Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

Abstract

BACKGROUND: Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions. OBJECTIVE: To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases. DESIGN: The study was designed as a patient-level randomized controlled trial. PARTICIPANTS: Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c]≥ 7.5 %) but could have well-controlled HTN. INTERVENTIONS: All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM-and HTN-focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention). MAIN OUTCOMES AND MEASURES: Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point. RESULTS: Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55 % female and 50 % white; the mean baseline A1c was 9.1 % (SD=1 %) and mean SBP was 142 mmHg (SD=20). Eighty-two percent of scheduled interviews were conducted; 69 % of intervention patients and 70 % of control patients reached the 24-month time point. Expressing model estimated differences as (intervention -control), at 24 months, intervention patients had similar A1c [diff=0.1 %, 95 % CI (−0.3, 0.5), p=0.51] and SBP [diff=−0.9 mmH g, 95% CI (−5.4, 3.5), p=0.68] values compared to control patients. Likewise, DBP (diff=0.4 mmHg, p=0.76), weight (diff=0.3 kg, p=0.80), and physical activity levels (diff=153 MET-min/week, p=0.41) were similar between control and intervention patients. Results were also similar at the 6-and 12-month time points. CONCLUSIONS: In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.

The effect of a practice‐based multicomponent intervention that includes health coaching on medication adherence and blood pressure control in rural primary care

“…In this study, the investigators demonstrate that a practice‐based, multicomponent intervention, including monthly phone‐based health coaching delivered by local health coaches, in conjunction with home BP monitoring and practice improvement activities, improves medication adherence and produces modest reduction in BP over 2 years in rural African American and white patients with a history of uncontrolled HTN. These findings are consistent with prior investigators’ findings, but extend this work to include rural and minority patients with uncontrolled hypertension in a primary care anchored delivery model.…”

“…Many interventions have been tested to improve BP control in patients with HTN . The findings from randomized controlled trials (RCTs) have indicated that the use of antihypertensive drug therapy is one of the most effective ways to reduce both systolic and diastolic BP .…”

Profile of nursing diagnoses in people with hypertension and diabetes

“…Afterwards, the nursing diagnoses were compared and, when there was disagreement, the two researchers debated until reaching an agreement. The data obtained were organized in a database built in the software Excel version 2016 and statistical analysis was done through the Statistical Package for the Social Sciences (SPSS), version 21 …”

“…(9) Studies addressing ND for hypertensive and diabetic individuals were found, however, with small number of participants and convenience sampling, (12) case study, (13,14) others studies addressing ND/nursing interventions for hypertensive people only (15)(16)(17) or describing the ND/nursing process for diabetics (18,19) and addressing the management of the two chronic diseases without describing the ND. (20,21) Therefore, although there has been a wide discussion about the nursing process and the management of hypertension and DM, there has also been a shortage of articles describing the profile of ND of hypertensive individuals and also diabetic users of PHC with sample size from the population of interest and with data obtained through anamnesis and physical examination of all the participants by the researchers themselves. Within this perspective, this study is of great relevance to improve the care of nurses working in PHC, as well as to corroborate or confront the existing NDs in the literature.…”

Capsule Commentary on Edelman et al., Nurse-Led Behavioral Management of Diabetes and Hypertension in Community Practices: A Randomized Trial

“…1 Patients who received the intervention showed no improvement in primary endpoints of systolic blood pressure or HbA1c compared to patients in the control group. Additionally, the two groups were similar for all secondary outcomes, including diastolic blood pressure, weight, and physical activity.…”