There are approximately 25.8 million people in the US that have been diagnosed with diabetes. Type 2 diabetes is associated with many complications and coexisting conditions including kidney failure, nontraumatic lower-limb amputations, blindness, heart attacks and strokes, which could result in patients being depressed with low self-efficacy resulting in difficulty helping patients maintain good control of hemoglobin A1c levels. The aim of this quality-improvement project was to evaluate whether NPs in collaborative practices with PCPs are effective in improving control of HbA1c, BP, and low-density lipoprotein cholesterol (LDL-C) values in adult patients with uncontrolled hyperglycemia, and to assess whether NP-guided care affects depression and self-efficacy in patients with uncontrolled hyperglycemia.
A prospective pre- and post-intervention quality-improvement project was implemented in primary care clinics using an NP to coordinate and provide care to adult patients with uncontrolled type 2 diabetes to improve the clinical metrics that affect their morbidity and mortality. Two ambulatory care internal medicine modules were used for this study which provide medical services to 3677 adult patients with type 2 diabetes with a convenience sample of 28 adult patients with type 2 diabetes and an HbA1c value of 8% or higher being selected for this project. Pre-intervention and post-intervention HbA1c values were evaluated as the primary outcome measure and values for BP, LDL-C, body weight, and depression and self-efficacy scores were secondary outcome measures.
Follow-up care, done every 2 to 5 weeks, over a period of five months was used to initiate and adjust medications, to order laboratory studies, to review and discuss laboratory results, to encourage lifestyle changes, to schedule office-based follow-up visits with the PCP or nurse, to refer patients to health education classes, to refer participants to specialty care, and to administer depression and self-efficacy screenings.
Results show that after interventions, 50% of 26 patients achieved HbA1c benchmarks, 95.6% achieved systolic and diastolic BP benchmarks, and 57.8% achieved LDL-C benchmarks and depression scores decreased slightly.
This study supports the evidence that integrating nurse practitioners into primary care teams can provide methods of support to adults with uncontrolled hyperglycemia that improve clinical outcomes and self-efficacy for patients with type 2 diabetes. It demonstrated significant improvements in patient’s HbA1c and self-efficacy scores from before to after intervention. NPs are effective in improving clinical metrics because of their capacity to initiate, change, and adjust medications or medication doses without physician authorization. The willingness of NPs to embrace alternate methods of patient communication (via telephone, e-mail or e-visits, faxes, and texting) to provide care to patients with diabetes may make them effective in improving HbA1c control.