Social, medical and economic burdens of diabetes care result from microvascular, macrovascular and neurological complications. Sustained reduction in hyperglycemia can reduce the incidence of these complications by as much as 50 percent. Studies have demonstrated improved glycemic control with nurse case-management or educational care models. However, none have controlled for their independent contributions, intervened with advanced practice nurses (APN), or targeted highest risk individuals.
The objective of this project is to examine whether interventions of diabetes self-management education programs with or without APN case managers improve outcomes and are cost effective.
Patients were randomly assigned to one of four groups: 1) Disease-management and diabetes education; 2) Disease-management alone; 3) Diabetes education alone; and 4) Routine Care. Veterans receiving primary care in VISN-5 and meeting high-risk criteria (HbA1c ³ 9.0%) were screened for inclusion. Patient outcome measures were collected at baseline, three months and twelve months. These included: Quality of Life (QOL), HgbAlc levels, and incidence of diabetes-related hospitalizations/ER visits. In addition, patient-level intervention costs, health care use and costs were examined. ANOVA comparisons were used to test hypotheses.
From 1999 through 2002, 708 patients were randomized to the four groups; 526 remained in the study for at least three months and 233 completed twelve months. At three months, groups receiving disease-management with diabetes education or disease-management alone experienced a mean decrease in A1c levels of 2.14 and 2.38, respectively and were significantly different from routine care. A1c changes at twelve months decreased on average of 2.35 and 2.39 respectively, and remained significantly different from routine care. Changes in QOL and preliminary expenditure analyses showed no significant differences between intervened and routine care groups.
The study’s impact on change in A1c is significantly greater in the intervention groups that received APN case-management than in the routine care group at three and twelve months. No intervention impact was detected in the QOL measure. The American Diabetes Association awarded National Recognition to the Diabetes Self-Management Education component of this grant for meeting evidence-based standards in clinical practice.
- Bradham DD, Mangan M, Warrick A, Geiger-Brown J, Reiner JI, Saunders HJ. Linking innovative nursing practice to health services research. The Nursing Clinics of North America. 2000 Jun 1; 35(2):557-68.