Alison Edie

Effects of Nurse-Managed Protocols in the Outpatient Management of Adults With Chronic Conditions: A Systematic Review and Meta-analysis

Medical management of chronic illness consumes 75% of every health care dollar spent in the United States (1). Thus, provision of economical and accessibleyet high-qualitycare is a major concern. Diabetes mellitus, hypertension, and hyperlipidemia are prime examples of chronic diseases that cause substantial morbidity and mortality (2, 3) and require long-term medical management. For each of these disorders, most care occurs in outpatient settings where well-established clinical practice guidelines are available (47). Despite the availability of these guidelines, there are important gaps between the care recommended and the care delivered (810). The shortage of primary care clinicians has been identified as 1 barrier to the provision of comprehensive care for chronic disease (11, 12) and is an impetus to develop strategies for expanding the roles and responsibilities of other interdisciplinary team members to help meet this increasing need. The patient-centered medical home concept was developed in an effort to serve more persons and improve chronic disease care. It is a model of primary care transformation that builds on other efforts, such as the chronic care model (13), and includes the following elements: patient-centered orientation toward the whole person, team-based care coordinated across the health care system and community, enhanced access to care, and a systems-based approach to quality and safety. Care teams may include nurses, primary care providers, pharmacists, and behavioral health specialists. An organizing principle for care teams is to utilize personnel at the highest level of their skill set, which is particularly relevant given the expected increase in demand for primary care services resulting from the Patient Protection and Affordable Care Act. With this increased demand, the largest health care workforce, registered nurses (RNs), may be a valuable asset alongside other nonphysician clinicians, including physician assistants, nurse practitioners, and clinical pharmacists, to serve more persons and improve chronic disease care. Robust evidence supports the effectiveness of nurses in providing patient education about chronic disease and secondary prevention strategies (1419). With clearly defined protocols and training, nurses may also be able to order relevant diagnostic tests, adjust routine medications, and appropriately refer patients. Our purpose was to synthesize the current literature describing the effects of nurse-managed protocols, including medication adjustment, for the outpatient management of adults with common chronic conditions, namely diabetes, hypertension, and hyperlipidemia. Methods We followed a standard protocol for all steps of this review. A technical report that fully details our methods and presents results for all original research questions is available at www.hsrd.research.va.gov/publications/esp/reports.cfm. Data Sources and Searches In consultation with a master librarian, we searched MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, EMBASE, and CINAHL from 1 January 1980 through 31 January 2014 for English-language, peer-reviewed publications evaluating interventions that compared nurse-managed protocols with usual care in studies targeting adults with chronic conditions (Supplement 1). Supplement 1. Search Strategy We selected exemplary articles and used a Medical Subject Heading analyzer to identify terms for nurse protocols. We added selected free-text terms and validated search terms for randomized, controlled trials (RCTs) and quasi-experimental studies, and we searched bibliographies of exemplary studies and applicable systematic reviews for missed publications (15, 17, 2029). To assess for publication bias, we searched ClinicalTrials.gov to identify completed but unpublished studies meeting our eligibility criteria. Study Selection, Data Extraction, and Quality Assessment Two reviewers used prespecified eligibility criteria to assess all titles and abstracts (Supplement 2). Eligibility criteria included the involvement of an RN or a licensed practical nurse (LPN) functioning beyond the usual scope of practice, such as adjusting medications and conducting interventions based on a written protocol. Potentially eligible articles were retrieved for further evaluation. Disagreements on inclusion or exclusion were resolved by discussion or a third reviewer. Studies excluded at full-text review are listed in Supplement 3. Abstraction and quality assessment were done by 1 reviewer and confirmed by a second. We piloted the abstraction forms, designed specifically for this review, on a sample of included articles. Key characteristics abstracted included patient descriptors, setting, features of the intervention and comparator, match between the sample and target populations, extent of the nurse interventionists training, outcomes, and quality elements. Supplements 4 and 5 summarize quality criteria and ratings, respectively. Supplement 2. Eligibility Criteria Supplement 3. List of Excluded Studies Supplement 4. Criteria Used in Risk of Bias Assessment Supplement 5. Detailed Study Characteristics Because many studies were done outside the United States, we queried the authors of such studies about the education and scope of practice of the nurse interventionists. Authors were e-mailed a table detailing the credentialing and scope of practice of various U.S. nurses and asked to classify their nurse interventionist. Data Synthesis and Analysis The primary outcomes were the effects of nurse-managed protocols on biophysical markers (for example, glycosylated hemoglobin or hemoglobin A1c [HbA1c]), patient treatment adherence, nurse protocol adherence, adverse effects, and resource use. When quantitative synthesis (that is, meta-analysis) was feasible, dichotomous outcomes were combined using odds ratios and continuous outcomes were combined using mean differences in random-effects models. For studies with unique but conceptually similar outcomes, such as ordering a guideline-indicated laboratory test, we synthesized outcomes across conditions if intervention effects were sufficiently homogeneous. We used the Knapp and Hartung method (30, 31) to adjust the SEs of the estimated coefficients. For categories with several potential outcomes (for example, biophysical markers) that may vary across chronic conditions, we selected outcomes for each chronic condition a priori: HbA1c level for diabetes, blood pressure (BP) for hypertension, and cholesterol level for hyperlipidemia. In 1 example (32), we imputed missing SDs using estimates from similar studies. We computed summary estimates of effect and evaluated statistical heterogeneity using the Cochran Q and I 2 statistics. We did subgroup analyses to examine potential sources of heterogeneity, including where the study was conducted and intervention content. Subgroup analyses involved indirect comparisons and were subject to confounding; thus, results were interpreted cautiously. Publication bias was assessed using a ClinicalTrials.gov search and funnel plots when at least 10 studies were included in the analysis. When quantitative synthesis was not feasible, we analyzed data qualitatively. We gave more weight to evidence from higher-quality studies with more precise estimates of effect. The qualitative syntheses identified and documented patterns in efficacy and safety of the intervention across conditions and outcome categories. We analyzed potential reasons for inconsistency in treatment effects across studies by evaluating variables, such as differences in study population, intervention, comparator, and outcome definitions. We followed the approach recommended by the Agency for Healthcare Research and Quality (33) to evaluate the overall strength of the body of evidence. This approach assesses the following 4 domains: risk of bias, consistency, directness, and precision. These domains were considered qualitatively, and a summary rating of high, moderate, low, or insufficient evidence was assigned. Role of the Funding Source The Veterans Affairs Quality Enhancement Research Initiative funded the research but did not participate in the conduct of the study or the decision to submit the manuscript for publication. Results Our electronic and manual searches identified 2954 unique citations (Figure 1). Of the 23 potentially eligible studies, 4 were excluded because we could not verify whether nurses had the authority to initiate or titrate medications and the author did not respond to our query for clarification (3437). We excluded a trial of older adults in which we could not differentiate the target illnesses (38). Approximately two thirds of the authors we contacted for missing data or clarification responded. Figure 1. Summary of evidence search and selection. * Methods or follow-up articles. We included 18 unique studies (23004 patients) that focused on patients with elevated cardiovascular risk (Table) (32, 3955). Of these, 16 were RCTs and 2 were controlled before-and-after studies on diabetes (49, 53). The comparator was usual care in all but 1 study, in which a reverse-control design was used, and each intervention served as the control for the other. Eleven studies were done in Western Europe and 7 in the United States. Median age of participants was 58.3 years (range, 37.2 to 72.1 years) based on 16 studies. Approximately 47% of the participants were female. Race was not reported in 84% of the studies. Supplement 5 gives detailed study characteristics. No outstanding studies were identified through ClinicalTrials.gov. Supplement 6 provides funnel plots that assess publication bias. Table. Study and Patient Characteristics of Included Diabetes, Hypertension, and Hyperlipidemia Studies Supplement 6. Assessment of Publication Bias: Funnel Plots Overall, these studies displayed moderate risk of bias. Two studies were judged as having a high risk of bias because of inadequate randomization (44, 5

