The cost-effectiveness of substituting physicians with diabetes nurse specialists: a randomized controlled trial with 2-year follow-up. Substitution model with central role for nurse specialist is justified in the care for stable type 2 diabetic outpatients. Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial. An evaluation of a Diabetes Specialist Nurse prescriber on the system of delivering medicines to patients with diabetes. Community-based care for the management of type 2 diabetes: an evidence-based analysis. Evaluation of a hospital diabetes specialist nursing service: a randomized controlled trial. A cluster randomised controlled trial of the effect of a treatment algorithm for hypertension in patients with type 2 diabetes. A Mobile Health Intervention for Self-Management and Lifestyle Change for Persons With Type 2 Diabetes, Part 2: One-Year Results From the Norwegian Randomized Controlled Trial RENEWING HEALTH A cluster randomized controlled trial of the effectiveness and cost-effectiveness of Intermediate Care Clinics for Diabetes (ICCD): study protocol for a randomized controlled trial Nursing Case Management and Glycemic Control Among Brazilians With Type 2 Diabetes: Pragmatic Clinical Trial Specialist nurse-led clinics to improve control of hypertension and hyperlipidemia in diabetes: economic analysis of the SPLINT trial. Nurse Case Management To Improve Glycemic Control in Diabetic Patients in a Health Maintenance Organization Shared care with task delegation to nurses for type 2 diabetes: prospective observational study. Educational outreach in diabetes to encourage practice nurses to use primary care hypertension and hyperlipidaemia guidelines (EDEN): a randomized controlled trial. A Low-Intensity Mobile Health Intervention With and Without Health Counseling for Persons With Type 2 Diabetes, Part 1: Baseline and Short-Term Results From a Randomized Controlled Trial in the Norwegian Part of RENEWING HEALTH The effectiveness of nurse‐led care in general practice on clinical outcomes in adults with type 2 diabetes [Interventions to improve the management of diabetes mellitus in primary health care and outpatient community settings]. 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A qualitative study of the key factors in implementing telemedical monitoring of diabetic foot ulcer patients Cost-effectiveness of a stepped-care intervention to prevent major depression in patients with type 2 diabetes mellitus and/or coronary heart disease and subthreshold depression: design of a cluster-randomized controlled trial A randomized trial of early discharge and nurse specialist transitional follow-up care of high-risk childbearing women. A pilot randomized trial in primary care to investigate and improve knowledge, awareness and self-management among South Asians with diabetes in Manchester. Nurse-led motivational interviewing to change the lifestyle of patients with type 2 diabetes (MILD-project): protocol for a cluster, randomized, controlled trial on implementing lifestyle recommendations iConnect CKD – virtual medical consulting: A web‐based chronic kidney disease, hypertension and diabetes integrated care program Outcome of one-year of specialist care of patients with type 2 diabetes: a multi-center prospective survey (JDDM 2). Can diabetes management be safely transferred to practice nurses in a primary care setting? A randomised controlled trial. The TrueBlue study: Is practice nurse-led collaborative care effective in the management of depression for patients with heart disease or diabetes? Controlled trial of a multifaceted intervention for improving quality of care for rural patients with type 2 diabetes. Nurse-run, telephone-based outreach to improve lipids in people with diabetes. Promoting Health in Type 2 Diabetes: Nurse-Physician Collaboration in Primary Care Patients and nursing staff views of using the education needs assessment tool in rheumatology clinics: a qualitative study. The Effectiveness of Depression Care Management on Diabetes-Related Outcomes in Older Patients Screening for gestational diabetes mellitus in primary versus secondary care: The clinical outcomes of a randomised controlled trial. Model of care for the management of complex Type 2 diabetes managed in the community by primary care physicians with specialist support: an open controlled trial. Improving glycaemic control self-efficacy and glycaemic control behaviour in Chinese patients with type 2 diabetes mellitus: randomised controlled trial. Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: a randomized controlled trial.
