Effectiveness of nurse practitioner coordinated team group visits for type 2 diabetes in medically underserved Appalachia

Teamwork and its impact on chronic disease clinical outcomes in primary care: a systematic review and meta-analysis

OBJECTIVE

Teamwork positively affects staff performance and patient outcomes in chronic disease management. However, there is limited research on the impact of specific team components on clinical outcomes. This review aims to explore the impact of teamwork components on key clinical outcomes of chronic diseases in primary care.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

This systematic review and meta-analysis conducted searching EMBASE, PubMed, Cochrane Central Register of Controlled Trials. Studies included must have at least one teamwork component, conducted in primary care for selected chronic diseases, and report an impact of teamwork on clinical outcomes. Mean differences and 95% confidence intervals were used to determine pooled effects of intervention.

RESULTS

A total of 54 studies from 1988 to 2021 were reviewed. Shared decision-making, roles sharing, and leadership were missing in most studies. Team-based intervention showed a reduction in mean systolic blood pressure (MD = 5.88, 95% CI 3.29-8.46, P= <0.001, I2 = 95%), diastolic blood pressure (MD = 3.23, 95% CI 1.53 to 4.92, P = <0.001, I2 = 94%), and HbA1C (MD = 0.38, 95% CI 0.21 to 0.54, P = <0.001, I2 = 58%). More team components led to better SBP and DBP outcomes, while individual team components have no impact on HbA1C. Fewer studies limit analysis of cholesterol levels, hospitalizations, emergency visits and chronic obstructive pulmonary disease-related outcomes.

CONCLUSION

Team-based interventions improve outcomes for chronic diseases, but more research is needed on managing cholesterol, hospitalizations, and chronic obstructive pulmonary disease. Studies with 4-5 team components were more effective in reducing systolic blood pressure and diastolic blood pressure. Heterogeneity should be considered, and additional research is needed to optimize interventions for specific patient populations.

Systematic review of the effectiveness of nurse-led care in reducing glycated haemoglobin in adults with Type 1 or 2 diabetes

BACKGROUND

Type 1 and 2 diabetes care, especially within primary health-care settings, has traditionally involved doctor-led clinics. However, with increasing chronic disease burden, there is scope for nurses to expand their role in assisting diabetes self-management.

AIMS

This study aimed to determine the effectiveness of nurse-led care in reducing glycated haemoglobin in adults with Type 1 or 2 diabetes.

METHODS

Methodology from the Joanna Briggs Institute Method for Systematic Review Research and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, including identifying publications, assessing study quality, summarizing evidence and interpreting findings. The search strategy involved using the Medical Subject Headings and keyword variations when searching MEDLINE (Ovid), Scopus, PubMed and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Inclusion criteria were samples with Type 1 or 2 diabetes, mean age of ≥18 years, English language studies and publication date of January 2011-December 2021.

RESULTS

Overall, 34 articles from 16 countries met inclusion criteria. Though not always clinically significant, results indicated that nurse-led care had beneficial impacts on glycated haemoglobin values, with reductions from 0.03% to 2.0%. This was evident when nurses received formal training, used treatment algorithms, had limited medical support, utilized technology and offered defined culturally sensitive and appropriate diabetes care.

CONCLUSIONS

Findings support nurse-led Type 1 and 2 diabetes care. Although further research is required, changes may necessitate increased recognition of nurse-led care and funding. Nurse-led care models should differ according to health-care settings.

Differences in Secure Messaging, Self-management, and Glycemic Control Between Rural and Urban Patients: Secondary Data Analysis

BACKGROUND

Rural patients with diabetes have difficulty accessing care and are at higher risk for poor diabetes management. Sustained use of patient portal features such as secure messaging (SM) can provide accessible support for diabetes self-management.

OBJECTIVE

This study explored whether rural patients' self-management and glycemic control was associated with the use of SM.

METHODS

This secondary, cross-sectional, mixed methods analysis of 448 veterans with diabetes used stratified random sampling to recruit a diverse sample from the United States (rural vs urban and good vs poor glycemic control). Administrative, clinical, survey, and interview data were used to determine patients' rurality, use of SM, diabetes self-management behaviors, and glycemic control. Moderated mediation analyses assessed these relationships.

RESULTS

The sample was 51% (n=229) rural and 49% (n=219) urban. Mean participant age was 66.4 years (SD 7.7 years). More frequent SM use was associated with better diabetes self-management (P=.007), which was associated with better glycemic control (P<.001). Among rural patients, SM use was indirectly associated with better glycemic control through improved diabetes self-management (95% CI 0.004-0.927). These effects were not observed among urban veterans with diabetes (95% CI -1.039 to 0.056). Rural patients were significantly more likely than urban patients to have diabetes-related content in their secure messages (P=.01).

