Practice Nurse Model Improves Primary-Care Diabetes Outcomes

Miriam E Tucker

March 20, 2017

A novel primary-care practice model in which nurses take the lead in helping type 2 diabetes patients start on insulin treatment can improve glycemic control, new research suggests.

Findings from the Stepping Up pragmatic cluster randomized controlled clinical trial were published online March 8 in  the BMJ by John Furler, PhD, of the department of general practice, University of Melbourne, Australia, and colleagues.

In Stepping Up, primary-care practice roles were reoriented, giving the practice nurse an enhanced role in leading insulin initiation — a common stumbling block in type 2 diabetes management — with mentoring by a registered nurse with diabetes educator credentials, in collaboration with the primary-care physician.

Simple protocols were used for beginning insulin therapy and titration (Fam Pract. 2014;31:349–356).

After 1 year, 70% of eligible patients in the 36 intervention practices had started insulin treatment compared with 22% attending the 38 control practices, and the former had significantly lower HbA1c levels.

A Reluctance to Initiate Insulin

Dr Furler and colleagues explain that there can often be a reluctance to initiate insulin when indicated in type 2 diabetes, which arises from a combination of factors, including concern by the clinician about hypoglycemia and weight gain, by the patient, — who may fear needles  — or by barriers from the healthcare system, which may not allow sufficient time for patient education.

Regardless of the reason, delaying the start of insulin therapy "when clinically indicated is neither ethical nor effective. Furthermore, health systems will not cope with demand if insulin initiation remains anchored in specialist centers," they stress.

"Thus, our pragmatic, translational study has important implications across health systems globally for the organization of care for people with type 2 diabetes," they write.

The study was done in Australia, but such practice models are promising and feasible elsewhere, diabetes clinical nurse specialist Kellie Antinori-Lent, RN, CDE, of the University of Pittsburgh Medical Center (UPMC), Pennsylvania, told Medscape Medical News.

"The Stepping Up protocol worked in Australia, and I think it could also work in the US. We need to keep looking for alternative, innovative models of care and study them," she explained.

And in fact, UPMC has a similar program in several of its primary-care clinics, she noted, with certified diabetes educators themselves embedded in the primary-care practices and engaged in patient education and assisting people in achieving target glucose, blood pressure, and lipids, as well as improved quality of life (Contemp Clin Trials. 2014;39:124–131).

"When the physician can only spend 15 to 20 minutes with each patient, you need some other individual to help with this process," Ms Antinori-Lent said.

"This model is exciting. They focused on starting insulin. That's just one part of the puzzle.…Improving glycemic control and helping patients with self-care behaviors are key as well."

Shifting Roles in Primary Care

More than three-quarters of the 74 primary-care practices included in the Australian study were private practice, with the rest either corporate practices or community-health centers. A total of 248 patients completed the 12-month follow-up.

The practices in the intervention group held a 60- to 90-minute on-site briefing and training session for the primary-care physicians and practice nurses. Eligible patients consulted the physician first, who referred them to the practice nurse. The nurse, in turn, discussed the pros and cons of insulin initiation and concerns and expectations with the patient but did not prescribe the insulin or manage the actual dosing. Registered nurses with diabetes educator credentials were available to support and mentor the practice nurse.

Practice nurses and physicians were encouraged to see patients as often as thought to be clinically appropriate over the study year, drawing on the diabetes nurse educator as needed (even for patients who remained reluctant to start insulin).

The intervention practices received 183 mentoring support visits from the diabetes nurse educator, with a mean of 5.2 visits per practice (range, 1–8).

The control practices were given a copy of the Australian type 2 diabetes management guidelines and offered training in the Stepping Up model after the study was completed.

Improved Insulin Initiation, Glycemic Control

For the primary outcome, change in HbA1c at 1 year, there was a statistically significant mean reduction of 0.6 percentage points with the Stepping Up intervention (P < .001), with most of the change achieved by 6 months.

In the intervention practices, 105 of 151 patients started insulin, compared with just 25 of the 115 in the control practices (odds ratio, 8.3; P < .001), with a median 32 vs 85 days to initiation in the two arms, respectively (P = .005).

Target HbA1c (≤7%) was achieved by twice as many patients in the intervention practices (36%), compared with 19% of the controls (odds ratio, 2.2; P = .02), with 32 of 54 intervention-practice patients using insulin at 12 months, compared with just two of 22 in the control practices.

Depressive symptoms had not worsened by 12 months, and there were no significant differences in scores on overall physical health, while scores for mental health favored the intervention.

However, at 12 months there was an average weight gain in the intervention arm vs weight loss in the control group (+1.7 kg vs  −1.1 kg). There were no significant differences in blood pressure or other biochemical measures between arms at follow-up, except that triglycerides remained higher in the control group.

No severe hypoglycemic events (requiring assistance) or other adverse events were reported in either study arm.

"Our effective model of care has the potential to improve outcomes while making better use of scarce healthcare resources," Dr Furler and colleagues write.

Ms. Antinori-Lent commented, "I think the ideal model would be to have a diabetes educator embedded in the practice, like at UPMC, but there aren't enough of us to go around. So, to have someone oversee implementation of this model is key."

In her personal experience, getting past the first injection is most of the battle, she says.

"Once you get a patient to see those tiny little 4-mm needles, once you put it in their skin, they usually say, 'Oh, that isn't as bad as I thought' or 'I didn't even feel that. I can do this.' "

She added that although incorporating the reorienting of a practice nurse's role into a business plan takes time and money up front, doing so could pay for itself if more patients meet benchmarks: "This would probably help them with reimbursement."

The study was funded by the Australian National Health and Medical Research Council and was supported by an educational/research grant by Roche Diagnostics Australia. The study was also supported by an educational/research grant by Roche Diabetes Care, the RACGP Foundation RACGP/Independent Practitioner Network Grant and received in-kind support from Sanofi. Dr Furler was supported by a National Health and Medical Research Council Career Development Fellowship. Disclosures for the coauthors are listed in the paper. Ms. Antinori-Lent has no relevant financial relationships.  

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BMJ.  Published online March 8, 2017. Abstract



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