Objective: To compare outcome measures of nurse-directed diabetes management for 9 to 12 months between a nonintegrated model (patients removed from the primary care clinic and followed up in a separate diabetes clinic with supervision by an endocrinologist) and an integrated model (nurse placed in the primary care clinic with supervision by primary care physicians).
Study design: Observational.
Methods: A nurse trained to follow approved detailed treatment algorithms (glycemia and dyslipidemia algorithms for both models plus a hypertension algorithm for the integrated model) was given prescription authority.
Results: A total of 367 patients were randomly selected from a primary care clinic for the nonintegrated model, and 178 patients were referred to the nurse by primary care physicians for the subsequent integrated model. Ultimately, one quarter of patients in the nonintegrated model were using insulin (mostly bedtime insulin only), while three quarters of patients in the integrated model were using insulin (mostly intensified regimens). The initial mean (SD) glycosylated hemoglobin (A1C) levels fell from 8.9% (2.6%) to 7.0% (1.2%) of total hemoglobin in the nonintegrated model and from 11.1% (2.3%) to 7.2% (0.9%) of total hemoglobin in the integrated model (to convert A1C level to proportion of total hemoglobin, multiply by 0.01). Taking initial values into account, the final A1C levels were not statistically different (P = .61). In the nonintegrated and integrated models, respectively, 60% and 49% met the American Diabetes Association (ADA) A1C goal, and 82% and 96% met the low-density lipoprotein cholesterol (LDLC) goal. In the integrated model, 90% met the blood pressure (BP) goal, and 47% met all 3 goals (ADA A1C, LDL-C, and BP).
Conclusion: An integrated model of diabetes care is generalizable and should be considered by policy makers to improve diabetes outcomes, especially among underserved minority populations.