AIMS To evaluate the cost-effectiveness of an intervention substituting physicians with nurse specialists . BACKGROUND Increasing population s of people with diabetes in most Western countries require creative solutions that give high- quality chronic care while controlling costs . Instigating nurse specialists as a substitute for physicians yields positive results in this area . Research about such interventions in a hospital-based setting is limited . METHODS This paper is a report of a study of a r and omized , non-blinded clinical trial including people with diabetes mellitus types 1 and 2 . In the intervention group  nurse specialists  were the central carers , providing care that conformed to a preset protocol . Patients were included between 2004 and 2007 .  Costs , quality of life and adverse events were measured , cost-effect ratios and incremental cost-effect ratios were calculated based on health-re source utilization rates , corresponding market prices and national tariffs from 2007 . RESULTS Health related quality of life scores did not differ significantly between the control and the intervention group . In the intervention group , fewer patients were hospitalized and fewer side effects from drugs were reported compared to controls . Nurse specialists as central care givers generated a modest reduction in costs per quality adjusted life year gained compared to usual care . CONCLUSION Nurse specialists give diabetes care that is similar to care provided by physicians in terms of quality of life and economic value . Instigating a nurse specialist as central carer yields opportunities to generate cost savings . Developing interventions which also focus on prevention of complications is recommended when aim ing for long-term organisational cost savings AIM OF THE STUDY Assessment of effects on quality of care , in terms of patient outcomes , when tasks in the care for out patients with stable type 2 diabetes are transferred from internist to nurse specialist and from outpatient clinic to general practice . BACKGROUND For the management of chronic diseases with a high prevalence and requiring current monitoring , it is suggested that substitution of care may be an appropriate solution to safeguard high quality care . DESIGN AND METHODS A 12-month nonequivalent control group design was used . General practitioners ( GPs ) referring diabetes patients to the University Hospital Maastricht were asked to choose for the traditional model or the nurse specialist model . Informed consent was obtained from patients with stable diabetes type 2 attending these practice s. All patients received care according to the model chosen by their GP . Identified outcomes were : clinical status , health status , self-care behaviour , knowledge of diabetes , patient satisfaction , and consultation with care-providers . RESULTS In the control group ( n=47 ) no patients were treated with oral hypoglycaemic agents ( OHA ) only . The control group was compared with an intervention subgroup ( n=52 ) also without patients receiving OHA only . Clinical data were available for all patients . Patients without complete data from question naires had better mean concentration of HbA1c than patients with complete data ( P=0.004 ) . The traditional care model and the nurse specialist model achieved equal outcomes , while glycaemic control of patients in the nurse specialist model improved ( from 8.6 % to 8.3 % ) but deteriorated in the traditional model ( from 8.6 % to 8.8 % ; P-value between groups=0.001 ) . CONCLUSIONS The model with nurse specialists taking on roles and tasks beyond those traditionally regarded as their remit as well as new ones , is effective for the care of stable diabetic out patients OBJECTIVE To determine the effectiveness of specialist nurse-led clinics for hypertension and hyperlipidemia provided for diabetic patients receiving hospital-based care . RESEARCH DESIGN AND METHODS This study was a r and omized controlled implementation trial at Hope Hospital , Salford , U.K. The subjects consisted of 1,407 subjects presenting for annual review with raised blood pressure(>or=140/80 mmHg ) , raised total cholesterol ( > or=5.0 mmol/l ) , or both . Individuals with diabetes were r and omized to usual care or usual care with subsequent invitation to attend  specialist nurse-led clinics . Nurses provided clinics for participants , with attendance every 4 - 6 weeks , until targets were achieved . Lifestyle advice and titration of drug therapies were provided according to the locally agreed upon guidelines . Patients with both conditions were eligible for enrollment in either or both clinics . At subsequent annual review , blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register . Data relating to deaths were obtained from the national strategic tracing service . The primary outcome was the odds ratio of achieving targets in hypertension and hyperlipidemia , attributable to the  specialist nurse-led intervention . RESULTS Overall , specialist nurse-led clinics were associated with a significant improvement in patients achieving the target after 1 year ( odds ratio [ OR ] 1.37 [ 95 % CI 1.11 - 1.69 ] , P = 0.003 ) . This primary analysis revealed a borderline difference in effect between the two types of clinics ( test for