CONCLUSIONS

More frequent SM use is associated with engaging in diabetes self-management, which, in turn, is associated with better diabetes control. Among rural patients with diabetes, SM use is indirectly associated with better diabetes control. Frequent patient-team communication through SM about diabetes-related content may help rural patients with diabetes self-management, resulting in better glycemic control.

A Narrative Review of Diabetes Group Visits in Low-Income and Underserved Settings

BACKGROUND

Prior studies have supported the efficacy of diabetes group visits. However, the benefit of diabetes group visits for low-income and underserved individuals is not clear. The purpose of this study was to conduct a narrative review in order to clarify the efficacy of diabetes group visits in low-income and underserved settings.

METHODS

The authors performed a narrative review, categorizing studies into nonrandomized and randomized.

RESULTS

A total of 14 studies were identified. Hemoglobin A1c was the most commonly measured outcome, which improved for the majority of group visit participants. Preventive care showed consistent improvement for intervention arms. There were several other study outcomes including metabolic (i.e., blood pressure), behavioral (i.e., exercise), functional (i.e., quality of life), and system-based (i.e., cost).

CONCLUSION

Diabetes group visits for low-income and underserved individuals resulted in superior preventive care but the impact on glycemic control remains unclear.

Optimizing adult diabetes care in community health

BACKGROUND AND PURPOSE

Diabetes mellitus is an epidemic. Many organizations and states have established reportable quality care measures. Our organization explored novel ways of chronic disease management. The purpose of this article is to decrease the percentage of patients with a hemoglobin A1c (HbA1c) more than 8%.

METHODS

Prospective, pre- and postintervention, quality improvement project was implemented in the Employee and Community Health Clinic using an endocrinology nurse practitioner (NP) to coordinate and provide care to adult patients with diabetes. A convenience sample of 103 patients with diabetes was selected for this project. Patients were excluded from the project if they did not complete preintervention satisfaction surveys or did not sign research release forms.

CONCLUSIONS

One hundred three patients were referred, and two met exclusion criteria. Of those patients, 51% were female with an average HbA1c of 9.1%. Eighty-one of the referred patients attended their appointment. The patients who sought care had a reduction in HbA1c from 9.0% ± 1.8% to 8.3% ± 1.7% (p value < .001). Patients who did not appear had no significant change in their HbA1c from 9.8% ± 3.1% to 9.4% ± 2.7% (p value = .61).

IMPLICATIONS FOR PRACTICE

Incorporating specialty trained NPs can lead to improvements in HbA1c, patient-reported control of diabetes, and a reduction in the frequency of hypoglycemia.

An overview of the outcomes and impact of specialist and advanced nursing and midwifery practice, on quality of care, cost and access to services: A narrative review

OBJECTIVES

This paper presents the results of a systematic rapid review and narrative synthesis of the literature of the outcomes and impact of specialist and advanced nursing and midwifery practice regarding quality of care, cost and access to services.

DESIGN

A rapid review was undertaken of the relevant national and international literature, regulatory and policy documents relating to the establishment and definition of nurses' and midwives' specialist and advanced practice roles.

DATA SOURCES

A search of the Cumulative Index to the Nursing and Allied Health Literature (CINAHL), PubMed (MEDLINE) was undertaken from 2012 to 2015. The study also included primary data collection on the perceived impact of specialist and advanced practice nursing and midwifery roles and enablers and barriers to these roles using semi-structured interviews. These are not included in this paper.

REVIEW METHOD

To facilitate a systematic approach to searching the literature, the PICO framework, was adapted.

RESULTS

The database search yielded 437 articles relevant to the analysis of specialist and advanced practice in relation to quality care, cost and access to services with additional articles added in a manual review of reference lists. In the final review a total of 86 articles were included as they fulfilled the eligibility criteria.

CONCLUSION

The evidence presented in the 86 articles indicates that nursing and midwifery practitioners continue to be under-utilised despite the evidence that greater reliance on advanced nurse practitioners could improve accessibility of primary care services while also saving on cost. Results point to continued difficulties associated with accurate measurement of the impact of these roles on patient outcomes. This review demonstrates that there is a need for robust measurement of the impact of these roles on patient outcomes.

Perceptions of Nursing in Appalachia: A State of the Science Paper

INTRODUCTION

Nursing practice is continuously evolving in response to global health care need, sociopolitical culture, and advancing medical knowledge necessitating ongoing evaluation of professional practice. The purpose of this state of this science paper was to explore current perceptions of nursing and critique the depth of knowledge specific to nursing practice in the Appalachian region.

