical activity , smoking , and alcohol ) , health-related quality of life , and patients ' willingness to change behaviors . The measurements will take place at baseline and after 14 months . Discussion Applying motivational interviewing for patients with diabetes in primary care has been studied , but to our knowledge , no other study has yet evaluated the implementation and sustainability of motivating and involving patients in day-to-day diabetes care in general practice . If this intervention proves to be effective and cost-effective , large-scale implementation of this nurse-oriented intervention will be considered and anticipated . Trial registration Current Controlled Trials IS RCT N68707773 AIM OF THE STUDY Assessment of effects on quality of care , in terms of patient outcomes , when tasks in the care for out patients with stable type 2 diabetes are transferred from internist to nurse specialist and from outpatient clinic to general practice . BACKGROUND For the management of chronic diseases with a high prevalence and requiring current monitoring , it is suggested that substitution of care may be an appropriate solution to safeguard high quality care . DESIGN AND METHODS A 12-month nonequivalent control group design was used . General practitioners ( GPs ) referring diabetes patients to the University Hospital Maastricht were asked to choose for the traditional model or the nurse specialist model . Informed consent was obtained from patients with stable diabetes type 2 attending these practice s. All patients received care according to the model chosen by their GP . Identified outcomes were : clinical status , health status , self-care behaviour , knowledge of diabetes , patient satisfaction , and consultation with care-providers . RESULTS In the control group ( n=47 ) no patients were treated with oral hypoglycaemic agents ( OHA ) only . The control group was compared with an intervention subgroup ( n=52 ) also without patients receiving OHA only . Clinical data were available for all patients . Patients without complete data from question naires had better mean concentration of HbA1c than patients with complete data ( P=0.004 ) . The traditional care model and the nurse specialist model achieved equal outcomes , while glycaemic control of patients in the nurse specialist model improved ( from 8.6 % to 8.3 % ) but deteriorated in the traditional model ( from 8.6 % to 8.8 % ; P-value between groups=0.001 ) . CONCLUSIONS The model with nurse specialists taking on roles and tasks beyond those traditionally regarded as their remit as well as new ones , is effective for the care of stable diabetic out patients Aim : To verify if Group Care , a model to manage Type 2 diabetes ( T2DM ) by systemic continuing group education , can be administered by nurses and dieticians under pedagogic guidance , and improve metabolic control , quality of life , Locus of Control , and insulin resistance . Material and subjects : Twenty-five patients with non-insulin-treated T2DM were r and omized to Group Care and 24 to continued habitual individual care and education delivered by a diabetes specialist and pedagogist , respectively . Six nurses and 1 dietician received training by an accredited programme , a detailed operating manual and pedagogical supervision throughout the study . Follow-up was for 2 yr and included measurements of fasting blood glucose , glycated hemoglobin ( HbA1c ) , body mass index , waist circumference , lipids , creatinine , blood pressure , serum insulin , homeostasis model assessment ( HOMA ) index of insulin resistance , health behaviors , quality of life , state and trait anxiety , and Locus of Control . Results : One patient on Group Care and 3 controls dropped out . At the end of study , the patients on Group Care had lower HbA1c ( 7.6± 0.8 vs 8.4± 1.3 , p<0.05 ) , insulin ( 18.0± 9.6 vs 24.3± 13.7 , p<0.001 ) , HOMA index ( 6.9± 5.4 vs 9.2± 6.6 , p<0.05 ) , and fatalistic attitude ( 17.2± 5.9 vs 24.9± 4.2 , p<0.001 ) and better quality of life ( 65.0± 11.0 vs 78.4± 19.6 , p<0.001 ) than controls . Conclusions : Group Care delivered by trained nurses and dietitan is associated with better outcomes than those obtained by a medically and pedagogically qualified team . It may offer a model for health operators to re-organize clinical practice and for patients to improve lifestyle and strengthen the therapeutic alliance with their carers The Diabetes Control and Complications Trial ( DCCT ) and the Kumamoto study [ 1 , 2 ] showed that near-normal glycemic control reduces the development and progression of microvascular and neuropathic complications by approximately 50 % in type 1 and type 2 diabetes mellitus . Additional analyses [ 3 - 5 ] indicate that therapy to achieve near normalization of blood glucose levels is cost-effective compared with other treatments . Thus , the American Diabetes Association has recommended that all persons with diabetes attempt to achieve near normalization of blood glucose levels [ 6 ] . This recommendation is not routinely followed in medical practice . In a 1989 national survey of physician practice behaviors in the United States , 64 % of physicians agreed that achieving target HbA1c values is very important but only 18 % reported that they ordered HbA1c tests every 2 to 3 months for patients with type 1 diabetes [ 7 ] . Although 98 % agreed that patient education improves glucose control , only 55 % reported that they routinely used a dietitian or a diabetes educator in patient care . Studies indicate that bringing clinical practice into line with