interaction between groups : P = 0.06 ) . Secondary analysis , consistent with the prior beliefs of the health care professionals involved , suggested that targets were achieved more frequently in patients enrolled in the specialist nurse-led clinic for hyperlipidemia ( OR 1.69 [ 1.25 - 2.29 ] , P = 0.0007 ) than for hypertension ( OR 1.14 [ 0.86 - 1.51 ] , P = 0.37 ) . Intervention ( enrolled to either or both clinics ) was associated with a reduction in all-cause mortality ( OR 0.55 [ 0.32 - 0.92 ] , P = 0.02 ) . CONCLUSIONS This study provides good evidence to support the use of specialist nurse-led clinics as an effective adjunct to hospital-based care of patients with diabetes . If the st and ards of care recommended in the National Service Framework for Diabetes are to be achieved , then such proven methods for delivering care must be adopted AIM To evaluate the impact of a  Diabetes Specialist Nurse prescriber  on insulin and oral hypoglycaemic agent  medication errors and length of stay . BACKGROUND The National Health Service has committed to a 40 % reduction in the number of drug errors in the use of prescribed medicines . Drug errors in diabetes care are a common cause of significant morbidity and complications . Nurse prescribing creates an opportunity for nurses to improve care for these patients . DESIGN A quasi-experiment using six wards in a single hospital trust . METHODS Inpatient care of a convenience sample of patients with diabetes was evaluated before ( n = 27 ) and after ( n = 29 ) the intervention of a Diabetes Specialist Nurse prescriber . Prospect i ve data were collected to measure  insulin and oral hypoglycaemic medication errors and length of stay . RESULTS There was a significant reduction in the total number of errors between the pre-intervention and intervention group ( mean reduction 21 errors ) ( p = 0.016 ) . The median length of stay was reduced by three days . The total number of errors and length of stay were affected by admission category ( p = 0.0004 ) . CONCLUSIONS A medicines management intervention , provided by a Diabetes Specialist Nurse prescriber , had a positive effect on the system of delivering medicines to patients with diabetes and significantly reduced the number of errors . This reduction had some effect on length of stay . The cost saving was sufficient to finance a Diabetes Specialist Nurse prescriber post . RELEVANCE TO CLINICAL PRACTICE ( i ) Errors frequently occur in the prescription and administration of medicines to patients with diabetes . ( ii ) The education of healthcare professionals is a factor contributing to these errors . ( iii ) Nurse prescribing provides a new system by which to educate patients and staff about their medicines . ( iv ) A Diabetes Specialist Nurse prescriber can reduce insulin and OHA MEs . This reduction had some effect on LOS UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes  : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care . CLINICAL NEED TARGET POPULATION AND CONDITION Diabetes ( i.e. diabetes mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the body 's ability to produce or effectively use insulin . The majority ( 90 % ) of diabetes patients have type 2 diabetes . ( 1 ) Based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics . While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines , factors associated with glycemic control are less well studied , one of which is the provider(s ) of care . Multidisciplinary approaches to care may be particularly important for diabetes management . According guidelines from the Canadian Diabetes Association ( CDA ) , the diabetes health care team should be multi- and interdisciplinary . Presently in Ontario , the core diabetes health care team consists of at least a family physician and /or diabetes specialist , and diabetes educators ( registered nurse and registered dietician ) . Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management . Several systematic review s and meta-analyses have examined multidisciplinary care programs , but these have either been limited to a specific component of multidisciplinary care ( e.g. intensified education programs ) , or were conducted as part of a broader disease management program , of which not all were multidisciplinary in nature . Most review s also do not clearly define the intervention(s ) of interest , making the evaluation of such multidisciplinary community programs challenging . EVIDENCE -BASED ANALYSIS METHODS RESEARCH QUESTIONS What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse , registered dietician and physician ( primary care and /or specialist ) for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 2 ] INCLUSION CRITERIA English language full-reportsPublished between January 1 , 2000 and September 28 , 2008R and omized controlled trials ( RCTs ) , systematic review s and meta-analysesType 2 diabetic adult population ( ≥18 years of age)Total