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The latest evidence for practice

Una Adderley
Specialist Nurse
Team Leader

Does telemedicine improve glycaemic control in people with type 2 diabetes?

There is growing interest in the benefits of using telemedicine for the management of chronic disease and research evidence is starting to emerge to guide clinical decision-making around this field of care.

This US randomised, controlled trial compared the short-term efficacy of home telemonitoring with active medication management by a nurse practitioner compared to care that consisted of a monthly care co-ordination telephone call for patients with type 2 diabetes. 150 patients with type 2 diabetes who were taking oral hypoglycaemic agents and/or insulin and who had an entry level HbA1C of _7.5% were randomly allocated to either active care management with home telemonitoring or a monthly care co-ordination telephone call.

Both groups of patients received monthly calls for diabetes education and a self-management review. The patients in the telemonitoring group used the telemonitoring equipment to send information about blood glucose, blood pressure and weight to a nurse practitioner. The results found greater reductions in HbA1C at 3 and 6 months in the telemonitoring group compared to the telephone call group. 

A commentary notes that although other research studies have reported apparent benefits from telemedicine in relation to diabetes management, this study makes a unique contribution in using telemedicine to swiftly change medication in response to abnormal telemedicine data. The commentary notes that further research evaluation should include consideration of cost effectiveness and whether this intervention is also effective for patients with high blood pressure, abnormal lipid panels and hyperglycaemia.

Reference
Stone RA, Rao RH, Sevick MA et al. Active care management supported by home telemonitoring in veterans with type 2 diabetes: the DiaTel randomized controlled trial. Diabetes Care 2010;33:478-84.

Commentary
Bowles KH. Evid Based Nurs 2010;13(3):74.

Are advanced practice nurses better than GPs at managing cardiovascular risk?

Patients who are at high risk of cardiovascular events receive a significant proportion (if not all) of their care from primary care and often from practice nurses.  This Dutch pragmatic randomised, controlled trial sought to establish whether such care was as effective as that delivered by GPs.

1,626 patients drawn from six healthcare practices were randomly allocated to either care delivered by a GP or care delivered by an advanced practice nurse whose responsibilities included the management of patients with chronic disease such as diabetes, COPD, and asthma. The patients were aged between 30 and 74 years and had been identified as having a 10-year risk of fatal CVD at a level equal to 18% on the Framingham scale. The patients were followed for one year. The study found that advanced practice nurses achieved the same outcomes as, and in some aspects, better outcomes than those achieved by GPs.

A commentary notes that this study was strengthened by including high-risk patients (which previous studies had often excluded).  However, most of the patients had already been diagnosed before entering the study and were aware of their need for lifestyle changes to reduce risk. It was also unclear whether the nurses and GPs were offering a similar approach to care or whether the nurses had received specific training in cardiovascular risk reduction. 

Although the results do not support the practice of simply delegating care for patients who require cardiovascular risk management from GPs to practice nurses, they do suggest that practice nurses who have received adequate training in this area can deliver care that is at least as good as, if not better than, that delivered by GPs.

Reference
Voogdt-Pruis HR, Beusmans GH, Gorgels AP et al. Effectiveness of nurse-delivered cardiovascular risk management in primary care: a randomised trial. Br J Gen Pract 2010;60:40-6.

Commentary
Koelewijn-van Loon M. Evid Based Nurs 2010;13:(2):43.