Effect of Nurse-Directed Diabetes Care in a Minority Population

Abstract

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.