scientific knowledge can be difficult . Methods used to achieve diabetes control in clinical trials are re source intensive . The American Diabetes Association currently recommends that patients with diabetes see their primary care physicians two to four times per year . Data from the National Health Interview Survey , a nationally representative survey [ 8 ] , indicate that most patients with diabetes are seen by nonspecialists and that 69 % of physician visits last less than 15 minutes . Algorithms for diabetes care exist but may be complex and difficult for physicians to follow , given patient load , diversity of patients seen , lack of information systems , and time constraints . Simple , low-cost methods of translating guidelines into clinical care are required . One solution may be to make greater use of personnel other than physicians . Nurse case management was an integral part of intensive therapy in the DCCT and has proven to be effective in reducing smoking and cholesterol levels after acute myocardial infa rct ion [ 3 , 9 ] . A nonr and omized study [ 10 ] of more than 700 patients with diabetes in a health maintenance organization suggests that nurse case management may be effective in improving metabolic control . Other studies [ 11 , 12 ] show a strong association between algorithm-directed nurse interventions and improved glycemic control . To our knowledge , no r and omized , controlled clinical trial of nurse case management in diabetes has yet been published . In a 12-month r and omized , controlled trial , we compared a nurse case management model of diabetes care with usual diabetes management in a primary care setting . Methods Patients Our study was approved by the institutional review board of the Prudential Center for Health Care Research , and all patients gave written informed consent . Participants were recruited from two of the largest clinics within the Jacksonville Health Care Group , which is the largest provider of primary care services for the Prudential HealthCare HMO plan of Jacksonville , Florida . The Jacksonville Health Care Group is a group of 43 primary care physicians who provide care in eight clinics to more than 75 000 Prudential HealthCare plan members . Potential study participants were identified through a data base used to support quality -improvement activities . Prudential HealthCare HMO members who had diabetes were included in the data base if they had visited a physician for diabetes ( International Classification of Diseases , 9th Revision , codes 250.0 to 250.9 ) , had had a hospital cl aim processed for diabetes , had been seen by the utilization management nurse , or had been referred to an ophthalmologist for a diabetic retinal examination . This data base is up date d regularly . A list with each member 's name , address , telephone number , medical record number , member identification number , age , sex , physician , and clinic was generated by merging the data from the data base with enrollment information . In addition , a list of members who may have had diabetes was created by using pharmacy data . Adult members with diabetes who were potential study participants each received a recruitment call and were invited to schedule an appointment with a research assistant to discuss participation in the study . We made a total of 14 calls at different times and on different days before coding a member as unavailable . After consent was given and the eligibility assessment was completed , baseline information was obtained and an HbA1c test was ordered if the result of one given within the previous 60 days was not available . Patients were ineligible for the study if they had a recent HbA1c value less than 7.0 % ; had uncontrolled hypertension ( blood pressure > 180/110 mm Hg ) ; had unstable angina ( class 4 ) ; had had a myocardial infa rct ion in the past 3 months ; had had two or more episodes of seizures ; had alcoholism or drug abuse documented in the chart ; had late-stage complications of diabetes or other chronic conditions , such as severe immunodeficiency or cirrhosis ; were pregnant or were planning to become pregnant in the next 12 months ; or were unable to perform self-management . Patients were r and omly assigned in blocks to either the nurse case management ( intervention ) group or the usual care group . R and omization was based on a 1:1 allocation ratio and a block size of three . Each block contained six patients , three in each study group . This r and omization scheme ensured that the desired allocation ratio-one intervention patient to one usual care patient-was maintained after sequential enrollment of every sixth patient . Outcome Measures Change in HbA1c value was the primary outcome measure . Decreased HbA1c values correlate directly with reduced risk for diabetes-related microvascular and neuropathic complications in type 1 and type 2 diabetes [ 1 , 3 ] . We also assessed health-related quality of life by using four generic questions developed by the Centers for Disease Control and Prevention for the Behavioral Risk Factor Surveillance System ( BRFSS ) [ 13 , 14 ] . These questions evaluate key conceptual domains of health-related quality of life : 1 ) patient-perceived general health status , 2 ) patient-perceived physical dysfunction during the previous 30 days , 3 ) patient-perceived mental dysfunction during the previous 30 days , and 4 ) patient-perceived functional incapacity during the previous 30 days for either mental or physical reasons . The BRFSS quality -of-life measures have been vali date d in a national