Diabetes Control in the Community, Under the Management of a Diabetes-Clinic Nurse Specialist, and the Effect of a Parallel Diabetologist Advice

Abstract

Introduction:

Nurses play a key role in managing care and educating people with diabetes in various healthcare systems worldwide, while physicians play this role in others. In addition, some healthcare systems authorize specialist nurses to change patient dose regimens. Therefore, we examined diabetes outcomes in the community by the management of a diabetes-clinic nurse only versus parallel management with a diabetologist.

Methods:

Retrospective data were collected for 100 consecutive people with diabetes registered in a community clinic with a diabetes-clinic nurse specialist as a case manager from 1/2018. About half of the patients selected received parallel advice from a diabetologist. Inclusion criteria included poor control of type 2 diabetes (HbA1c above 9%). Patients using an insulin pump, glucose sensor technologies, or multiple injection insulin programs were excluded.

Results:

One hundred people with diabetes who met the study criteria were included in the study, 64 males and a mean age of 60.03 ± 11.11. In a follow-up of 161.31 ± 68.65 days, HbA1c levels decreased by 3.17% ± 1.95% and did not change in a further follow-up of 162.36 ± 72.75 days. Significant improvement was also observed in controlling the other risk factors examined. Parallel consultation with a diabetologist and the nurse’s use of her authority for dose modifications showed no differences in all parameters. Logistic regression for analyzing the effect of the variables related to the patient showed only a moderate effect.

Conclusions:

Access to professional services remains a significant challenge for healthcare systems in long-term diabetes control. Monitoring poorly controlled people with diabetes with the help of a diabetes-clinic nurse specialist in the community clinic significantly improved diabetes and risk factors control and persisted long after the intervention. Healthcare systems should consider expanding the service of the diabetes-clinic nurse specialist in the community. Further studies will be required to examine the results in different patient subgroups.

Introduction

The incidence of diabetes has risen sharply in recent decades, with a faster rise in low- and middle-income countries. As a result, diabetes-related early mortality and complications have increased.¹ Comprehensive diabetes treatment includes glycemic control, healthy lifestyle guidance, and risk factors modifications. Therefore, people with diabetes require a systematic approach and a skilled staff with well-organized health services. Diabetes control protocols for various medical staff personnel and educators have been adopted in multiple centers worldwide.² These include nurses, nurse practitioners, physician assistants, primary care physicians, and diabetologists, either endocrinologists or diabetes specialist physicians.

As part of its role, the registered nurse (RN) is responsible for preventing and detecting diabetes early, identifying risk factors, and assisting patients in the control process. In addition, the nurse’s involvement helps improve the implementation of a customized treatment plan by the patient, including specific guidance for the patient, such as proper nutrition, glucose monitoring, medication adherence, and defining the control goals.³ Community nurses often receive postgraduate education and training in diabetes treatment. In Israel, for example, the Ministry of Health authorized RNs specializing in diabetes to change medication dosages of up to 50% in oral therapy and up to 20% in insulin therapy, subject to medical protocols.⁴

Several studies have shown the nurse’s success in identifying people with poorly controlled diabetes and helping them control the disease and reduce hospitalizations.^5,6 Other studies have shown the benefits of the nurse as a case manager for treating diabetes and their effect on HA1C and blood pressure control, especially for high-risk patients with poor control.^7-9 Another study investigated structured intervention by the clinic nurse for people with diabetes under routine follow-up of the family physician, compared to patients with family physician follow-up only. In a 12-month follow-up, the patients from the nurse intervention group had a higher prevalence of completing routine blood tests and lower cholesterol levels. Furthermore, only a minor change in HbA1c and blood pressure was noticed. However, the nurses in this study were general clinic nurses with no specific postgraduate education and training in diabetes control.¹⁰ In a previous study, we described the management of people with diabetes in the community following an intervention by an RN with diabetes training. After 25 months of follow-up, a decrease in HbA1c, LDL cholesterol, and systolic blood pressure was observed, in addition to increased visits to the GP, dietitian, and ophthalmologists.¹¹ The improvement in the control of HbA1c, LDL cholesterol, and systolic blood pressure continued with a further follow-up of 10 years, although the number of visits to the GP and dietitian decreased.¹²

Maccabi Healthcare Services (MHS) is the second-largest health fund in Israel, with 2.8 million insured people nationwide and over 150 000 people with diabetes, according to the diabetes registry. However, less than 10% of the people with diabetes in MHS are treated in diabetes clinics in the community. Therefore, in the past 7 years, MHS has implemented a model for managing people with diabetes. According to this model, the central diabetes clinic’s staff monitors people with diabetes in the community clinics. In this setting, a registered nurse working in the diabetes clinic serves as the case manager. We aimed to investigate diabetes control of poorly controlled people with diabetes in the community, with a nurse from a central diabetes clinic as the case manager, explicitly comparing the nurse-only care to the combined follow-up effect with a diabetologist physician.

