Delivery of Multifactorial Interventions by Nurse and Dietitian Teams in a Community Setting to Prevent Diabetic Complications: A Quality-Improvement Report

Background

Clinical trials showed that multifactorial interventions can prevent microvascular and macrovascular complications of diabetes, but delivery of proven therapies in clinical practice is often suboptimal.

Study Design

Quality-improvement report.

Setting & Participants

Teams composed of a nurse and a dietitian were established in 5 communities, 2 urban and 3 rural, in Northern Alberta, Canada, and provided care for 424 individuals with diabetes plus hypertension or albuminuria.

Quality-Improvement Plan

To promote the use of proven therapies and achieve tight control of risk factors through community teams providing lifestyle advice, adjusting therapy using algorithms and regular follow-up.

Outcomes

The proportion of subjects prescribed angiotensin-converting enzyme–inhibitor, statin, and antiplatelet therapy and the proportion of subjects reaching targets for blood pressure (<130/80 mm Hg), blood glucose (hemoglobin A_1c [HbA_1c] < 7%), and low-density lipoprotein cholesterol (<96 mg/dL).

Measurements

Blood pressure, HbA_1c, low-density lipoprotein cholesterol, albumin-creatinine ratio, weight, and estimated glomerular filtration rate from serum creatinine.

Results

Blood pressure, HbA_1c, and low-density lipoprotein cholesterol levels improved during follow-up (133 ± 19/74 ± 11 versus 129 ± 17/71 ± 10 mm Hg, 8.1% ± 1.9% versus 7.5% ± 1.3%, and 104 ± 35 versus 93 ± 31 mg/dL, respectively; P < 0.001 for all), whereas there was no increase in weight (95 ± 22 versus 95 ± 23 kg; P = 0.3). The proportion of patients prescribed angiotensin-converting enzyme–inhibitor, lipid-lowering, and antiplatelet therapy increased (37% versus 60.1%; P < 0.001), as did the proportion of patients reaching targets for blood pressure, low-density lipoprotein cholesterol (43.5% versus 55% and 43.4% versus 61.6%, respectively; P < 0.001), and HbA_1c levels (32.1% versus 38.8%; P < 0.05).

Limitations

Short duration of follow-up and absence of economic evaluation, validity, and generalizability require confirmation in clinical trials and other settings.

Conclusions

Delivery of multifactorial interventions by nurse/dietitian teams in a community setting appears feasible and may achieve clinically significant improvements in blood pressure, lipids, and glycemic control, which would be expected to decrease cardiovascular morbidity and mortality.

Index Words: Diabetes, cardiovascular disease, diabetic nephropathy, prevention, health care delivery