sample of adults in the United States [ 15 ] . Patient-perceived health was found to be a good proxy indicator for chronic disease conditions . The other three domains further characterize general health functioning and quality of life [ 15 ] . In this analysis , we report findings related to the patient-perceived general health status domain . Intervention and Follow-up The nurse case manager was a registered nurse and a certified diabetes educator . She was trained to follow a set of detailed management algorithms under the direction of a board-certified family medicine physician and an endocrinologist who were responsible for all diabetes management decisions for patients in the intervention group but were not primary care providers for these patients . The algorithms were specific for type of diabetes and were developed by a multidisciplinary team on which endocrinology , family medicine , nursing , pharmacy , health services research , and epidemiology were represented . The algorithms progressively moved a patient toward improvement of glycemic control through adjustments in medication , meal planning , and reinforcement of exercise ( Figure 1 ) . Figure 1 . Algorithm for management of type 2 diabetes mellitus . Patients assigned to receive nurse case management met with the nurse for an initial assessment , were instructed about a blood glucose monitoring schedule , and returned for a follow-up visit 2 weeks later . The initial visit with the nurse averaged 45 minutes . At the 2-week follow-up visit , the nurse review ed the patient 's blood glucose log ; explained the algorithm step to which the patient had been assigned ; and used this information as the baseline for subsequent medication adjustments , meal planning , and exercise reinforcement . Patients receiving nurse case management  were also referred to a 5-week , 12-hour diabetes education program that included individual counseling by a dietitian , individual counseling by an exercise therapist , and group diabetes education classes . Subsequent in-person follow-up visits occurred quarterly . Patients in the nurse case management group  who were taking insulin  received weekly follow-up telephone calls . After the nurse review ed the blood glucose log and discussed glucose values with the patient , medication regimens were adjusted as needed and meal planning and exercise were reinforced . Patients treated with oral agents or diet and exercise  received follow-up telephone calls every 2 weeks . The nurse case manager met at least biweekly with the family medicine physician and the endocrinologist to review patient progress , medication adjustments , and other issues related to diabetes care . All medication adjustments or changes were communicated to the patients ' regular primary care physicians . Patients assigned to receive usual care were given blood glucose meters and strips , were encouraged to discuss enrollment in the diabetes education class with their physicians if they had not done so in the past year , and continued to receive diabetes care and follow-up from their primary care physicians . The 5-week diabetes education program is a st and ard , free-of-charge benefit for all HMO members with diabetes . All Jacksonville Health Care Group primary care physicians participate in an annual diabetes care seminar and undergo regular peer review of their adherence to published diabetes care st and ards . Tests to AIM To evaluate the impact of a  Diabetes Specialist Nurse prescriber  on insulin and oral hypoglycaemic agent  medication errors and length of stay . BACKGROUND The National Health Service has committed to a 40 % reduction in the number of drug errors in the use of prescribed medicines . Drug errors in diabetes care are a common cause of significant morbidity and complications . Nurse prescribing creates an opportunity for nurses to improve care for these patients . DESIGN A quasi-experiment using six wards in a single hospital trust . METHODS Inpatient care of a convenience sample of patients with diabetes was evaluated before ( n = 27 ) and after ( n = 29 ) the intervention of a Diabetes Specialist Nurse prescriber . Prospect i ve data were collected to measure  insulin and oral hypoglycaemic medication errors and length of stay . RESULTS There was a significant reduction in the total number of errors between the pre-intervention and intervention group ( mean reduction 21 errors ) ( p = 0.016 ) . The median length of stay was reduced by three days . The total number of errors and length of stay were affected by admission category ( p = 0.0004 ) . CONCLUSIONS A medicines management intervention , provided by a Diabetes Specialist Nurse prescriber , had a positive effect on the system of delivering medicines to patients with diabetes and significantly reduced the number of errors . This reduction had some effect on length of stay . The cost saving was sufficient to finance a Diabetes Specialist Nurse prescriber post . RELEVANCE TO CLINICAL PRACTICE ( i ) Errors frequently occur in the prescription and administration of medicines to patients with diabetes . ( ii ) The education of healthcare professionals is a factor contributing to these errors . ( iii ) Nurse prescribing provides a new system by which to educate patients and staff about their medicines . ( iv ) A Diabetes Specialist Nurse prescriber can reduce insulin and OHA MEs . This reduction had some effect on LOS Shortages in health care personnel have caused the expansion of nurses * duties . Physician acceptance of this augmented role for the nurse will depend