sample size ≥30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines ( of which at least one must be a specialist in diabetes ) with integrated communication between the care providers . Compared to usual care ( defined as health care provision by non-specialist(s ) in diabetes , such as primary care providers ; may include referral to other health care professionals/services as necessary)≥6 months follow-up EXCLUSION CRITERIA Studies where discrete results on diabetes can not be abstract edPredominantly home-based interventions Inpatient-based interventions OUTCOMES OF INTEREST The primary outcomes for this review were glycosylated hemoglobin ( rHbA1c ) levels and systolic blood pressure ( SBP ) . SEARCH STRATEGY A literature search was performed on September 28 , 2008 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1 , 2000 and September 28 , 2008 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with unknown eligibility were review ed with a second clinical epidemiologist , then a group of epidemiologists until consensus was established . The quality of evidence was assessed as high , moderate , low or very low according to GRADE methodology . Given the high clinical heterogeneity of the articles that met the inclusion criteria , specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario , models of care that were commonly reported in the literature , as well as suggestions from an Expert Advisory Panel Meeting held on January 21 , 2009 . SUMMARY OF FINDINGS The initial search yielded 2,116 unique citations , from which 22 RCTs trials and nine systematic review s published were identified as meeting the eligibility criteria . Of these , five studies focused on care provided by at least a nurse , dietician , and physician ( primary care and /or specialist ) model of care ( Model 1 ; see Table ES 1 ) , while three studies focused on care provided by at least a pharmacist and primary care physician ( Model 2 ; see Table ES 2 ) . Based on moderate quality evidence , specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in HbA1c of 1.0 % compared with usual care . The effects of this model on SBP , however , are uncertain compared with usual care , based on very-low quality evidence . Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in both HbA1c of 1.05 % ( based on high quality evidence ) and SBP of 7.13 mm Hg ( based on moderate quality evidence ) compared to usual care . For both models , the evidence does not suggest a preferred setting of care delivery ( i.e. , primary care vs. hospital outpatient clinic vs. community clinic ) . Table ES1 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.00 [ -1.27 , -0.73]4 % (p=0.37)Moderate- quality Subgroup : Moderate-to-High Quality -0.91 [ -1.19 , -0.62]0 % (p=0.74)Systolic Blood Pressure ( mm Hg)-2.04 [ -13.80 , 9.72]89 % (p=0.002)Very-low quality * Mean change from baseline to follow-up between intervention and control groupsTable ES2 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.05 [ -1.57 , -0.52]0 % (p=0.75)High- quality Systolic Blood Pressure ( mm Hg)-7.13 [ -11.78 , -2.48]46 % (p=0.17)Moderate quality * Mean change from baseline to follow-up between intervention and control groups AIMS To evaluate the effectiveness and cost implication s of a  hospital diabetes specialist nursing service . METHODS We conducted a prospect i ve , open , r and omized , controlled trial of st and ard in-patient care for adults with diabetes , with and without the intervention of a diabetes specialist nursing ( DSN ) service . The setting was a single UK university hospital . SUBJECTS were unselected patients referred to the hospital DSN service . Primary outcome measures were length of hospital stay and patterns of readmission ( frequency and time to first readmission ) . Secondary outcome measures were subjects ' diabetes-related quality of life , diabetes knowledge score , satisfaction with treatment , and GP and community care contacts following discharge . Costs were estimated from the hospital and published sources . RESULTS Median length of stay was lower in the intervention group ( 11.0 vs. 8.0 days , P < 0.01 ) . Readmission rates were the same in the two groups ( 25 % ) , and mean time to readmission was similar in the two groups , although slightly less in the control group ( 278 vs. 283 days , P = 0.80 ) . The cost per patient for nursing input was 38.94 pounds sterling . However , when the reduced length of stay was accounted for , the intervention produced a mean cost per admission of 436 ponds sterling lower than that of the control group ( P = 0.19 ) . Patients in the intervention group were more knowledgeable regarding their diabetes and more satisfied with their care . CONCLUSIONS Diabetes specialist nurses are potentially cost saving by reducing hospital length of stay ( LOS ) . There was no evidence of an adverse effect of reduced LOS on re-admissions , use of community re sources , or patient