Review: In adult outpatients, nurse-managed protocols improve HbA1c levels and blood pressure

Medication titration by nurses according to protocols was associated with a modest improvement in control of some chronic diseases, including diabetes, according to a review and meta-analysis.


Medication titration by nurses according to protocols was associated with a modest improvement in control of some chronic diseases, including diabetes, according to a review and meta-analysis. The nurse-managed program was associated with a −0.4% decrease in HbA1c level, as well as improvements in systolic and diastolic blood pressures in hypertensive patients.

The study was published in Annals of Internal Medicine on July 15, 2014, and a summary was published in the August ACP Diabetes Monthly. The following commentary by Kevin A. Schulman, MD, was published in the ACP Journal Club section of the Dec. 16, 2014, Annals of Internal Medicine.

In the meta-analysis by Shaw and colleagues, nurse-managed protocols improved diabetes and hypertension outcomes for patients. The evidence base included data from 18 clinical trials and > 20,000 patients. One limitation was that most of the trials had moderate or high risk for bias, including inadequate randomization and potential for contamination from concurrent interventions.

However, the most important aspect of the review is that this question was even in doubt. In a major academic medical center, whenever we want to improve clinical quality, the conversation quickly migrates to a new role for nurses as a key component of any intervention. More broadly, as we face a potential shortage of primary care physicians, the ability to use both nurses and physicians to the “top of their license” offers an opportunity to achieve our triple aim of cost reductions, quality improvement, and increased access.

Interventions included in the review by Shaw and colleagues focused on the use of nurse-managed protocols in nurse-led clinics or by specialty-trained nurses or nurse care managers for management of cardiovascular disease or diabetes. Most studies were done in academic centers or hospital-based clinics or were embedded in primary care practices. However, with the emergence of retail medicine, the opportunity for novel delivery schemes leveraging the increasingly common nurse practitioner retail clinics for advanced primary care services may be attractive. From an economic perspective, these models can have lower provider and overhead costs than traditional primary care practices. Retail clinics allow access and convenience but have yet to be organized into systems of care or focus specifically on the management of chronic illness. However, this transformation seems to be the logical next step in the evolution of these models.

Nurse-managed protocols seem to be a promising option for devolving care from primary care physicians. However, a critical weakness of any of these concepts is the need to share data between providers and between sites of care, especially between retail clinical sites and primary care or specialty practices. This gap remains to be addressed.