Methods

The diabetes-clinic nurse service in MHS Central District was initiated in January 2018. All the people with uncontrolled diabetes treated in the primary care community clinic are referred to the nurse, an RN who usually works in the diabetes clinic. A diabetologist physician was available part-time. During their visits, the patients verified that they had enough medications and were prescribed as needed. Therefore, a patient who presented to the clinic during the diabetologist’s working hours was referred for additional consultation. Information about 100 people with type 2 diabetes who met the inclusion and exclusion criteria was anonymously collected. This convenience sample was built from the first 50 patients who presented to the clinic and were treated only by the RN. The other 50 patients were the first who presented to the clinic and were referred to parallel counseling by a diabetologist. Data were retrieved from the medical records from June to October 2021 for the consecutive people with diabetes who began diabetes follow-up in the community clinic on 1.1.2018. Inclusion criteria included the diagnosis of type 2 diabetes and HbA1c above 9% before they began diabetes follow-up in the clinic. Patients using an insulin pump, glucose sensor technologies, or multiple injection insulin programs were excluded. Data extracted included HbA1c, LDL cholesterol and triglycerides (TG) levels, and systolic and diastolic blood pressure measurements (SBP and DBP, respectively). All data were recorded as the last measurements before the beginning of the nurse’s intervention in the clinic and for 2 follow-ups, with at least 3 months apart between the visits. Additional data were: age, sex, and background diseases according to the medical records registries, such as heart disease, cancer, COPD, and hypertension. In addition, it was documented whether the nurse used their authority to change treatment doses for every patient and whether a diabetologist physician performed parallel counseling.

The data were analyzed using SPSS software version 27 using descriptive statistics. A paired t-test was used to compare measurements per patient, and an unpaired t-test was used to compare the groups of patients who required dose change by the RN or received additional advice from a diabetologist versus those who did not. Logistic regression was finally used to assess the effects of the variables on the nurse’s use of her authority to change dosage and parallel consultation with the diabetologist.

The study was approved by the research committee and the Ethics Committee of MHS (0094-21-MHS).

Results

One hundred consecutive patients who met the study criteria were identified, of whom 64 were males, and the mean age was 60.03 ± 11.11. Although the study aimed for half of the sample to be concurrently treated by a diabetologist physician as well, on data analysis, only 49 patients met this criterion. Data for the patient’s sample are described in Table 1. There were no baseline differences between the nurse-diabetologist and the nurse-only groups, including long-acting insulin, oral agents, and novel agents, except for the baseline LDL (one-tail P-value .043).

Table 1.

Baseline Characteristics.

	Whole sample (n = 100)				Nurse + Diabetologist					Nurse only
	N	Min	Max	Mean	N	Min	Max	Mean		N	Min	Max	Mean
Sex (M)	100			64	49			35		51			29
Age (year)	100	38.11	83.21	60.03 ± 11.11	49	39.48	83.21	58.92 ± 11.34		51	38.11	83.1	61.14 ± 10.87
Nurse authority usage (n)	97			32	46			18		51			14
Comorbidities
Hypertension (n, %)	100			54	49			26	53.1%	51			28	54.9%
Malignancy (n, %)	100			8	49			3	6.1%	51			5	9.8%
COPD (n, %)	100			11	49			5	10.2%	51			6	11.8%
Cardiovascular (n, %)	100			28	49			14	28.6%	51			14	27.5%
Renal failure (n, %)	100			47	49			24	49.0%	51			23	45.1%
Baseline laboratory
HbA1c (%)	100	9	15.6	10.96 ± 1.53	49	9	14.3	10.89 ± 1.62		51	9	15.6	11.03 ± 1.46
LDL (mg/dl)	65	29	232	109.28 ± 48.95	34	29	232	100.88 ± 47.01*		31	31	226	118.48 ± 50.14
Triglycerides (mg/dl)	92	74	1467	295.3 ± 255.18	47	82	806	265.49 ± 176.4		45	74	1467	326.44 ± 316.54
Systolic blood pressure (mmHg)	97	99	180	128.56 ± 15.83	48	99	170	128.1 ± 17		49	99	180	129 ± 14.77
Diastolic blood pressure (mmHg)	97	56	95	74.77 ± 8.78	48	56	95	73.79 ± 8.88		49	58	90	75.73 ± 8.66
Time to first visit
From diabetes diagnosis(months)	100	0	208.6	83.4 ± 71.2	49	0	208.6	83.6 ± 72.7		51	0	205	83.3 ± 70.4
From poor control (months)	100	0	154.9	14.2 ± 29.3	49	0	154	17.2 ± 31.9		51	0	154.9	11.1 ± 26.4

All comparisons between Nurse + Diabetologist versus Nurse Only were non significant, except LDL: one-tail t-test P = .043.

At the first follow-up of 161.31 ± 68.65 days (median 135.5 days), HbA1c levels decreased by 3.17% ± 1.95% (n = 100), and after the second follow-up of 162.36 ± 72.75 days (median 154 days), a further minor decrease of 0.067% ± 1.3% in HbA1c levels was observed. Parallel consultation by a diabetologist showed no significant differences in reducing HbA1c between the baseline and the first follow-up and between the first and second follow-ups (Figure 1) and no significant differences in LDL, TG, SBP, or DBP levels between the baseline and the first follow-up (Figure 2).

