Nurse case management with a therapeutic algorithm for people living with diabetes, hypertension and raised LDL cholesterol: after 1 year 22% of those receiving the intervention have all three parameters under control versus 10% of those receiving usual care
- Correspondence to Susan J Appel
Capstone College of Nursing, University of Alabama, PO Box 870358, Tuscaloosa, AL 35487-0358, USA;
Implications for practice and research
■ Nurse case managers can improve simultaneous control of hypertension, hyperglycaemia and hyperlipidaemia among patients living with Type 2 diabetes with the use of an algorithm guiding changes in medications versus usual care.
■ Frequent patient contact with nurse case managers can lead to improved lifestyle modifications and intensified medication regimes which reduce cardiometabolic risk.
■ Clinical inertia by primary care providers is an issue when managing diabetes as well as other chronic illnesses.
■ The use of algorithms and/or protocols by nurse case managers who have more frequent patient contact can assist in reducing the deleterious health outcomes of not treating to target.
Type 2 diabetes mellitus is a disease that serves to accelerate cardiovascular disease. Too often when attempting to modify risk factors among patients with diabetes, clinicians focus primarily on glycaemic control alone. Optimising a patient's A1C has many benefits, but done in isolation of other associated metabolic risk factors may not adequately reduce their cardiovascular morbidity or mortality as the majority of patients diagnosed with diabetes will die of cardiovascular-related illnesses.1,–,3 The American Diabetes Association defines cardiometabolic risk as, “a cluster of risk factors that are good indicators of a patient's overall risk for Type 2 diabetes and cardiovascular disease.”1,–,3 The study by Ishani et al aimed to answer the question: Can nurse case management with an algorithm simultaneously improve rates of control for all of the following risk factors: hypertension, hyperglycaemia and hyperlipidaemia among veterans living with Type 2 diabetes versus usual care?
A randomised unblinded controlled trial was used to answer the research question. The investigators randomised 568 veterans living with diabetes to either usual care (n=278) or an intervention group (n=278) overseen by nurse case managers. Inclusion criteria were blood pressure>140/90 mm Hg, haemoglobin A1C>9.0% and a low-density lipoprotein>100 mg/dL. Exclusion criteria consisted of individuals with a life expectancy of less than 1 year, active substance abuse, significant mental health dysfunctions, pregnancy or planning on becoming pregnant and/or being a resident of an assisted living facility. The intervention arm consisted of an initial meeting with a case manager followed by telephone contact every 2 weeks until the participants met their target goals and then less frequently. The intervention group jointly formulated action plans with their case manager to modify lifestyle behaviours which included goals for weight loss, smoking cessation, dietary and physical activity changes. The case managers made adjustment during the contacts to medications according to study protocol and then informed primary care physicians. The duration of the study was 12 months and the participants returned for a final visit and a formal quantitative analysis of their risk factors.
Participants within the intervention group were significantly more likely to achieve all three of the prescribed targets for glycaemic, lipid and blood pressure control versus the usual care group. Likewise, a greater number of the intervention group members achieved statistically significant improvements of individual component of the cardiometabolic risk factors.
Nurse case managers working with patients living with diabetes can simultaneously and significantly reduce their cardiometabolic risk factors when given a protocol to manage these conditions with essential medications. This study was unique since the majority of trials focused on modification of only one, or at the most, two risk factors, usually glycaemic control with the addition of either hypertension or lipids. Greater treatment effects were identified within this study versus others found within the literature which can be contributed to the autonomy given to the case managers to first change the medications and then secondarily contact the primary care physicians.