The nurse specialist as main care-provider for patients with type 2 diabetes in a primary care setting: effects on patient outcomes
Introduction
As health care delivery is being reconfigured, so is the future role of care-providers. Diabetes care has gradually moved from the more traditional hospital clinic to care shared between secondary and primary care-providers (Hampson et al., 1996). However, as most patients with type 2 diabetes are being treated in primary care (de Sonnaville et al., 1997), because there is an increasing prevalence rate (Ruwaard et al., 1993), and because general practitioners (GPs) are facing a heavy and increasing workload (Duijn van and Mentink, 1998), a solution to safeguard high-quality diabetes care in the Netherlands may be to transfer the work carried out by physicians to other health care professionals.
Substitution of care can be divided into horizontal and vertical substitution. Horizontal substitution refers to the transfer of tasks between care-providers with comparable levels of expertise. This means that tasks can be transferred from specialist to generalist or from inside the hospital to outside the hospital. Vertical substitution refers to the transfer of tasks between care-providers across different levels of expertise. Substitution does not automatically imply a complete transfer, but it can also mean that the professionals share tasks and responsibilities to bridge deficiencies in care (Spreeuwenberg, 1994).
Following the US and the UK, the Netherlands too has seen nurses in a particular area of care expand their specialist skills into areas perhaps more traditionally seen as the activity of medicine (Barton et al., 1999). Despite the popularity of nurse specialists performing a new role in chronic care that challenges established professional boundaries, evaluation studies regarding the outcome and/or process variables are limited mainly due to the—as yet—underdeveloped nature of this field of study (McGillis Hall, 1997; Lengacher et al., 1997; Temmink et al., 2000; Vrijhoef et al., 2000).
In five general practices (11 GPs) in the region of Venlo, a pilot project was introduced in which a diabetes nurse performs the role as main care-provider within a shared care model for patients with type 2 diabetes. The jointly formulated objectives of this shared care model were (1) the improvement of glycaemic control of patients, (2) the efficient provision of diabetes care for patients, (3) the improvement of quality of life of patients as well as (4) their levels of satisfaction with respect to diabetes care.
In order to assess if the model is justified, evidence about the realisation of objectives (1), (3) and (4) as well as about the effects on other relevant patient outcomes were provided by this study. For this purpose selected patient outcomes were evaluated within a 12-month pretest–posttest design, while the subgroup of patients treated with oral hypoglycaemic agents (OHA) and/or insulin was compared with a group from another study directed at outpatients with stable type 2 diabetes (Vrijhoef et al., 2001). An indication for the efficiency of care delivered by the model was based on data from this study as well as from another study on the costs generated by this model (Keijzer, 1999).
Section snippets
Patients and setting
Patients were recruited from the population of five general practices (11 GPs) in the region of Venlo between September 1997 and April 1998. Patients with previously documented type 2 diabetes attending the general practice were invited by their GP to participate in the study. Patients were provided with a written description of the study and those who supplied written informed consent were enrolled. After enrolment, patients were followed for a period of 12 months. The study was approved by
Patients
Out of the 325 eligible patients identified by the GPs, 150 (46.2%) did not participate. Reasons for non-participation were lack of interest (7.7%), too much trouble (3.4%), several low prevalence reasons (6.5%, such as: mobility problems (0.9%), feeling too old (0.6%), private reasons (1.5%), admitted to hospital (2.2%), and unwilling to change care-provider (1.2%)) or unknown (28.6%). Data from consultations were available for all 175 participants. Data from questionnaires were available for
Discussion
The effectiveness of new models for chronic care has largely gone untested (Davis et al., 1999). In this study, evidence about a shared care model for patients with type 2 diabetes was gathered when the diabetes nurse was the main care-provider in a primary care setting. Applying a quasi-experimental design, it was found that the glycaemic control, diastolic blood pressure, and the concentration of total cholesterol and triglyceride of patients receiving shared care improved, while quality of
Conclusions
The evidence from this study seems to justify the continuation of a model of shared diabetes care with the diabetes nurse as main care-provider for patients with type 2 diabetes in a primary care setting. High quality care was safeguarded, while future research should provide evidence about the cost-effectiveness. With the continuous rise in the need for chronic disease management, the pressure will increase on nurses to deliver that care. When non-physicians are assigned the responsibilities
Acknowledgements
This study was supported by a grant from Stimuleringsprogramma Gezondheidsonderzoek [Incentive Programme for Health Care Research] and Health Insurer VGZ [Zorgverzekeraar VGZ]. The authors gratefully acknowledge the help of H. van Dam, H. Geven, A. Seegers (†), M. Vorstermans, and M. van Wilderen-Smeets in providing care in its broadest meaning and T. Vullings for her help with data-entry.
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