Effectiveness of diabetes resource nurse case management and physician profiling in a fee-for-service setting: a cluster randomized trial

Abstract

Nurses with advanced training-diabetes resource nurses (DRNs)-can improve care for people with diabetes in capitated payment settings. Their effectiveness in fee-for-service settings has not been investigated. We conducted a 12-month practice-randomized trial involving 22 practices in a fee-for-service metropolitan network with 92 primary care physicians caring for 1891 Medicare patients ≥65 years with diabetes mellitus. Each practice was randomized to one of three intervention groups: physician feedback on process measures using Medicare claims data; Medicare claims feedback plus feedback on clinical measures from medical record (MR) abstraction; or both types of feedback plus a practice-based DRN. The primary endpoint investigated was hemoglobin A(1c) level. Other measures were low-density lipoprotein (LDL) cholesterol level, blood pressure, annual hemoglobin A(1c) testing, annual LDL screening, annual eye exam, annual foot exam, and annual renal assessment. Data were collected from medical chart abstraction and Medicare claims. The number of patients with hemoglobin A(1c) <9% increased by 4 (0.9%) in the Claims group; 9 (2.1%) in the Claims + MR group (comparison with Claims: P = 0.97); and 16 (3.8%) in the DRN group (comparison with Claims: P = 0.31). Results were similar for the other clinical outcomes, with no differences significant at P = 0.10. For process of care measures, decreases were seen in all groups, with no significant differences in change scores. Quality improvement strategies must be evaluated in the appropriate setting. Initiatives that have been effective in capitated systems may not be effective in fee-for-service environments.

Figure

Flow diagram showing the randomization of practices to the study arms in the randomized controlled trial testing the effectiveness of a diabetes resource nurse in improving diabetes care for Medicare patients in a fee-for-service primary care setting. HTPN indicates HealthTexas Provider Network (the Baylor Health Care System–affiliated physician network in Dallas–Fort Worth, Texas); Claims study arm, feedback on diabetes processes of care provided, based on Medicare claims data; Claims + MR study arm, feedback on diabetes processes of care provided plus patient outcomes based on Medicare claims data and medical record abstraction; Claims + MR + DRN study arm, feedback on diabetes processes of care provided plus patient outcomes based on Medicare claims data and medical record abstraction, plus access to a practice-based diabetes resource nurse.