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Nurse Case Management To Improve Glycemic Control in Diabetic Patients in a Health Maintenance Organization: A Randomized, Controlled Trial

Ronald E. Aubert, PhD, MSPH; William H. Herman, MD, MPH; Janice Waters, RN, CDE; William Moore, MD; David Sutton, MD; Bercedis L. Peterson, MS, PhD; Cathy M. Bailey, BS; and Jeffrey P. Koplan, MD, MPH
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From Prudential Center for Health Care Research, Atlanta, Georgia; University of Michigan School of Medicine, Ann Arbor, Michigan; Jacksonville Health Care Group and Northeast Florida Endocrine and Diabetes, P.A., Jacksonville, Florida; and Duke University Medical Center, Durham, North Carolina. Acknowledgments: The authors thank the study coordinator, Stephanie Powers, for coordination of all aspects of the primary data collection; Mary Cogswell for assistance with study development; Maryjo Greco-Krumviede and Pat Barta for their participation in algorithm development; Mary-Grace Flaherty and Xiomara Rivera for review and assistance with manuscript preparation; the physicians and staff of the Jacksonville Health Care Group; the Prudential HealthCare plan members for their participation and support; and Roche Diagnostics/Boehringer Mannheim Corporation for the in-kind contribution of Accu-Chek Advantage blood glucose meters and monitoring strips. Requests for Reprints: Ronald E. Aubert, PhD, MSPH, Prudential Center for Health Care Research, 2859 Paces Ferry Road, Suite 820, Atlanta, GA 30339. Current Author Addresses: Drs. Aubert and Koplan and Ms. Bailey: Prudential Center for Health Care Research, 2859 Paces Ferry Road, Suite 820, Atlanta, GA 30339.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(8):605-612. doi:10.7326/0003-4819-129-8-199810150-00004
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Background: Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control.

Objective: To compare diabetes control in patients receiving nurse case management and patients receiving usual care.

Design: Randomized, controlled trial.

Setting: Primary care clinics in a group-model health maintenance organization (HMO).

Patients: 17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus.

Intervention: The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist. Changes in therapy were communicated to primary care physicians. All patients received ongoing care through their primary care physicians.

Measurements: The primary outcome, hemoglobin A1c (HbA1c) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed.

Results: 72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA1c values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA1c values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events.

Conclusions: A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.


Grahic Jump Location
Figure 1.
Algorithm for management of type 2 diabetes mellitus.1c1c

HbA = hemoglobin A ; NPH = neutral protamine Hagedorn.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Mean hemoglobin A1c (HbA1c) change score by baseline HbA1c quintile and treatment group.

Dashed line represents usual care; solid line represents nurse case management.

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Grahic Jump Location
Figure 3.
Mean hemoglobin A1c (HbA1c) value at follow-up by treatment group.

Dashed line represents nurse case management; solid line represents usual care.

Grahic Jump Location




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