Diabetes management can be safely transferred to practice nurses
- Correspondence to: Doris Young
University of Melbourne, 200 Berkeley Street, Carlton, VIC 3053, Australia;
Implications for nursing practice
▪ Practice nurses (PNs) following protocols provide as effective care for patients with type 2 diabetes as general practitioners (GPs).
▪ Patients are more satisfied with PNs helping them with diabetes management compared with GPs.
Implications for nursing research
▪ Further large-scale studies need to be conducted to trial models of care delivered by PNs in this context as well as more generally.
▪ Economic analyses need to be performed to ascertain the comparative cost-effectiveness of the two models of care.
▪ Qualitative and observational studies would provide further explanation of the different models of care.
People with chronic diseases such as type 2 diabetes need a team approach to their care, and many models have been trialled to deliver cost-effective, continuous, comprehensive and coordinated care.1 2 It is thus timely for primary care researchers to design interventions to see whether PNs trained in diabetes management, following a protocol, can deliver similar care to GPs for matched patients. This study by Houweling and colleagues aims to answer part of this question by conducting a small trial in one general practice in The Netherlands.
The authors tested this hypothesis by randomly assigning 230 patients with type 2 diabetes to either an intervention (two PNs) or usual care (five GPs) in the same practice. The PNs in the intervention arm had 1 week of intensive training in diabetes management using Dutch diabetes guidelines and were permitted to order laboratory investigations and prescribe medications to achieve targets in glucose levels, blood pressure and lipids. The primary outcome measure was a mean decrease in HbA1C levels at the end of 14 months. Process outcomes such as number of visits, time spent with patients and patient satisfaction were also measured and compared.
There were no significant differences between the two groups with respect to the reduction of HbA1c, blood pressure and lipid profile at the end of the study. In both groups, more patients met the target blood pressure and lipid levels. PNs saw their patients more often (mean of 6.1 visits) during the study period as compared with GPs (mean of 2.8 visits) and spent more time with their patients (21 vs 10 min). Patients being treated by the PNs were more satisfied than those being treated by the GPs.
This study concluded that diabetes management can be safely transferred to PNs in a primary care setting and that PNs management of type 2 diabetes is comparable with that managed by GPs. Before major policy and practice change are implemented, it is important to point out that this randomised controlled trial only involved one general practice in The Netherlands. Therefore, the results may not be generalisable to other practices in the country, and the study needs to be replicated in a larger number of practices to demonstrate similar effect. Furthermore, the issues of confounders and contamination with the trial being conducted in the same practice were not addressed adequately, as patients attending the same practice often share information with each other.
This small study did show that PNs can be trained to deliver this care following protocols and guidelines. Whether they can be given prescribing rights is a matter for policy makers in the particular country to decide. The cost-effectiveness and benefits of this model of care also need further study, as PNs spent more time with their patients than did GPs. The costs of this time spent have to be balanced against patient satisfaction, as diabetes is a lifelong chronic condition. If the PNs can provide better self-management support, which is important in chronic disease management,2 then the model is worth considering in its own right.