perception of quality of care BACKGROUND Good blood pressure ( BP ) control reduces the risk of complications in people with type 2 diabetes , yet many do not achieve this . Guidelines for managing hypertension recommend increasing antihypertensive medications until control is achieved , but the effect of such recommendations in routine primary care is unknown . AIM To evaluate the effectiveness of a BP treatment algorithm in primary care patients with type 2 diabetes . DESIGN OF STUDY A cluster r and omised controlled trial of 1534 patients with type 2 diabetes . SETTING Forty-two practice s in Nottingham , UK . METHOD Practice s were r and omised to continue usual care or to use a treatment algorithm design ed so that practice nurses and GPs would increase antihypertensive treatment in steps until the target of 140/80 mmHg was reached . Participants were assessed by a clinical interview and case note review at recruitment and at 1 year . The primary outcome measure was the proportion of participants achieving target BP at 1 year . RESULTS At 1 year there was no difference between the proportions of participants with well controlled BP in the intervention and control arms ( 36.6 % versus 34.3 % ; P = 0.27 ) . Mean systolic and diastolic blood pressures were identical in the two arms ( 143/78 mmHg ) . There was some evidence that participants in the intervention arm were more likely to be receiving higher doses of their antihypertensive drugs , although there was no significant difference in the number of different antihypertensive drugs prescribed . Participants in the intervention arm had a higher rate of primary care BP-related consultations over 12 months than those receiving usual care ( rate ratio = 1.55 , 95 % confidence interval [ CI ] = 1.26 to 1.88 , P<0.001 ) . CONCLUSION Despite increased monitoring and possibly higher doses of medication there was no improvement in blood pressure control . Improvements achieved by specialist nurse-led clinics in secondary care may not translate to people with type 2 diabetes in primary care setting Background Self-management is crucial in the daily management of type 2 diabetes . It has been suggested that mHealth may be an important method for enhancing self-management when delivered in combination with health counseling . Objective The objective of this study was to test whether the use of a mobile phone – based self-management system used for 1 year , with or without telephone health counseling by a diabetes specialist nurse for the first 4 months , could improve glycated hemoglobin A1c ( HbA1c ) level , self-management , and health-related quality of life compared with usual care . Methods We conducted a 3-arm prospect i ve r and omized controlled trial involving 2 intervention groups and 1 control group . Eligible participants were persons with type 2 diabetes with an HbA1c level ≥7.1 % ( ≥54.1 mmol/mol ) and aged ≥18 years . Both intervention groups received the mobile phone – based self-management system Few Touch Application ( FTA ) . The FTA consisted of a blood glucose – measuring system with automatic wireless data transfer , diet manual , physical activity registration , and management of personal goals , all recorded and operated using a diabetes diary app on the mobile phone . In addition , one intervention group received health counseling based on behavior change theory and delivered by a diabetes specialist nurse for the first 4 months after r and omization . All groups received usual care by their general practitioner . The primary outcome was HbA1c level . Secondary outcomes were self-management ( heiQ ) , health-related quality of life ( SF-36 ) , depressive symptoms ( CES-D ) , and lifestyle changes ( dietary habits and physical activity ) . Data were analyzed using univariate methods ( t test , ANOVA ) and multivariate linear and logistic regression . Results A total of 151 participants were r and omized : 51 to the FTA group , 50 to the FTA-health counseling ( FTA-HC )  group , and 50 to the  control group . Follow-up data after 1 year were available for 120 participants ( 79 % ) . HbA1c level decreased in all groups , but did not differ between groups after 1 year . The mean change in the heiQ domain skills and technique acquisition was significantly greater in the FTA-HC group after adjusting for age , gender , and education ( P=.04 ) . Other secondary outcomes did not differ between groups after 1 year . In the FTA group , 39 % were substantial users of the app ; 34 % of the FTA-HC group were substantial users . Those aged ≥63 years used the app more than their younger counterparts did ( OR 2.7 ; 95 % CI 1.02 - 7.12 ; P=.045 ) . Conclusions The change in HbA1c level did not differ between groups after the 1-year intervention . Secondary outcomes did not differ between groups except for an increase in the self-management domain of skill and technique acquisition in the FTA-HC group . Older participants