Study Overview
Objective. To determine whether nurse-managed protocols are effective for the outpatient management of adults with diabetes, hypertension, and hyperlipidemia.
Study design . Systematic review and meta-analysis.
Data sources . The authors searched MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL for English-language peer-reviewed studies published between January 1980 and January 2014 that evaluated interventions that compared nurse-managed protocols with usual care in investigations targeting adults with chronic conditions. Two reviewers used eligibility criteria to assess titles, abstracts, and full texts, and resolved their disagreements by discussion or by consulting a third reviewer. Eligibility criteria included the involvement of an RN or LPN functioning beyond the usual scope of practice, such as adjusting medications, and conducting interventions based on a written protocol.
Main outcome measures . The effects of nurse-managed protocols on biophysical markers, patient treatment adherence, nurse protocol adherence, adverse effects, and resource use. When quantitative synthesis was feasible, dichotomous outcomes were combined using odds ratios and continuous outcomes were combined using mean differences in random-effects models. When quantitative synthesis was not feasible, the authors annualized data qualitatively, giving more weight to evidence from higher-quality studies. They evaluated overall strength of evidence (SOE) by assessing risk of bias, consistency, directness, and precision, and assigned a rating of high, moderate, or low SOE, or insufficient evidence.
Main results . Of the 2954 studies in the search results, 18 were ultimately eligible and included in the review, 16 randomized controlled trials and 2 before and after diabetes studies. Eleven were done in Western Europe and 7 in the United States. An RN or non-US equivalent was the interventionist in all studies (none used an LPN). In only 11 of the 18 studies were nurses independently allowed to initiate new medications. The meta-analysis found that hemoglobin A1c (HbA1c) level decreased by 0.4% (moderate SOE) (95% confidence interval {CI}, 0.1% to 0.7%) ( n = 8), systolic and diastolic blood pressure decreased by 3.68 mm Hg (CI, 1.05 to 6.31) and 1.56 mm Hg (CI, 0.36 to 2.76), respectively (moderate SOE) ( n = 12); total cholesterol level decreased by 9.37 mg/dL (20.77-mg/dL decrease to 2.02-mg/dL increase) ( n = 9); and low-density-lipoprotein cholesterol level decreased by 12.07 mg/dL (CI, 28.27-mg/dL decrease to 4.13-mg/dL increase) (low SOE) ( n = 6). The SOE was insufficient to estimate a treatment effect for all other outcomes.
Conclusion. A team approach that uses nurse-managed protocols may have positive effects on the outpatient management of adults with chronic conditions such as diabetes, hypertension, and hyperlipidemia.
Commentary
Hypertension, diabetes, and hyperlipidemia are major causes of morbidity and mortality worldwide and are widely prevalent in the United States. These chronic illnesses require long-term medical management, often requiring management of multiple medications and patient lifestyle changes and self-monitoring [1]. The patient-centered medical home, which involves a team approach, is increasingly being recognized as a promising model for delivering effective chronic disease care. Likewise, expanding the role of nurses as part of team care is increasingly being explored to help achieve high quality patient outcomes. The use of nurse-managed protocols can be an appropriate strategy in this scenario.
In this study, the researchers aimed to determine whether nurse-managed protocols are effective for outpatient management of adults with diabetes, hypertension, and hyperlipidemia and performed a systematic review and meta-analysis. Researchers followed a standardized procedure to conduct their search and carefully reviewed the studies, including contacting authors for missing data or clarification. They followed the approach recommended by the Agency for Healthcare Research and Quality (AHRQ) to evaluate the overall strength of the body of evidence [2].
However, some limitations must be taken into account. They acknowledge that they may have missed studies in which nurses had autonomy to practice in capacities beyond their scope of practice. In addition, the literature lacked details about the interventions and protocols used. Also, the researchers searched for studies across a 34-year range (1980–2014). Changes occurring in the nursing profession over these years may have impacted the findings.
Applications for Clinical Practice
Team-based care that includes nurse-managed protocols for titrating medications can be beneficial in the management of chronic conditions in primary care patients. With physician shortages predicted, which will impact primary care more than other specialties, team approaches using nurse-managed protocols have the potential to help lighten physician workloads and ensure quality care.
—Paloma Cesar de Sales, BN, RN, MS