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Effect of Nurse-Directed Diabetes Care in a Minority Population

From the Clinical Trials Unit, Charles R. Drew University, Los Angeles, California

Address correspondence and reprint requests to Mayer B. Davidson, MD, Director, Clinical Trials Unit, Charles R. Drew University, 1731 East 120th St., Los Angeles, CA 90059. E-mail: madavids{at}cdrewu.edu

OBJECTIVE—To determine whether diabetes care directed by nurses following detailed protocols and algorithms and supervised by a diabetologist results in meeting the evidence-based American Diabetes Association (ADA) process and outcome measures more often than care directed under usual care in a minority population.

RESEARCH DESIGN AND METHODS—Studies were mainly conducted in two Los Angeles County clinics. In clinic A, nurse-directed diabetes care was provided to 252 patients (92% Hispanic and 2% African-American) referred by their primary care providers. These patients were hierarchically matched with 252 diabetic patients in clinic B (79% Hispanic and 19% African American). When nurse-directed care was abruptly discontinued in clinic A for administrative reasons, it was reestablished in clinic B. Those patients were randomly selected from a teaching clinic, and the outcomes in 114 patients who completed 1 year were compared with outcomes derived the year before receiving nurses’ care. The following process and outcome measures were assessed in the study: 1) number of visits, 2) diabetes education, 3) nutritional counseling, 4) HbA_1c, 5) lipid profiles, 6) eye exams, 7) foot exams, 8) renal evaluations, and 9) ACE inhibitor therapy in appropriate patients.

RESULTS—For patients under nurse-directed diabetes care in both clinics A and B, almost all process measures were carried out significantly more frequently than for the appropriate control patients. Under the care of nurses in clinic A, HbA_1c levels fell 3.5% from 13.3 to 9.8% in the 120 patients who were followed for at least 6 months, as compared with a 1.5% fall from 12.3 to 10.8% under usual (physician-directed) care in clinic B. During the year before enrolling in nurse-directed care in clinic B, mean HbA_1c levels decreased from 10.0 to 8.5%. At the end of a year under the nurses’ care, the values fell further to 7.1%. The median value fell from 8.3 to 6.6%.

CONCLUSIONS—Specially trained nurses who follow detailed protocols and algorithms under the supervision of a diabetologist can markedly improve diabetes outcomes in a minority population. This approach could help blunt the increased morbidity and mortality noted in minority populations.

Abbreviations: ADA, American Diabetes Association • ARB, angiotensin receptor blocker • DMCP, Diabetes Managed Care Program • ESRD, end-stage renal disease

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