Nurse Telephone Management of Cholesterol in Diabetes

Not Applicable

Completed

Brief Summary: The current project is evaluating the effect of a nurse-administered phone care in diabetes to improve access to care and healthcare delivery. The setting is a federally qualified community health center serving over 1600 diabetic patients, 80% of whom are Latino. Using our diabetes registry, we have randomly assigned 762 patients to either participate in a telephone-based, nurse-run outreach program (N=381) or to continue with usual care(N=381). Three of our registered nurses learned algorithms addressing management of cholesterol, blood pressure, kidney disease, aspirin use, eye screening, and pneumovax and influenza vaccines. The program began recruitment in September 2005 and has finished follow up in May 2007. The program initially focused only on cholesterol management utilizing national guidelines and algorithms on patients with elevated cholesterol (LDL) levels but has expanded to include glycemic and blood pressure control. We found that Registered Nurses were able and willing to provide telephone care to diabetic patients according to moderately complex algorithms and to track patient data electronically with overall job satisfaction. Overall, the nurses have expressed enthusiasm but have also experience frustrations with maintaining contact and improving motivation in patients. The impact of this program on diabetes outcomes and its cost-effectiveness is currently being analyzed with the goal of implementing this program in our institution.

Detailed Description: This randomized, controlled trial tested the effectiveness of a nurse-run, telephone-based intervention to improve lipid control in patients with diabetes. Our patient population is predominantly low-income and Latino. Using our diabetes registry, we randomly assigned 381 patients to continue with their usual care and 381 to participate in our nurse run program. Three registered nurses learned algorithms for diabetes care. These algorithms address management of lipids, glycemic control, blood pressure, nephropathy, aspirin use, eye screening, pneumovax and influenza vaccines, obesity, and cigarette smoking. The nurses were also trained in motivational interviewing techniques and facilitation of patient self-management. The primary goal was to improve lipid control in our diabetic population. Secondary outcomes address blood pressure control, glycemic control, renal function, and medication adherence. In addition, a cost-effective analysis is being performed.

Recruitment & Eligibility

Inclusion Criteria

Patients included in Denver Health diabetes registry.
Type I and Type II diabetic patients
Age >17 years old
Actively utilizing Westside Clinic for their primary care (at least two visits in the past year)
Speak either English or Spanish.

Exclusion Criteria

We sought to maximize the generalizability of the study and therefore had only minimal exclusion criteria:

Pregnant or lactating women
Patients with end-stage renal disease (creatinine > 3.0 mg/dl)
Patients with a co-morbid illness with life expectancy less than 12 months, (e.g. terminal cancer or Child's Class C hepatic cirrhosis).

Arm && Interventions

Group	Intervention	Description
Standard Care	Standard Clinical Care	Patients in the usual care or control group were contacted at the beginning of the study only if they had not had an LDL level in the previous 12 months. A letter requesting their presentation for an LDL test was sent to their last known address along with a lab slip and a reminder to schedule an appointment with their PCP for follow-up of results. No additional contact was made with them by the study nurses.
Phone Counseling	Phone Counseling	The telephone outreach intervention was considered an adjunct to usual care. The study nurse focused on optimizing lipids utilizing published guidelines through phone contact.

Primary Outcome Measures

Name	Time	Method
Number of Patients With a Low Density Lipid (LDL) Value Less Than 100 mg/dL	18 months	Number of patients with and without cardiovascular disease (CVD) with LDL value less than 100 mg/dL at the end of the study

Secondary Outcome Measures

Name	Time	Method
Number of CVD Patients With LDL Less Than 70 mg/dL.	18 months
Number of Patients With BP Less Than 130/80 mm Hg	18 months	Number of patients meeting blood pressure goals as defined by the American Diabetes Association guidelines.
Number of Patients With Hgb A1c Less Than 7 Percent at the End of the Study	18 months	Number of patients with Hgb A1c as recommended by the American Diabetes Association guidelines.