METHODOLOGY

A review of the literature in multiple databases was conducted to explore perceptions of nursing in Appalachia.

RESULTS

Categories of perception included the following: (a) perceptions of nurses and education leaders that practice in the Appalachian region, (b) perceptions of communities of Appalachia and Appalachian health care systems, and (c) perceptions of patients possessing inherent cultural characteristics of the Appalachian region.

DISCUSSION

None of the literature specifically addressed perceptions of nursing. Much of the available literature was over 5 years old. A significant deficiency in understanding perceptions of nursing in Appalachia was identified.

Barriers to Diabetes Self-Management Among Rural Individuals in the Workplace

Higher rates of type 2 diabetes mellitus (T2DM) are found in rural populations and barriers lessen the ability of these individuals to effectively manage diabetes. By lessening potential barriers to self-care management, health professionals, especially occupational health nurses, can assist individuals confidently manage T2DM. In this article, the authors provide an overview of diabetes self-management barriers for rural populations and implications for health professionals who assist individuals with T2DM in the workplace.

Diabetes self-management interventions for adults with type 2 diabetes living in rural areas: a systematic literature review

In rural communities, high rates of diabetes and its complications are compounded by limited access to health care and scarce community resources. We systematically reviewed the evidence for the impact of diabetes self-management education interventions designed for patients living in rural areas on glycemic control and other diabetes outcomes. Fifteen studies met inclusion criteria. Ten were randomized controlled trials. Intervention strategies included in-person diabetes (n = 9) and telehealth (n = 6) interventions. Four studies demonstrated between group differences for biologic outcomes, four studies demonstrated changes in behavior, and three studies demonstrated changes in knowledge. Intervention dose was associated with improved A1c or weight loss in two studies and session attendance in one study. Interventions that included collaborative goal-setting were associated with improved metabolic outcomes and self-efficacy. Telehealth and face-to-face diabetes interventions are both promising strategies for rural communities. Effective interventions included collaborative goal-setting. Intervention dose was linked to better outcomes and higher attendance.

Shared medical appointments for patients with diabetes mellitus: a systematic review

OBJECTIVES

Shared medical appointments (SMAs) are an increasingly used system-redesign strategy for improving access to and quality of chronic illness care. We conducted a systematic review of the existing literature on SMA interventions for patients with diabetes in order to understand their impact on outcomes.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from January 1996 through April 2012. PubMed search updated June 2013.

STUDY SELECTION

English-language peer-reviewed publications of randomized controlled trials (RCTs), nonrandomized cluster controlled trials, controlled before-and-after studies, or interrupted time-series designs conducted among adult patients with diabetes. Two independent reviewers used prespecified criteria to screen titles and abstracts for full text review.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two different reviewers abstracted data and rated study quality and strength of evidence. When possible, we used random-effects models to synthesize the effects quantitatively, reporting by a weighted difference of the means when the same scale was used across studies, and a standardized mean difference when the scales differed. We measured heterogeneity in study effects using Forest Plots, Cochran's Q, and I(2), and explored heterogeneity by using subgroup analyses for categorical variables and meta-regression analyses for continuous or discrete variables. Outcomes not suitable to meta-analysis were summarized qualitatively.

RESULTS

Twenty-five articles representing 17 unique studies compared SMA interventions with usual care. Among patients with diabetes, SMAs improved hemoglobin A1c (∆ = -0.55 percentage points [95 % CI, -0.11 to -0.99]); improved systolic blood pressure (∆ = -5.2 mmHg [95 % CI, -3.0 to -7.4]); and did not improve LDL cholesterol (∆ = -6.6 mg/dl [95 % CI, 2.8 to -16.1]). Nonbiophysical outcomes, including economic outcomes, were reported too infrequently to meta-analyze, or to draw conclusions from. The A1c result had significant heterogeneity among studies, likely secondary to the heterogeneity among included SMA interventions.

LIMITATION

Heterogeneity among the components of diabetes SMAs leads to uncertainty about what makes a particular SMA successful.

CONCLUSION

SMA interventions improve biophysical outcomes among patients with diabetes. There was inadequate literature to determine SMA effects on patient experience, utilization, and costs.

Patient-centered group diabetes care: a practice innovation

The purpose of this project was to evaluate the efficacy of group diabetes care for an underserved population using a patient-centered approach with the inclusion of interactive diabetes self-management education. In place of the traditional office visit, patients attended three group visits. Improvements in diabetes knowledge and patient-perceived self-efficacy resulted.