Nurse Managed Protocols Improve Health Outcomes

According to a recent study, the use of nurse managed protocols in caring for patients with chronic conditions, such as diabetes, hypertension, and hyperlipidemia, showed a benefit in performance measures for all 3 conditions [Ann Intern Med. 2014;161(12):113-121].

Diabetes, hypertension, and hyperlipidemia are chronic diseases that cause significant morbidity and mortality, and it is well known that gaps exist between recommended care and actual delivered care.

In an interview with First Report Managed Care, Ryan J. Shaw, PhD, RN, assistant professor, school of nursing, Duke University, said, “There is a shortage of primary care physicians, and as a result of the [Patient Protection and] Affordable Care Act, there are millions of new patients coming into the healthcare system. New models for managing chronic conditions, which consume 75% of US healthcare spending, are greatly needed. Registered nurses, the nation’s largest healthcare workforce, may be valuable [resources] that physicians can use to help meet these needs.”

If clearly defined protocols and training are given, nurses may be able to order relevant diagnostic tests, adjust routine medication, and appropriately refer patients. Dr. Shaw and his colleagues conducted a systematic review and meta-analysis to evaluate the effects of nurse managed protocols for the outpatient management of patients with diabetes, hypertension, and hyperlipidemia.

The researchers included 18 unique studies with a total of 23,004 patients extracted from sources such as MEDLINE and the Cochrane Central Register of Controlled Trials. Of these, 16 were randomized, controlled trials and 2 were controlled, before-and-after studies on diabetes. The primary outcomes were the effects of nurse managed protocols on biophysical markers, including changes in glycated hemoglobin (HbA1c), blood pressure (BP), and cholesterol levels, as well as changes in patient treatment adherence, nurse protocol adherence, adverse effects, and resource utilization. All of the studies used a protocol and required the nurse to titrate medications; 11 studies allowed the nurse to initiate new medications.

There were 15 studies focusing on patients with diabetes, 10 of which were randomized, controlled trials evaluating glucose control. Results of the randomized, controlled trials showed nurse managed protocols decreased HbA1c levels by 0.4% compared with usual care. The other 2 studies that were not randomized, controlled trials also showed a decrease in HbA1c but with greater variability.

Among the 14 studies that reported BP outcomes, nurse managed protocols were associated with a mean decrease in systolic BP (SBP) and diastolic BP (DBP). Results of the 12 randomized, controlled trials that specifically addressed BP showed SBP decreased by 3.68 mm Hg and DBP decreased by 1.56 mm Hg. The researchers estimated that the absolute treatment effect was a risk difference of 120 more patients achieving target BP per 1000 patients.

A total of 15 studies reported hyperlipidemia outcomes, 13 of which were randomized, controlled trials. All trials found the protocol to be associated with a mean decrease in both total and low-density lipoprotein (LDL) cholesterol. Specifically, results of the randomized, controlled trials demonstrated that the nurse managed protocols led to a decrease of 0.24 mmol/L in total cholesterol level and a decrease of 0.31 mmol/L in LDL cholesterol. The researchers also found that nurse managed protocols were statistically significantly more likely to achieve target cholesterol levels than control protocols. The absolute treatment effect was a risk difference of 106 more patients achieving target cholesterol per 1000 patients.

Nurse managed protocols also showed positive effects on other outcomes, including patient adherence to treatment, nurse adherence to protocols, adverse effects, and resource use. The strength of evidence was insufficient to determine a treatment effect for protocol adherence, adverse effects, and resource use. The researchers acknowledged some limitations of the study, one of which was the lack of detailed descriptions on the interventions and protocols used.

“We found that with clearly defined protocols and training, nurses in outpatient settings may be able to order relevant diagnostic tests, adjust routine medications, and appropriately refer patients with common chronic conditions,” Dr. Shaw concluded. “Nurses would not practice by themselves but would be working as part of a team, including physicians, pharmacists, and other health professionals. They would be closely monitored and would manage these chronic conditions on the physician’s orders. This is similar to what we already do in many inpatient hospital settings.”—Mary Mihalovic