Delivery of multifactorial interventions by nurse and dietitian teams in a community setting to prevent diabetic complications: a quality-improvement report

Abstract

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.