in fact on appropriate studies . Extending the responsibilities of the nurse practitioner to active patient treatment is the basis of this report . AIMS To evaluate the effectiveness and cost implication s of a  hospital diabetes specialist nursing service . METHODS We conducted a prospect i ve , open , r and omized , controlled trial of st and ard in-patient care for adults with diabetes , with and without the intervention of a diabetes specialist nursing ( DSN ) service . The setting was a single UK university hospital . SUBJECTS were unselected patients referred to the hospital DSN service . Primary outcome measures were length of hospital stay and patterns of readmission ( frequency and time to first readmission ) . Secondary outcome measures were subjects ' diabetes-related quality of life , diabetes knowledge score , satisfaction with treatment , and GP and community care contacts following discharge . Costs were estimated from the hospital and published sources . RESULTS Median length of stay was lower in the intervention group ( 11.0 vs. 8.0 days , P < 0.01 ) . Readmission rates were the same in the two groups ( 25 % ) , and mean time to readmission was similar in the two groups , although slightly less in the control group ( 278 vs. 283 days , P = 0.80 ) . The cost per patient for nursing input was 38.94 pounds sterling . However , when the reduced length of stay was accounted for , the intervention produced a mean cost per admission of 436 ponds sterling lower than that of the control group ( P = 0.19 ) . Patients in the intervention group were more knowledgeable regarding their diabetes and more satisfied with their care . CONCLUSIONS Diabetes specialist nurses are potentially cost saving by reducing hospital length of stay ( LOS ) . There was no evidence of an adverse effect of reduced LOS on re-admissions , use of community re sources , or patient perception of quality of care Background In Australia , diabetes was identified as a national health priority area in 1996 ; nevertheless the prevalence of type 2 diabetes has increased dramatically since then . Nurses have been working within Australian general practice s for several decades but only in recent years has the role of the practice nurse in primary health care increased . Objectives This review aims to identify the effectiveness of nurse‐led care in general practice as compared to general practitioner care on clinical outcomes in adults with type 2 diabetes . Inclusion criteria Types of participants Participants were adults ( aged > 18 years ) , with diabetes type 2 attending a general/family practice . Types of intervention Interventions of interest include nurse‐led care in general practice in which the nurse is identified as taking a lead role in the care of patients with type 2 diabetes compared to general practitioner‐led care . Types of studies To evaluate the effectiveness of nurse‐led diabetes care in general practice , this review sought r and omised controlled trials as the study design of choice . Other research design s such as controlled clinical trials , interrupted time series and controlled before and after design s were also considered . Types of outcomes The outcomes of interest were clinical outcomes including changes in systolic and diastolic blood pressure , body mass index , cholesterol levels , HbA1c ( glycated haemoglobin ) and fasting blood glucose . Search strategy A three step literature search was conducted for English language articles from January 1990 to December 2011 . Method ological quality Quantitative papers selected for retrieval were assessed by two independent review ers for method ological validity prior to inclusion in the review using st and ardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument . Data collection Quantitative data was extracted from papers included in the review using the st and ardised data extraction tool from the Joanna Briggs Institute . The data extracted included specific details about the interventions , population s , study methods and outcomes of significance to the review question and specific objectives . Data synthesis Data from quantitative papers , where possible , were pooled in statistical meta‐ analysis using the Meta‐ Analysis of Statistics Assessment and Review Instrument . Additionally , RevMan 5 was used for presenting forest plots of the meta‐ analysis . Results The electronic search yielded 804 potentially relevant papers of which 49 papers appeared to satisfy the criteria for inclusion and full texts of these papers were assessed against the inclusion criteria by two independent review ers . From these papers , five were included in the review , four r and omised control trials and one quasi‐experimental study . These articles provided evidence that nurse‐led care improves blood pressure and cholesterol levels for patients with type 2 diabetes attending a general practice . Conclusions There is some evidence to support the use of nurse‐led care in general practice for patients with type 2 diabetes . Implication s for Practice If nurse‐led care is implemented in the care of people with type 2 diabetes consideration needs to be given to the use of clinical algorithms , goal setting , individualised care plans , self management and follow up of lifestyle risk factors . Implication for Research More r and omised controlled trials are required to assess the efficacy of nurse‐led care including cost effectiveness PURPOSE the purpose of this study was to compare selected diabetes care processes and outcomes of nurse practitioners ( NPs ) and physicians ( MDs ) in the primary care of adults with type 2 diabetes . METHODS Adults with type 2 diabetes and no regular source of primary care were enrolled from the emergency room and r and omized to an NP or MD practice .  