Nurse-led patient-centered self-management support improves HbA1c in patients with type 2 diabetes—A randomized study
Introduction
Among most people, type 2 diabetes (T2D) is a progressive disease that deteriorates over time with the increased risk of mortality and morbidity due to the high risk of serious chronic complications [1], [2]. Appropriate glucose control can reduce the incidence of microvascular disease and risk for myocardial infarction and death [3], [4], even if the evidence is not totally clear for all age groups where some studies pointed out that individual goals for metabolic control are needed, especially for elderly people [5]. The International Diabetes Federation [6] recommends the lowering of hemoglobin A1c (HbA1c) to <53 mmol/mol (International Federation of Clinical Chemistry and Laboratory Medicine (IFCC)) equivalent to <7.0% (National Glucohemoglobin Standardization Program [NGSP]). More stringent HbA1c targets should be considered if people have a long life expectancy, short disease duration, no cardiovascular disease, and if this can be achieved without risk of serious hypoglycemia. It is therefore important to individualize treatment targets since not everyone benefits from an aggressive glucose treatment [7]. Glycemic control often requires lifestyle adjustments such as smoking cessation, weight loss, dietary changes, increasing physical activity, self-monitoring of blood glucose, and adherence to medication recommendations [6], [8].
In Sweden the majority of people with type 2 diabetes are treated by general practitioners and diabetes specialist nurses (DSNs). The DSN meets patients at least once a year and focuses on quality of care documents, such as national guidelines and the national diabetes register (NDR). The annual “diabetes controls” include biomedical measurements such as HbA1c, lipids, blood pressure, BMI, waist measurement and albuminuria. Information about medical treatment, diet, physical activities and smoking habits is given and foot examination should be performed [9], [10]. Adolfsson et al. [11] reported that a minority of the professionals at primary health care centers involve the patients in their overall treatment decisions. Criticism of the annual visits has been expressed regarding the focus on control instead of patient-centeredness [12].
Patient-centered care (PCC) is more than a method of communication. It focuses on patients’ preferences, experienced needs and values in decisions about care and treatment. Furthermore, it has a broadened perspective of illness, in which patients’ experiences and their own control are prominent. It also focuses on relations and interactions with health care professionals, and strives for an alliance between patients and professionals working together and sharing common grounds and goals [13], [14], [15], [16], [17], [18].
PCC is demanded by both international and national stakeholders [6], [18], and is seen as a critical indicator of high-quality health care delivery, particularly towards supporting self-management of chronic illnesses, patient-centered care is associated with improved health status in disease-related outcomes and the quality of life. Furthermore, it is associated with increased patient adherence to medications, improved chronic disease control and reduced use of diagnostic testing and referrals [13]. The International Alliance of Patientś Organization’s (IAPO) [19] declaration on patient-centered health care states that the core of PCC views the patients as being at the center of the healthcare system, something which should be designed around them. The declaration outlines five key principles: respect, choice and empowerment, patient involvement in health policy, access and support, and information [19]. Traditionally, diabetes specialist nurses (DSNs) in Sweden have had a disease-oriented or glucocentric approach [20]. However, such an approach is not consistent with the definition of patient-centeredness. Bostrom et al. [21] stated that DSNs were ambivalent to person-centered care because their professional role diminished and patient-centered care was a new and different approach of working. Studies imply that overcoming professional barriers for change and developing skills in patient-centered care is possible and do not require more time in consultations [22].
Most interventions aimed at improving metabolic control through advice on adjusting diet and increasing physical activities have only shown small to moderate effects on HbA1c in the short term [23]. Heisler et al. [24] among others, has stated that although increased knowledge alone is not enough to motivate patients to effectively manage diabetes, involvement in diabetes self-management interventions may result in improvements of the quality of life [25]. Besides effects of medication, improvements in glycemic control among patients with T2D have been demonstrated by a combination of educational and behavioral psychosocial interventions [26]. Psychological interventions improved depression while self-management intervention improved the quality of life [27]. Patient-centeredness and group education are recommended in T2 diabetes care nationally and internationally. However, it is not clear how such care is delivered in practice and this may give rise to problems in evaluating the effect of person-centered care in systematic reviews and meta-analyses.
A similar previous intervention study focusing on patient-centered self-management support in groups (DIVA1) by Hörnsten [28], [29] reported significant effects on HbA1c. A comparison of DIVA 1 and this study DIVA 2 (Diabetes intervention in Västerbotten, part 2) is given in Table 1. However, it remains unclear if the effect was due to the patient-centered method focusing on personal understandings of illness or the group dynamics—something this study will try to answer.
Section snippets
Aims
The aim of this study was to evaluate the effect of a nurse led patient-centered self-management support in T2D with regard to metabolic changes.
Design
This study within the DIVA 2-project consists of a randomized, controlled trial with three arms, and an external control group that aims to measure the effects on metabolic changes from a patient-centered self-management support intervention, which was led by nurses. The report includes baseline and annual (12 month) measurements of a five-year study.
Sample
Results
The mean participant attendance rate for the six sessions was 79.4% in the GI group and 95.8% in the II group. At baseline, there were no significant differences in age, gender, BMI, waist circumference, or blood pressure between the groups. Concerning HbA1c, an ANOVA with a Bonferroni post hoc test showed a significant difference in HbA1c between the GI and EC groups (p = 0.020), and a difference in total cholesterol between GI and IC groups (p = 0.007) at baseline. There was also a significant
Discussion
This study aimed to evaluate the effect of patient-centered self-management support led by nurses. We have previously demonstrated effects from this kind of intervention in groups of T2D-patients, but not as an individual approach. This study showed that the approach worked in groups as well as individually.
The main finding of our study was that a nurse-led patient-centered intervention is effective. The intervention groups significantly improved their HbA1c compared to the external control
Conflict of interests
The authors declare that they have no competing interests.
Authors’ contribution
The study design was decided upon by LJ, ÅH, HS, UI and HSt. The data collection was made by LJ and ÅH. The data analyses were performed by LJ, UI, HSt. The manuscript preparation was made by LJ, ÅH, UI and HS.
Acknowledgements
The authors would like to extend special thanks to the funders, the patients, and the participating DSNs at the local health care centers. In addition, a special thanks to Kerstin Larsson, biochemist at the Laboratory of Medicine, Östersund Hospital, and to Gunnar Nordin, EQUALIS, for advice and help with the HbA1c adjustment formula. The authors would also like to thank the Strategic Research Programme in Care Sciences, Umeå University and Karolinska Institute, and the Swedish Diabetes
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