Jacqui Young

The feasibility, acceptability and sustainability of nurse-led chronic disease management in Australian general practice: the perspectives of key stakeholders

This was the first Australian study investigating the acceptability, feasibility and sustainability of a nurse-led model of chronic disease management in general practice. A concurrent mixed-methods design was used within a 12-month intervention of nurse-led care in three general practices. Adult patients with type 2 diabetes, hypertension and/or stable ischaemic heart disease were randomized into nurse-led or standard care. Semi-structured interviews explored perceptions of key stakeholders towards this model including patients in the nurse-led arm, and all practice staff pre- and posttrial. The data were thematically analysed and the emergent themes were: importance of time; collaborative relationships; nurse job satisfaction, confidence and competence; patient self-management and choice. Our findings showed that nurses provided chronic disease management that was acceptable, feasible and sustainable. The collaborative involvement of doctors was intrinsic to patient acceptability of nurse-led care that facilitated job satisfaction, and therefore retention and growth within this nursing speciality.This was the first Australian study investigating the acceptability, feasibility and sustainability of a nurse-led model of chronic disease management in general practice. A concurrent mixed-methods design was used within a 12-month intervention of nurse-led care in three general practices. Adult patients with type 2 diabetes, hypertension and/or stable ischaemic heart disease were randomized into nurse-led or standard care. Semi-structured interviews explored perceptions of key stakeholders towards this model including patients in the nurse-led arm, and all practice staff pre- and posttrial. The data were thematically analysed and the emergent themes were: importance of time; collaborative relationships; nurse job satisfaction, confidence and competence; patient self-management and choice. Our findings showed that nurses provided chronic disease management that was acceptable, feasible and sustainable. The collaborative involvement of doctors was intrinsic to patient acceptability of nurse-led care that facilitated job satisfaction, and therefore retention and growth within this nursing speciality.

The effectiveness of nurse-led care in general practice on clinical outcomes in adults with type 2 diabetes

Background In Australia, diabetes was identified as a national health priority area in 1996; nevertheless the prevalence of type 2 diabetes has increased dramatically since then. Nurses have been working within Australian general practices for several decades but only in recent years has the role of the practice nurse in primary health care increased. Objectives This review aims to identify the effectiveness of nurse‐led care in general practice as compared to general practitioner care on clinical outcomes in adults with type 2 diabetes. Inclusion criteria Types of participants Participants were adults (aged >18 years), with diabetes type 2 attending a general/family practice. Types of intervention Interventions of interest include nurse‐led care in general practice in which the nurse is identified as taking a lead role in the care of patients with type 2 diabetes compared to general practitioner‐led care. Types of studies To evaluate the effectiveness of nurse‐led diabetes care in general practice, this review sought randomised controlled trials as the study design of choice. Other research designs such as controlled clinical trials, interrupted time series and controlled before and after designs were also considered. Types of outcomes The outcomes of interest were clinical outcomes including changes in systolic and diastolic blood pressure, body mass index, cholesterol levels, HbA1c (glycated haemoglobin) and fasting blood glucose. Search strategy A three step literature search was conducted for English language articles from January 1990 to December 2011. Methodological quality Quantitative papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardised critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. Data collection Quantitative data was extracted from papers included in the review using the standardised data extraction tool from the Joanna Briggs Institute. The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data synthesis Data from quantitative papers, where possible, were pooled in statistical meta‐analysis using the Meta‐Analysis of Statistics Assessment and Review Instrument. Additionally, RevMan 5 was used for presenting forest plots of the meta‐analysis. Results The electronic search yielded 804 potentially relevant papers of which 49 papers appeared to satisfy the criteria for inclusion and full texts of these papers were assessed against the inclusion criteria by two independent reviewers. From these papers, five were included in the review, four randomised control trials and one quasi‐experimental study. These articles provided evidence that nurse‐led care improves blood pressure and cholesterol levels for patients with type 2 diabetes attending a general practice. Conclusions There is some evidence to support the use of nurse‐led care in general practice for patients with type 2 diabetes. Implications for Practice If nurse‐led care is implemented in the care of people with type 2 diabetes consideration needs to be given to the use of clinical algorithms, goal setting, individualised care plans, self management and follow up of lifestyle risk factors. Implication for Research More randomised controlled trials are required to assess the efficacy of nurse‐led care including cost effectiveness.

