Nurse-managed protocols associated with modest improvement in control of chronic conditions, analysis finds

Medication titration by nurses according to protocols was associated with a modest improvement in control of chronic diseases in outpatient practice, a recent review and meta-analysis found.


Medication titration by nurses according to protocols was associated with a modest improvement in control of chronic diseases in outpatient practice, a recent review and meta-analysis found.

Researchers reviewed studies of patients with diabetes, hypertension, and hyperlipidemia published between 1980 and 2013 in which registered nurses titrated, or in some cases initiated, medications according to a protocol. They selected 18 studies (11 in Western Europe, 7 in the U.S.) with more than 20,000 patients for inclusion. Results were published in the July 15 Annals of Internal Medicine.

In a meta-analysis, nurse-managed titration was associated with decreases in HbA1c level (−0.4%; 95% CI, −0.1% to −0.7%), systolic blood pressure (−3.68 mm Hg; 95% CI, −1.05 to −6.31 mm Hg), and diastolic blood pressure (−1.56 mm Hg; 95% CI, −0.36 to −2.76 mm Hg). The analysis also found statistically insignificant drops in cholesterol with protocol care: −0.24 mmol/L (−9.37 mg/dL) in total cholesterol and −0.31 mmol/L (−12.07 mg/dL) in low-density lipoprotein cholesterol.

The results show that the nurse-managed protocols were associated with a consistently positive effect on patient care, the authors concluded, although they noted that only 1 of the included studies reported on adverse effects. The failure of the literature to provide detailed descriptions of the interventions and the fact that most of the studies were conducted outside of the U.S. were other limitations. Still, the meta-analysis indicates that nurses can successfully titrate medications and that such team approaches may improve outcomes for stable, chronically ill patients, the study authors wrote.

Although the meta-analysis was limited and research is needed into the effects on complex or unstable patients, the results suggest that nurse-managed protocols could be part of the solution to the shortage and busyness of primary care physicians, according to an accompanying editorial. “Like it or not, outpatient medicine has become too complicated for physicians to handle by themselves,” the editorialists wrote.