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FORUM - Translating research into quality health care for Veterans

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Research Highlight

One of Secretary Shulkin's top five priorities is "improving timeliness of services." Meeting this priority will require strategies that emphasize efficiency in healthcare delivery such as the VA Patient Aligned Care Teams (PACTs). Launched in 2011, PACT uses alternative formats for care delivery such as shared medical appointments and telemedicine. PACT also embraces the value of team-based care. In this spirit, new strategies for expanding the roles and responsibilities of interdisciplinary PACT team members, including nurses, are being developed and tested. One such strategy is "nurse-managed protocols," whereby nurses take on an expanded role in the management of selected chronic medical conditions by following a protocol set by current clinical guidelines or standards of practice.

The VA Evidence-based Synthesis Program (ESP) provides timely and accurate syntheses of targeted healthcare topics of importance to clinicians, managers, and policymakers. In the past decade, the four VA ESP centers have supported VA policy and clinicians with more than 125 evidence reports. The Durham ESP completed a synthesis of studies evaluating nurse-managed protocols for the outpatient management of adults with type 2 diabetes, hypertension, hyperlipidemia, and congestive heart failure (CHF).1, 2 Investigators examined peer-reviewed publications from January 1980 through December 2012 that evaluated interventions using nurse-managed protocols compared with usual care targeting adults with the aforementioned conditions. The evidence review included 29 unique studies, of which 26 were randomized controlled trials.

One of the key questions examined by the evidence review is whether nursemanaged protocols (compared with usual care) improve indicators of clinical quality and resource utilization of Veterans with chronic medical conditions. Overall, the evidence review found that for patients with elevated cardiovascular risk, interventions using nurse-managed protocols had a small to moderate positive effect on improving HbA1c, blood pressure, and hyperlipidemia, but effects varied substantially across studies. Nurse-managed protocols compared with usual care also were associated with more patients reaching target goals in total cholesterol and blood pressure.

For patients with CHF, nurse-managed protocols were associated with lower all-cause mortality, more patients being prescribed an angiotensin-converting enzyme inhibitor or angiotensin receptor blocking (ACE/ ARB) agent, and decreased CHF-related hospitalizations compared with usual care. Effects on other outcomes such as nursing staff satisfaction and treatment adherence were reported infrequently. All studies used an RN who had autonomy to titrate medications, and in most studies, initiated medications per protocol.

The evidence review also examined how well participating nurses adhered to the protocol. The review found that while indirect evidence (e.g., improved outcomes) suggests nurses adhere to protocols, direct evidence (e.g., through fidelity checks) is insufficient to establish how well nurses adhere to protocols when engaged in delivering nurse-managed care.

Finally, the evidence review sought to determine whether there are adverse effects associated with the use of nurse-managed protocols. Only one fair-quality study on diabetes in a health maintenance organization reported on adverse events. Severe low blood glucose events were identical (1.5 percent) at baseline and increased similarly, 2.9 percent in the control group compared with 3.1 percent in the intervention group.

With the implementation of PACTs, VA has begun to reconfigure team-based care models to expand the responsibilities of team members, such as nurses, to practice to the full extent of their education and training. Results from this systematic review and meta-analysis suggest that nursemanaged protocols have positive effects on the outpatient management of adults with stable, common chronic conditions such as type 2 diabetes, hypertension, hyperlipidemia, and CHF. However, descriptions of how nurses are trained to assume this expanded role are not well reported. Additionally, subgroup analyses showed some differences between in-person and telephone- based protocols. For example, interventions delivered primarily by telephone showed significantly greater effects for total and LDL cholesterol in patients with elevated cardiovascular risk, and greater mortality reductions in patients with CHF.

Evidence exists to support the effectiveness of nurse-delivered interventions in the management of Veterans with diabetes.3 Efforts are also underway to develop and test nurse-managed protocols in cardiology at the Durham VAHCS. Nurses constitute the largest healthcare workforce group employed at VA, thus they are in an ideal position to collaborate with other team members to increase access of effective care for Veterans with chronic diseases.

  1. Shaw RJ, et al. "Effects of Nurse-Managed Protocols in the Outpatient Management of Adults with Chronic Illness," VA-ESP Project #09-010; 2013.
  2. Shaw RJ, et al. "Effects of Nurse-managed Protocols in the Outpatient Management of Adults with Chronic Conditions: a Systematic Review and Meta-analysis," Annals of Internal Medicine 2014; 161(2):113-21.
  3. Watts SA, Sood A, "Diabetes Nurse Case Management: Improving Glucose Control: 10 Years of Quality Improvement Follow-up Data," Applied Nursing Research 2016; (29), 202-5. To view VA Evidence-based Synthesis Program reports or to nominate a review, go to www.hsrd.research.

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