Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization - A randomized, controlled trial

Background: Control of hyperglycemia delays or prevents complications of diabetes, but many persons with diabetes do not achieve optimal control. Objective: To compare diabetes control in patients receiving nurse case management and patients receiving usual care. Design: Randomized, controlled trial. Setting: Primary care clinics in a group-model health maintenance organization (HMO). Patients: 17 patients with type 1 diabetes mellitus and 121 patients with type 2 diabetes mellitus. Intervention: The nurse case manager followed written management algorithms under the direction of a family physician and an endocrinologist, Changes in therapy were communicated to primary care physicians. All patients received ongoing ca re through their primary care physicians. Measurements: The primary outcome, hemoglobin A(1c) (HbA(1c)) value, was measured at baseline and at 12 months. Fasting blood glucose levels, medication type and dose, body weight, blood pressure, lipid levels, patient-perceived health status, episodes of severe hypoglycemia, and emergency department and hospital admissions were also assessed. Results: 72% of patients completed follow-up. Patients in the nurse case management group had mean decreases of 1.7 percentage points in HbA(1c) values and 43 mg/dL (2.38 mmol/L) in fasting glucose levels; patients in the usual care group had decreases of 0.6 percentage points in HbA(1c) values and 15 mg/dL (0.83 mmol/L) in fasting glucose levels (P < 0.01). Self-reported health status improved in the nurse case management group (P = 0.02). The nurse case management intervention was not associated with statistically significant changes in medication type or dose, body weight, blood pressure, or lipids or with adverse events. Conclusions: A nurse case manager with considerable management responsibility can, in association with primary care physicians and an endocrinologist, help improve glycemic control in diabetic patients in a group-model HMO.