A feasibility study to improve practice nurses’ competence and confidence in providing care for mothers and infants

Background: Postnatal care is best provided in primary health care settings, yet Practice Nurses (PNs) lack relevant training and report difficulty in providing postnatal care. Aim: To evaluate the feasibility of a pilot educational intervention in improving PN competence and confidence to care for mothers and infants in the first postnatal year. Design: A feasibility study. Methods: PNs were recruited from selected general practices Queensland, Australia to undertake the pilot educational intervention that included a pre-intervention survey, two-day education program, program evaluation and completion of a practice journal. Results: Thirteen PNs from three general practices participated, with 31% completing all study components. Evaluation of the intervention was positive and all participants reported increased confidence and competence in providing postnatal care. Following detailed consideration of feasibility (process, resource, management and scientific assessment) we propose that changes to intervention delivery and data collection should be incorporated into a larger trial.

Practice nurse involvement in the management of adults with type 2 diabetes mellitus attending a general practice: results from a systematic review

Aim:Using the methodology of the Joanna Briggs Institute, a systematic review of current research was performed to determine if the addition of management by nurses had been more effective in improving clinical outcomes of patients with type 2 diabetes attending a general practice compared with standard care. Methods:A three-step literature search was conducted for suitable English studies with quantitative clinical outcomes that had been published from January 1990 to May 2014. Randomised controlled trials (RCTs) were particularly sought after; however, other research designs were considered. Articles were assessed by two independent reviewers for methodological validity, prior to inclusion in the review, using standardised critical appraisal instruments from the Joanna Briggs Institute. When possible, quantitative data were pooled in statistical meta-analysis. Results:Seven studies were of suitable quality and relevance for the review: these included three randomised control trials; two cluster- RCTs; a cluster, nonrandomised, controlled before-after study; and a cluster observational cohort study. These studies yield evidence that nurse management in addition to standard general practitioner care leads to modest improvements in blood pressure and total cholesterol levels in adults with type 2 diabetes attending a general practice. Conclusion:Meta-analysis identified modest, significant improvements amongst participants in nurse management interventions (NMIs) in the following clinical outcomes: mean SBP, mean DBP and mean total cholesterol. The majority of outcomes studied did not show any advantage to adding NMIs to general practitioner care. Two studies reported significant improvements of participants with poor control in mean haemoglobin A1c. An RCT that investigates the effect of NMIs on patients, with poor control in regard to clinical outcomes and cost effectiveness, is recommended.

Revenue effects of practice nurse-led care for chronic diseases

OBJECTIVE To determine the economic feasibility in Australian general practices of using a practice nurse (PN)-led care model of chronic disease management. METHODS A cost-analysis of item numbers from the Medicare Benefit Schedule (MBS) was performed in three Australian general practices, one urban, one regional and one rural. Patients (n =254; >18 years of age) with chronic conditions (type 2 diabetes, hypertension, ischaemic heart disease) but without unstable or major health problems were randomised into usual general practitioner (GP) or PN-led care for management of their condition over a period of 12 months. After the 12-month intervention, total MBS item charges were evaluated for patients managed for their stable chronic condition by usual GP or PN-led care. Zero-skewness log transformation was applied to cost data and log-linear regression analysis was undertaken. RESULTS There was an estimated A

Outcomes and opportunities: a nurse-led model of chronic disease management in Australian general practice

129 mean increase in total MBS item charges over a 1-year period (controlled for age, self-reported quality of life and geographic location of practice) associated with PN-led care. The frequency of GP and PN visits varied markedly according to the chronic disease. CONCLUSIONS Medicare reimbursements provided sufficient funding for general practices to employ PNs within limits of workloads before the new Practice Nurse Incentive Program was introduced in July 2012.