Chart review s were conducted to assess processes of care ; patient interviews and hemoglobin Al C ( Al C ) testing were performed to measure patient outcomes . RESULTS NPs were more likely than MDs to document provision of general diabetes education and education about nutrition , weight , exercise , and medications . They were more likely to document patient height , urinalyses results , and Al C values . No differences were found in documenting current medications ; alcohol , illicit drug , or tobacco use ; depression ; weight and blood pressure ; foot and cardiovascular exams ; blood glucose and creatinine testing ; or referral to ophthalmologists . No differences were found in patient outcomes . CONCLUSIONS This study provides preliminary evidence of interdisciplinary differences in the processes of care employed by primary care NPs and MDs in caring for patients with type 2 diabetes . NPs documented the provision of diabetes education and selected monitoring tests more frequently than MDs ; however , these differences were not reflected in 6-month patient outcomes OBJECTIVE To determine whether diabetes care directed by nurses following detailed protocol s and algorithms and supervised by a diabetologist results in meeting the evidence -based American Diabetes Association ( ADA ) process and outcome measures more often than care directed under usual care in a minority population . RESEARCH DESIGN AND METHODS Studies were mainly conducted in two Los Angeles County clinics . In clinic A ,  nurse-directed diabetes care  was provided to 252 patients ( 92 % Hispanic and 2 % African-American ) referred by their primary care providers . These patients were hierarchically matched with 252 diabetic patients in clinic B ( 79 % Hispanic and 19 % African American ) . When nurse-directed care was abruptly discontinued in clinic A for administrative reasons , it was reestablished in clinic B. Those patients were r and omly selected from a teaching clinic , and the outcomes in 114 patients who completed 1 year were compared with outcomes derived the year before receiving nurses ' care . The following process and outcome measures were assessed in the study : 1 ) number of visits , 2 ) diabetes education , 3 ) nutritional counseling , 4 ) HbA(1c ) , 5 ) lipid profiles , 6 ) eye exams , 7 ) foot exams , 8) renal evaluations , and 9 ) ACE inhibitor therapy in appropriate patients . RESULTS For patients under nurse-directed diabetes care  in both clinics A and B , almost all process measures were carried out significantly more frequently than for the appropriate control patients . Under the care of nurses in clinic A , HbA(1c ) levels fell 3.5 % from 13.3 to 9.8 % in the 120 patients who were followed for at least 6 months , as compared with a 1.5 % fall from 12.3 to 10.8 % under usual ( physician-directed ) care in clinic B. During the year before enrolling in nurse-directed care in clinic B , mean HbA(1c ) levels decreased from 10.0 to 8.5 % . At the end of a year under the nurses ' care , the values fell further to 7.1 % . The median value fell from 8.3 to 6.6 % . CONCLUSIONS Specially trained nurses who follow detailed protocol s and algorithms under the supervision of a diabetologist can markedly improve diabetes outcomes in a minority population . This approach could help blunt the increased morbidity and mortality noted in minority population Nursing staffs from two long-term care facilities attended a multisession educational program about the care of residents with diabetes ( treatment group ) . A control group consisted of the nursing staffs from two other similar facilities who did not participate in the educational program .  Both groups were given a knowledge pretest and posttest . A chart review also was conducted following the educational intervention to determine any changes in the diabetes care provided by the treatment group . Following the educational program , the treatment group had a significant increase in their mean score on the knowledge test compared with the control group . However , a. review of the residents ' charts revealed no significant increases in specific behaviors related to diabetes care . The findings suggest that , in addition to educational programs , more focused training concerning diabetes care is needed to improve the care of residents with diabetes in long-term care facilities . Implication s for diabetes educators are discussed The purpose of this study is to examine effects of a nurse-physician collaborative approach to care of patients with type 2 diabetes and to determine possible effect sizes for use in computing sample sizes for a larger study . Forty patients from a family practice clinic with type 2 diabetes were r and omly assigned to control or experimental groups . The control group received st and ard care , whereas the experimental group received st and ard care plus home visits from a nurse , as well as consultation with an exercise specialist and /or nutritionist . Follow-up continued for 3 months . Clinical end points included st and ard measures of diabetes activity as well as quality -of-life indicators .  