used the app more than the younger participants did Abstract Background World-wide healthcare systems are faced with an epidemic of type 2 diabetes . In the United Kingdom , clinical care is primarily provided by general practitioners ( GPs ) rather than hospital specialists . Intermediate care clinics for diabetes ( ICCD ) potentially provide a model for supporting GPs in their care of people with poorly controlled type 2 diabetes and in their management of cardiovascular risk factors . This study aims to ( 1 ) compare patients with type 2 diabetes registered with practice s that have access to an ICCD service with those that have access only to usual hospital care ; ( 2 ) assess the cost-effectiveness of the intervention ; and ( 3 ) explore the views and experiences of patients , health professionals and other stakeholders . Methods / Design This two-arm cluster r and omized controlled trial ( with integral economic evaluation and qualitative study ) is set in general practice s in three UK Primary Care Trusts . Practice s are r and omized to one of two groups with patients referred to either an  ICCD ( intervention ) or to hospital care ( control ) . Intervention group : GP practice s in the intervention arm have the opportunity to refer patients to an ICCD - a multidisciplinary team led by a specialist nurse and a diabetologist . Patients are review ed and managed in the ICCD for a short period with a goal of improving diabetes and cardiovascular risk factor control and are then referred back to practice .or Control group : St and ard GP care , with referral to secondary care as required , but no access to ICCD .  Participants are adults aged 18 years or older who have type 2 diabetes that is difficult for their GPs to control . The primary outcome is the proportion of participants reaching three risk factor targets : HbA1c ( ≤7.0 % ) ; blood pressure ( < 140/80 ) ; and cholesterol ( < 4 mmol/l ) , at the end of the 18-month intervention period . The main secondary outcomes are the proportion of participants reaching individual risk factor targets and the overall 10-year risks for coronary heart disease(CHD ) and stroke assessed by the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) risk engine . Other secondary outcomes include body mass index and waist circumference , use of medication , reported smoking , emotional adjustment , patient satisfaction and views on continuity , costs and health related quality of life . We aim ed to r and omize 50 practice s and recruit 2,555 patients . Discussion Forty-nine practice s have been r and omized , 1,997 patients have been recruited to the trial , and 20 patients  have been recruited to the qualitative study . Results will be available late 2012.Trial registration [ Clinical Trials.gov : Identifier NCT00945204 Background Type 2 diabetes mellitus is a chronic condition that requires ongoing , life-long care in order to be controlled . Objectives The aims of the study were to assess the effect of nursing case management on glycated hemoglobin ( HbA1c ) levels compared to usual care in people with type 2 diabetes mellitus and to determine if effects of nursing case management varied by gender , age , duration of disease , education , and income . Methods This is a pragmatic clinical trial , conducted in the municipality of B and eirantes , Paraná , Brazil , in 2011 and 2012 . Eighty individuals were recruited and r and omized equally to receive nursing case management or usual care . Covariates were sociodemographic and clinical factors . The outcome was HbA1c measured at baseline , 6 months , and 12 months . Results The sample consisted predominately of women ; most had been diagnosed with type 2 diabetes mellitus within the previous 5 years . Mean age was 50.14 ( SD = 7.00 ) , with 5.27 ( SD = 4.39 ) years of schooling and an average HbA1c of 9.90 % ( SD = 2.49 ) . Hemoglobin A1c was reduced from an average of 10.33 % to 9.0 % ( p < .01 ) in the nursing case management group and from 9.57 % to 8.93 % ( p = .05 ) in the usual care group ; the group by time effect was not significant . Case management effects varied by younger age ( p = .05 ) , duration of type 2 diabetes less than 5 years ( p = .03 ) , up to 4 years of schooling ( p = .04 ) , and being in the lowest-income stratum ( p = .02 ) . Discussion Both groups showed a statistically significant reduction of HbA1c at 6 and 12 months following baseline . The difference in proportional reduction of HbA1c between groups was not statistically significant OBJECTIVE To determine the cost-effectiveness of  specialist nurse-led clinics provided to improve lipid and blood pressure control in diabetic patients receiving hospital-based care . RESEARCH DESIGN AND METHODS A policy of targeting improved care through specialist nurse-led clinics is evaluated using a novel method , linking the cost-effectiveness of antihypertensive and lipid-lowering treatments with the cost and