Improving diabetes control in the community: A nurse managed intervention model in a multidisciplinary clinic

Objective To assess diabetes management and control measures in a central multidisciplinary primary care clinic, conducted by a nurse. Design A cross sectional study. Setting Central, multidisciplinary, primary care clinic. Subjects Randomly selected 100 people with diabetes. Interventions People with diabetes with suspected non-optimal glucose control (HbA1c > 7%), were invited to the clinic nurse to discuss optimal personal diabetes control, treatment and follow up. All were provided the necessary referrals to consultants and were called in for follow up visits, and received telephone reminders. All interventions were made according to the current American Diabetes Association Standards of Medical Practice recommendations. Main outcome measures Retrospective data were collected. Data included demographics and diabetes control measures (e.g. HbA1c, LDL, blood pressure, ophthalmologic examination etc.). Data was collected for three x 6 months periods: 1) six months before the nurse visit; 2) six months following the first nurse visit (the intervention); and 3) for patients who were followed up for at least one year after the intervention, the last six months of follow-up. Results With a median follow up of 25 months, HbA1c, LDL and systolic blood pressure levels dropped significantly from before starting the clinic through the intervention and remained low in the last half year of follow up. GP, Ophthalmologist and Dietician visits increased significantly during the study. Non-significant trends were observed with total and diabetes-related hospitalisations decreased, foot examination rates increased and mild weight loss. Conclusion Multidisciplinary intervention managed by a nurse, improve diabetes management and control measures. Observed changes persisted after the intervention period.