Focus group interviews were used to explore patients ’ responses to the program . Although findings were not statistically significant , a trend toward small to moderate positive effect sizes was found in glycosylated hemoglobin and blood pressure . Quality oflife measures also showed a trend toward small to moderate , but nonsignificant , improvements in physical functioning , bodily pain , vitality , social and global functioning , energy , impact of diabetes , and health distress . Focus group interviews indicated a very positive response from patients , who expressed feelings of empowerment . In this study , patients treated with  nurse-physician collaboration  demonstrated small , but nonsignificant , improvements in blood chemistry after only 3 months . Physical and social functioning , energy , and bodily pain also showed a small improvement . Changes in awareness of effects of diabetes on health and an expressed sense of self-efficacy suggest that effects could be sustainable over the longer term BACKGROUND To study the effects of two different structured shared care interventions , tailored to local needs and re sources , in an unselected patient population with type 2 diabetes mellitus . METHODS A three-year prospect i ve observational study of two interventions and st and ard care . The interventions involved extensive ( A ) or limited ( B ) task delegation from general practitioners to hospital-liaised nurses specialised in diabetes and included a diabetes register , structured recall , facilitated generalist-specialist communication , audit and feedback , patient-specific reminders , and emphasised patient education . The target population consisted of 2660 patients with type 2 diabetes treated in the primary care setting . Patients who were terminally ill or who had been diagnosed with dementia were excluded from the study . RESULTS The participation rates were high ( 90 % ) for patients , and none of the 64 GPs discontinued their participation in the study . Longitudinal analyses showed significant improvements in quality indicators for both intervention groups ( process parameters and achieved target values on the individual patient level ) ; in st and ard care , performance remained stable or deteriorated . Both patients and caregivers appeared satisfied with the project . CONCLUSION This study shows that structured shared care with task delegation to nurses , targeted at a large unselected general practice population , is feasible and can positively affect the quality of care for patients with type 2 diabetes AIMS AND OBJECTIVES To determine whether the management of  type 2 diabetes mellitus  in a primary care setting can be safely transferred to practice nurses . BACKGROUND Because of the increasing prevalence of type 2 diabetes mellitus and the burden of caring for individual patients , the dem and type 2 diabetes mellitus patients place on primary health care re sources has become overwhelming . DESIGN R and omised controlled trial . METHODS The patients in the intervention group were cared for by practice nurses who treated glucose levels , blood pressure and lipid profile according to a specified protocol . The control group received conventional care from a general practitioner . The primary outcome measure was the mean decrease seen in glycated haemoglobin ( HbA1c ) levels at the end of the follow-up period ( 14 months ) . RESULTS A total of 230 patients was r and omised with 206 completing the study . The between-group differences with respect to reduction in HbA1c , blood pressure and lipid profile were not significant . Blood pressure decreased significantly in both groups ; 7.4/3.2 mm Hg in the intervention group and 5.6/1.0 mm Hg in the control group . In both groups , more patients met the target values goals for lipid profile compared to baseline . In the intervention group , there was some deterioration in the health-related quality of life and an increase in diabetes-related symptoms . Patients being treated by a practice nurse were more satisfied with their treatment than those being treated by a general practitioner . CONCLUSION Practice nurses achieved results , which were comparable to those achieved by a general practitioner with respect to clinical parameters with better patient satisfaction . RELEVANCE TO CLINICAL PRACTICE This study shows that diabetes management in primary care can be safely transferred to practice nurses
Where reported , emergency admissions and quality of life were not found to be significantly different between groups .
No information was found regarding BMI , mortality , long term diabetic complications , adverse effects , or costs .
REVIEW ER 'S CONCLUSIONS The presence of a diabetes specialist nurse / nurse case manager may improve patients ' diabetic control over short time periods , but from currently available trials the effects over longer periods of time are not evident .
There were no significant differences overall in hypoglycaemic episodes , hyperglycaemic incidents , or hospital admissions .
Quality of life was not shown to be affected by input from a diabetes specialist nurse/nurse case manager
BACKGROUND The patient with diabetes has many different learning needs relating to diet , monitoring , and treatments .
In many health care systems specialist nurses provide much of these needs , usually aim ing to empower patients to self-manage their diabetes .
The present review aims to assess the effects of the involvement of specialist nurse care on outcomes for  people with diabetes  , compared to usual care in hospital clinics or primary care with no input from specialist nurses .
OBJECTIVES To assess the effects of diabetes specialist nurses / nurse case manager in diabetes on the metabolic control of patients with type 1 and type 2 diabetes mellitus .