level of behavioral change achieved by the specialist nurse-led clinics . Treatment cost-effectiveness is modeled from the U.K. Prospect i ve Diabetes Study and Heart Protection Study treatment trials , whereas specialist nurse-led clinics are evaluated using the Specialist Nurse-Led Clinics to Improve Control of Hypertension and Hyperlipidemia in Diabetes ( SPLINT ) trial . RESULTS Good lipid and blood pressure control are cost-effective treatment goals for patients with diabetes . Modeling findings from treatment trials , blood pressure lowering is estimated to be cost saving and life prolonging ( -1,400 dollars/ quality -adjusted life-year [ QALY ] ) , whereas lipid-lowering is estimated to be highly cost-effective ( 8,230 dollars/QALY ) . Investing in nurse-led clinics to help achieve these benefits imposes an addition on treatment cost-effectiveness leading to higher estimates : 4,020 dollars/QALY and 19,950 dollars/QALY , respectively . For both clinics combined , the estimated cost-effectiveness is 9,070 dollars/QALY . Using an acceptability threshold of 50,000 dollars/QALY , the likelihood that blood pressure-lowering clinics are cost-effective is 77 % , lipid clinics 99 % , and combined clinics 83 % . CONCLUSIONS A method is described for evaluating the cost-effectiveness of policies to change patient uptake of health care . Such policies are less attractive than treatment cost-effectiveness ( which implies cost-less self-implementation ) . However , specialist nurse-led clinics , as an adjunct to hospital-based diabetic care , combining both lipid and blood pressure control , appear effective and likely to provide excellent value for money The Diabetes Control and Complications Trial ( DCCT ) and the Kumamoto study [ 1 , 2 ] showed that near-normal glycemic control reduces the development and progression of microvascular and neuropathic complications by approximately 50 % in type 1 and type 2 diabetes mellitus . Additional analyses [ 3 - 5 ] indicate that therapy to achieve near normalization of blood glucose levels is cost-effective compared with other treatments . Thus , the American Diabetes Association has recommended that all persons with diabetes attempt to achieve near normalization of blood glucose levels [ 6 ] . This recommendation is not routinely followed in medical practice . In a 1989 national survey of physician practice behaviors in the United States , 64 % of physicians agreed that achieving target HbA1c values is very important but only 18 % reported that they ordered HbA1c tests every 2 to 3 months for patients with type 1 diabetes [ 7 ] . Although 98 % agreed that patient education improves glucose control , only 55 % reported that they routinely used a dietitian or a diabetes educator in patient care . Studies indicate that bringing clinical practice into line with scientific knowledge can be difficult . Methods used to achieve diabetes control in clinical trials are re source intensive . The American Diabetes Association currently recommends that patients with diabetes see their primary care physicians two to four times per year . Data from the National Health Interview Survey , a nationally representative survey [ 8 ] , indicate that most patients with diabetes are seen by nonspecialists and that 69 % of physician visits last less than 15 minutes . Algorithms for diabetes care exist but may be complex and difficult for physicians to follow , given patient load , diversity of patients seen , lack of information systems , and time constraints . Simple , low-cost methods of translating guidelines into clinical care are required . One solution may be to make greater use of personnel other than physicians . Nurse case management was an integral part of intensive therapy in the DCCT and has proven to be effective in reducing smoking and cholesterol levels after acute myocardial infa rct ion [ 3 , 9 ] . A nonr and omized study [ 10 ] of more than 700 patients with diabetes in a health maintenance organization suggests that nurse case management may be effective in improving metabolic control . Other studies [ 11 , 12 ] show a strong association between algorithm-directed nurse interventions and improved glycemic control . To our knowledge , no r and omized , controlled clinical trial of nurse case management in diabetes has yet been published . In a 12-month r and omized , controlled trial , we compared a nurse case management model of diabetes care with usual diabetes management in a primary care setting . Methods Patients Our study was approved by the institutional review board of the Prudential Center for Health Care Research , and all patients gave written informed consent . Participants were recruited from two of the largest clinics within the Jacksonville Health Care Group , which is the largest provider of primary care services for the Prudential HealthCare HMO plan of Jacksonville , Florida . The Jacksonville Health Care Group is a group