Quality of articles published in predatory nursing journals

BACKGROUND Predatory journals exist in nursing and lack the safeguards of traditional publishing practices. PURPOSE To examine the quality of articles published in predatory nursing journals. METHOD Randomly selected articles (n = 358) were reviewed for structural content and eight quality indicators. FINDINGS Two-thirds (67.4%) of the articles were published between 2014 and 2016, demonstrating the acceleration of publications in predatory nursing journals. The majority (75.9%) of the articles were research reports. Most followed the IMRAD presentation of a research report but contained errors, or the study was not pertinent to the nursing discipline. CONCLUSIONS Nursing research published in predatory journals may appear legitimate by conforming to an expected structure. However, a lack of quality is apparent, representing inadequate peer review and editorial processes. Poor quality research erodes the scholarly nursing literature.

A Peer-led Diabetes Education Program in a Homeless Community to Improve Diabetes Knowledge and Empowerment

ABSTRACT Peer-led diabetes education has been shown to be as effective, or more effective, than traditional education in improving glycemic control and diabetes self-care measures. A 4-week peer-led diabetes education program was conducted in a homeless community in Grand Rapids, Michigan to increase diabetes knowledge and empowerment. Knowledge scores increased significantly during sessions covering signs, symptoms, and complications of diabetes and diabetes medications (ps <.05). Empowerment scores after attending the 4-week program were significantly increased when compared to scores prior to the first session (p = .027). Field notes and postimplementation focus group support increased empowerment and knowledge among participants.

Long-acting reversible contraception: Assessment of knowledge and interest among college females

Abstract Objective: To implement the Long-Acting Reversible Contraception Quality Improvement (LARC QI) project using evidence-based contraceptive counseling techniques to improve knowledge and intent to use among college females. Participants: The project, conducted from April through September 2017, involved 41 female students, from a 4-year public college in North Carolina. Methods: Students participated in group educational sessions on all methods of birth control with an emphasis on LARC. Surveys were administered to group participants and descriptive statistics were used to determine the difference in knowledge scores and intent to use. Descriptive and qualitative analysis described usage of LARC methods. Results: LARC knowledge scores significantly improved. Intention to use also increased compared to reported actual use. The final chart review demonstrated an increase usage of the subdermal implant, but no change for intrauterine device. Conclusions: The college setting offers a unique opportunity to use evidence-based contraceptive counseling techniques to guide use of LARC.