Evaluation of a nurse-care management system to improve outcomes in patients with complicated diabetes.

OBJECTIVE: This study evaluated the efficacy of a nurse-care management system designed to improve outcomes in patients with complicated diabetes. RESEARCH DESIGN AND METHODS: In this randomized controlled trial that took place at Kaiser Permanente Medical Center in Santa Clara, CA, 169 patients with longstanding diabetes, one or more major medical comorbid conditions, and HbA(lc) >10% received a special intervention (n = 84) or usual medical care (n = 85) for 1 year. Patients met with a nurse-care manager to establish individual outcome goals, attended group sessions once a week for up to 4 weeks, and received telephone calls to manage medications and self-care activities. HbA(lc), LDL, HDL, and total cholesterol, triglycerides, fasting glucose, systolic and diastolic blood pressure, BMI, and psychosocial factors were measured at baseline and 1 year later. Annualized physician visits were determined for the year before and during the study. RESULTS: At 1 year, the mean reductions in HbA(lc), total cholesterol, and LDL cholesterol were significantly greater for the intervention group compared with the usual care group. Significantly more patients in the intervention group met the goals for HbA(1c) (<7.5%) than patients in usual care (42.6 vs. 24.6%, P < 0.03, chi(2)). There were no significant differences in any of the psychosocial variables or in physician visits. CONCLUSIONS: A nurse-care management program can significantly improve some medical outcomes in patients with complicated diabetes without increasing physician visits.

Application of a nurse-managed inpatient smoking cessation program.

This study reports on the effectiveness of a nurse case-managed smoking cessation program for general hospitalized patients that was continued for 3 years after clinical trials were completed. Patients admitted to the hospital who smoked were offered a smoking cessation program during their hospitalization. The program included physician advice, bedside education and counseling with a nurse specially trained in smoking cessation techniques, take-home materials (videotape, workbook, and relaxation audiotape), nicotine replacement therapy if requested or indicated, and four nurse-initiated post-discharge telephone counseling calls. Of the 2091 patients identified as smokers, 52% enrolled in the program, 18% wanted to quit on their own, 20% did not want to quit, and 10% were ineligible. The 12-month self-reported cessation rate (7-day point prevalence) was 35% if patients lost to follow-up were considered smokers, 49% if not. Patients hospitalized for cancer, cardiovascular, or pulmonary reasons were most likely to participate and had the highest self-reported cessation rates (63%, 57%, and 46%, respectively). This nurse-managed smoking cessation intervention was effective when it was put into standard hospital practice outside of its originating randomized clinical trial structure. The program, relatively inexpensive to deliver, appears to be acceptable to the majority of smokers who are hospitalized, resulted in high 1-year cessation rates, and can be extended to hospital employees and their families, work-sites, and communities on a cost-recovery basis.