Impact of nurse case management on diabetes co-morbidity

描述(由申请人提供)： 尽管有强有力的证据表明，达到推荐的糖化血红蛋白、低密度脂蛋白胆固醇和血压(BP)目标可以显著降低糖尿病患者的发病率、死亡率和成本，但大多数患者没有实现这些目标。我们研究计划的广泛目标是成功地将有关糖尿病治疗和管理的经验知识转化为可持续和有效的临床实践。目前的障碍包括医生接触时间不足，自我管理技能教育不足，培养行为改变和患者依从性的战略不足，以及将循证临床指南转化为实践的困难。护士病例管理(NCM)可以提供以较低的成本获得更好结果的机会。以前的研究只针对单一的临床参数(血糖控制)，而在很大程度上没有解决众所周知的与糖尿病相关的并发症，如高血压、高脂血症和抑郁症。 我们建议进行一项为期三年的随机临床试验，考察加强护士病例管理对高危糖尿病患者(糖化血红蛋白8.5、低密度脂蛋白130或血压140/90)的影响，并将纳入相当大的少数人群。护士病例经理将在与试验组的定期临床访问中会面，并采用更有条理的方法，通过使用激励性访谈技术来改善患者的自我管理和行为改变。NCM干预还将包括提供基本的糖尿病自我管理教育，跟踪患者结果，并执行程序的常规命令。措施。临床指南将被用来促使医生采取行动，护士将提供个性化的患者随访。我们的研究在解决NCM文献中的几个缺陷方面是独一无二的--成本效益、效果的持久性、对患者生活质量和依从性的影响以及患者和提供者的满意度。将使用有组织的培训计划，干预的细节将被很好地记录下来。最后，我们将审查遇到的障碍和克服这些障碍的手段，以及在高危人群中成功实施这种多风险因素干预所必需的组织要素。

DESCRIPTION (provided by applicant): Despite strong evidence that achieving recommended HbA1c, LDL cholesterol and blood pressure (BP) goals can substantially reduce morbidity, mortality, and costs in patients with diabetes, the majority of patients do not achieve these targets. The broad goal of our research program is to successfully translate empirical knowledge regarding diabetes treatment and management into sustainable and effective clinical practice. Current barriers include lack of physician contact time, insufficient education on self-management skills, inadequate strategies to foster behavior change and patient adherence, and the difficulty of translating evidence-based clinical guidelines into practice. Nurse case management (NCM) may offer the opportunity for better outcomes at lower cost. Previous studies have targeted a single clinical parameter (glycemic control) and have not, for the most part, addressed the well-known co-morbidities associated with diabetes such as hypertension, hyperlipidemia, and depression. We propose a three-year, randomized clinical trial examining the impact of enhanced nurse case management added to usual primary care given to high-risk patients with diabetes (HbA1c > 8.5, LDL cholesterol >130, or BP >140/90) and will include a significant minority population. Nurse case mangers will meet at regular clinic visits with the experimental group and engage in a more structured approach to improving patient self-management and behavior change through the use of motivational interviewing techniques. The NCM intervention will also include the provision of basic diabetes self-management education, tracking of patient outcomes, and implementation of standing orders for process . measures. Clinical guidelines will be used to prompt physician action and nurses will provide individualized patient follow-up . Our study is unique in addressing several shortcomings in the NCM literature- cost effectiveness, durability of effect, impact on quality of life and adherence of patients ; and satisfaction of both patients and providers. A structured training program will be used and specifics of the intervention will be well documented. Finally, we will examine the barriers encountered and means for overcoming them, as well as the organizational elements that are necessary to successfully implement this multiple risk factor intervention in high-risk populations.