Figure 1.

HbA1c change between follow-up periods by parallel diabetologist consultation.

Abbreviation: ns, non significant.

*P < .05.

Figure 2.

Change in diabetes control measures from baseline by parallel diabetologist consultation.

Similarly, no significant differences were found in all parameters using the nurse’s authority to change doses. Logistic regression using the patient’s variables (background diseases, age, sex, and diabetes control) to model the probability of reducing HbA1c levels in the diabetologist-nurse arm, or using the nurse’s authority for dosage changes, showed only a mild effect (R² = .041, R² = .105, respectively).

Discussion

More than 5% of deaths are attributed to diabetes and its complications,¹³ so diabetes control is a high priority in the healthcare systems. To control the disease, there is a need to monitor and educate patients, commonly by an RN as the case manager, which has proven to be an effective means of controlling diabetes over time. In recent decades there has been a process of integrating a nurse specialist in diabetes to treat people with diabetes in the community. This process is positively perceived among primary care physicians to improve patient control.¹⁴

This study collected retrospective data for 100 patients, about half treated concurrently with a diabetologist. During a 5-month follow-up period, a decrease in HbA1c levels of 3.17% was observed and remained stable for an additional 5-month follow-up. These results are similar to data from similar studies examining glucose control changes in people with diabetes in similar follow-ups. Li et al⁸ showed a 2.72% reduction in HbA1c levels among patients treated by a nurse as a case manager for about 6 months. Another study we conducted showed a lower decrease in HbA1c levels of only 1.12%.¹¹ However, in contrast with the current study, where patients were significantly poorly controlled (HbA1c levels above 9%), the previous study enrolled patients with HbA1c levels above 7%.

A previous study showed that the primary clinic’s staff positively perceived consultations and follow-up by the professional personnel, which illustrates the importance of integrating this help to treat diabetes in the community.¹⁴ However, in analyzing the current study’s data according to a parallel consultation with a diabetologist, no significant differences were found in controlling glucose, lipids, or blood pressure. The similar improvement in these indices may be related to the primary physician’s involvement in managing the risk factors of the patients and the high level of patient education by the nurse.

The education of patients by medical personnel is a significant task in treating chronic diseases. Education can later be translated into an improvement in disease control. For example, in a study from New Zealand, the intervention of a nurse in a primary care clinic, which included patient education, resulted in an improvement in diabetes control and a reduction in the need for diabetologist visits.¹⁵ The improved diabetes control, in combination with the knowledge given by the nurse, probably contributed to the decrease in the need for diabetologist visits for further counseling. In contrast, a study conducted in France on people with diabetes showed that the main contributing factor to the education of patients about diabetes was follow-up and counseling by a diabetologist compared to nurse-only counseling.¹⁶ However, the later study examined general community nurses who only assisted patients with insulin injection and glucose monitoring and not a nurse specialist or an RN with specific training in diabetes.

No significant differences were found in all diabetes control parameters examined during follow-up by the nurse’s use of the authority for dose changes in this study. However, all patients received personal education from the nurse; therefore, this patient education can also explain this finding. Further studies will be required to examine these parameters in larger samples.

This study has several limitations. First, this study was conducted in only 1 clinic, with a small, convenience sample, and the results may not reflect the entire population of people with diabetes. However, the chosen clinic is a large, urban clinic representing central Israel’s urban population. Furthermore, the success rates in the overall reduction of blood glucose levels are comparable to those observed in other studies in other populations. Additional large-scale studies will be required to examine the results in different subpopulations. Secondly, patients were not randomly assigned to seek advice from a diabetologist. Those who did consult with a diabetologist might have been more difficult to control. However, the patients’ control measures (HbA1c, cholesterol, and blood pressure levels) were similar before the follow-up. Furthermore, the present study reflects a real-life situation without interfering with the patients’ options for consultation. Although specific populations of people with diabetes may require more intensive counseling, further dedicated research will be necessary to examine this issue. Third, patient selection bias was avoided by serial selecting all the eligible patients who visited the clinic. However, this study examined significantly poorly controlled patients (HbA1C > 9%). It is possible that the results may be related to the level of control of diabetes so that among patients with better control, significant differences will be found between parallel consultations with a diabetologist. Further studies are required to address this issue.

Conclusions

Diabetes treatment includes controlling blood glucose levels as well as treating risk factors. People with diabetes in various health systems need a systematic approach with organized health services and skilled staff. Nurses have shown positive involvement in disease management, patient education, and improved chronic disease control.

This study demonstrated the benefit of controlling diabetes and associated risk factors by a diabetes specialist RN with authority to change medication doses, with or without a parallel diabetologist physician counseling.

Healthcare systems are advised to consider expanding the availability and authority of an RN who is an expert or skilled in diabetes to provide a desirable response to patients in the community.