Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Nurse contacts improved glycemic control

ACP J Club. 1995 July-Aug;123:14. doi:10.7326/ACPJC-1995-123-1-014


Source Citation

Weinberger M, Kirkman MS, Samsa GP, et al. A nurse-coordinated intervention for primary care patients with non-insulin-dependent diabetes mellitus: impact on glycemic control and health-related quality of life. J Gen Intern Med. 1995 Feb;10:59-66.


Abstract

Objective

To evaluate nurse-initiated telephone contacts between visits to primary care physicians for patients with type 2 diabetes mellitus.

Design

Randomized controlled trial with 1-year follow-up.

Setting

General medicine clinic (GMC) of a U.S. Veterans Affairs medical center (VAMC).

Patients

275 patients (mean age 63 y, 99% men, 9% white) who had type 2 diabetes and were using an oral hypoglycemic agent or insulin, had access to a telephone, and received primary care from the VAMC GMC. Patients were excluded if they were not competent for interview; lived in a nursing home; had severely impaired vision, hearing, or speech; or were expected to die within 1 year. Follow-up was 91%.

Intervention

After stratification by insulin use, patients were allocated to monthly telephone intervention with 1 of 3 nurses (n = 204) or to a usual care group (n = 71). Intervention patients were interviewed by a nurse at least once a month about their medication, diet, and glucose monitoring; their means of achieving compliance; and their hypoglycemic and hyperglycemic symptoms. The nurse also helped facilitate communication with the GMC physician, discussed upcoming outpatient appointments, and encouraged patients to call with questions.

Main outcome measures

Glycemic control (glycosylated hemoglobin [GHb] and fasting blood sugar [FBS] levels), health-related quality of life (scores measuring functional status, well-being, and general health perception), and number of diabetes-related symptoms (patient self-reports of hyperglycemia and hypoglycemia).

Main results

At 1 year, the mean number of contacts per intervention group patient was 13. Patients in the intervention group had better glycemic control than control patients (mean FBS 9.7 mmol/L vs 10.7 mmol/L, P = 0.011 and mean GHb 10.5% vs 11.1%, P = 0.046, respectively). The groups did not differ for measures of health-related quality of life or for diabetes-related symptoms.

Conclusion

Telephone contacts by nurses with patients with type 2 diabetes mellitus were effective in achieving glycemic control but did not affect health-related quality of life or the number of diabetes-related symptoms.

Source of funding: Department of Veterans Affairs.

For article reprint: Dr. M. Weinberger, Health Services (11H), Roudesbush VA Medical Center, 1481 West Tenth Street, Indianapolis, IN 46202, USA.FAX 317-554-0114.


Commentary

The study by Weinberger and colleagues is a well-designed randomized study of a complex intervention for patients with type 2 diabetes mellitus. Preemptive phone management by trained nurses who monitored patient symptoms, advised about dietary modifications, and facilitated access to physician care when appropriate improved glycemic control but did not affect health-related quality of life.

There are 3 noteworthy aspects of this study. First, the generalizability is limited. The study included men who were military veterans, the intervention was open-ended (nurses were free to provide various medical services), the patients had high comorbidity (patients took 5 to 6 medications at baseline), and the improved access to care may have allowed more medication adjustments. Second, the effect on GHb was modest. No effect on quality of life resulted. Finally, the increased resource allocation per patient was trivial (12 min/mo); the outcome improvement came at little cost.

Substantial improvement in physiologic outcomes from telephone-based home care will probably require more elaborate interventions. Specifically, they must address the inherent individual variation within all chronic illness and incorporate personalized care that integrates the social, ethnic, and medical characteristics of each patient. As every clinician knows, changing patient behavior is difficult even when better health is the goal. This study encourages further work. Perhaps it is time to ask our patients for help.

John D. Goodson, MD
Harvard Medical SchoolBoston, Massachusetts, USA