Evid Based Nurs doi:10.1136/eb-2012-100945
  • Primary health care
  • Randomised control trial

Compared to standard physician care for diabetes, nurse specialists provide similar care in terms of quality of life

  1. Michelle L Litchman
  1. College of Nursing, University of Utah, Salt Lake City, Utah, USA
  1. Correspondence to: Michelle L Litchman
    College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT 84112, USA; michelle.litchman{at}

Commentary on:  Arts EE, Landewe-Cleuren SA, Schaper NC, et al. The cost-effectiveness of substituting physicians with diabetes nurse specialists: a randomized controlled trial with 2-year follow-up. J Adv Nurs 2012;68:1224–34

Implications for practice and research

  • Care provided by diabetes nurse specialists to uncomplicated patients with diabetes was not inferior to physician care, in terms of patient quality of life and expenditures.

  • Care patterns were not equal between study groups; diabetes nurse specialists followed a preset protocol and had referral limitations.


Diabetes is economically burdensome worldwide. Treating diabetes and preventing its complications cost at least US$465 billion in 2011, translating to 11% of total healthcare expenditures in adults.1 Despite the overwhelming costs of diabetes, overall care remains undesirable. Programmes demonstrating reduction in diabetes-related healthcare costs, while resulting in positive outcomes, will be important to replicate. Arts and colleagues explored whether diabetes nurse specialists were a cost-effective solution when compared to physician care.


The setting was a hospital in the Netherlands. Over a 2-year period, a total of 294 participants with uncomplicated type 1 or type 2 diabetes were randomised to an intervention group, receiving care from advanced practice diabetes nurse specialists, or to usual care from a physician. Group participant characteristics were statistically equivalent at baseline. Diabetes nurse specialists treated patients using a preset protocol and were restricted in referral options while physicians had no treatment or referral restrictions. Groups were evaluated for quality of life (EQ-5D), cost-effect ratios (CERs) and incremental cost-effect ratios (ICERs). CER reports the cost per level of utility while the ICER reports the cost per quality-adjusted life-year. The EQ-5D measurement was evaluated using a between-within analysis of variance (ANOVA) analysis while the CER and ICER were evaluated using an independent sample t test. The null hypothesis of non-inferiority of the intervention group was tested using a one-tailed test.


The intervention group was not inferior to the control group regarding quality of life, CER and ICER. On average, diabetes nurse specialists had more face-to-face time with patients than physicians (224.5 vs 85.8 min of consultation per patient, p<0.05); however, the authors did not consider time as a part of cost evaluation. An equal number of adverse events were found in each group. Reason for study attrition was not detailed by group, nor was a comparison of attrition by individual characteristics.


Evidence indicates advanced practice nurses achieve high-patient satisfaction scores with no differences in health outcomes when compared to physicians in the primary care setting.2 This study adds evidence for diabetes nurse specialists as the central healthcare provider in the acute setting. Arts and colleagues hypothesised diabetes nurse specialists would provide care of at least equal quality and would not generate significantly higher costs than physicians. Consequently, the investigators used a one-tailed test that could not have detected if diabetes nurse specialist care was superior to, or more cost-effective than, physicians. Although modest reductions in costs were reported, differences were insignificant. There were no outcome data reported with regards to A1C, lipids and blood pressure; information regarding this data is cited in an article yet to be published, thus results cannot be assessed by readers. It is difficult to address the cost-effectiveness of an intervention without clinical outcome data, which must be considered as part of cost.

The study would have been strengthened had the investigators recruited the 340 participants projected in their power analysis. Given the exclusion criteria, it is unknown how diabetes nurse specialists would have performed with more complex patients with diabetes. New trends suggest collaborative practice efforts between professionals are needed to meet the diverse needs of patients with diabetes3 ,4 while maintaining cost effectiveness.5 Diabetes nurse specialists followed a preset protocol with limited collaborative referral sources—it is unknown what the clinical outcomes and cost would have been if the diabetes nurse specialists could have made their own patient care decisions. Limited attention was paid to the loss of patient productivity in cost calculations. This comparative research is an important step in assessing diabetes nurse specialists as the central healthcare provider but further studies are needed to examine the quality and cost-effectiveness of advanced practice nurses providing care to complex patients with diabetes.


  • Competing interests None.


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