of 43 primary care physicians who provide care in eight clinics to more than 75 000 Prudential HealthCare plan members . Potential study participants were identified through a data base used to support quality -improvement activities . Prudential HealthCare HMO members who had diabetes were included in the data base if they had visited a physician for diabetes ( International Classification of Diseases , 9th Revision , codes 250.0 to 250.9 ) , had had a hospital cl aim processed for diabetes , had been seen by the utilization management nurse , or had been referred to an ophthalmologist for a diabetic retinal examination . This data base is up date d regularly . A list with each member 's name , address , telephone number , medical record number , member identification number , age , sex , physician , and clinic was generated by merging the data from the data base with enrollment information . In addition , a list of members who may have had diabetes was created by using pharmacy data . Adult members with diabetes who were potential study participants each received a recruitment call and were invited to schedule an appointment with a research assistant to discuss participation in the study . We made a total of 14 calls at different times and on different days before coding a member as unavailable . After consent was given and the eligibility assessment was completed , baseline information was obtained and an HbA1c test was ordered if the result of one given within the previous 60 days was not available . Patients were ineligible for the study if they had a recent HbA1c value less than 7.0 % ; had uncontrolled hypertension ( blood pressure > 180/110 mm Hg ) ; had unstable angina ( class 4 ) ; had had a myocardial infa rct ion in the past 3 months ; had had two or more episodes of seizures ; had alcoholism or drug abuse documented in the chart ; had late-stage complications of diabetes or other chronic conditions , such as severe immunodeficiency or cirrhosis ; were pregnant or were planning to become pregnant in the next 12 months ; or were unable to perform self-management . Patients were r and omly assigned in blocks to either the nurse case management ( intervention ) group or the usual care group . R and omization was based on a 1:1 allocation ratio and a block size of three . Each block contained six patients , three in each study group . This r and omization scheme ensured that the desired allocation ratio-one intervention patient to one usual care patient-was maintained after sequential enrollment of every sixth patient . Outcome Measures Change in HbA1c value was the primary outcome measure . Decreased HbA1c values correlate directly with reduced risk for diabetes-related microvascular and neuropathic complications in type 1 and type 2 diabetes [ 1 , 3 ] . We also assessed health-related quality of life by using four generic questions developed by the Centers for Disease Control and Prevention for the Behavioral Risk Factor Surveillance System ( BRFSS ) [ 13 , 14 ] . These questions evaluate key conceptual domains of health-related quality of life : 1 ) patient-perceived general health status , 2 ) patient-perceived physical dysfunction during the previous 30 days , 3 ) patient-perceived mental dysfunction during the previous 30 days , and 4 ) patient-perceived functional incapacity during the previous 30 days for either mental or physical reasons . The BRFSS quality -of-life measures have been vali date d in a national sample of adults in the United States [ 15 ] . Patient-perceived health was found to be a good proxy indicator for chronic disease conditions . The other three domains further characterize general health functioning and quality of life [ 15 ] . In this analysis , we report findings related to the patient-perceived general health status domain . Intervention and Follow-up The nurse case manager was a registered nurse and a certified diabetes educator . She was trained to follow a set of detailed management algorithms under the direction of a board-certified family medicine physician and an endocrinologist who were responsible for all diabetes management decisions for patients in the intervention group but were not primary care providers for these patients . The algorithms were specific for type of diabetes and were developed by a multidisciplinary team on which endocrinology , family medicine , nursing , pharmacy , health services research , and epidemiology were represented . The algorithms progressively moved a patient toward improvement of glycemic control through adjustments in medication , meal planning , and reinforcement of exercise ( Figure 1 ) . Figure 1 . Algorithm for management of type 2 diabetes mellitus . Patients assigned to receive nurse case management met with the nurse for an initial assessment , were instructed about a blood glucose monitoring schedule , and returned for a follow-up visit 2 weeks later . The initial visit with the nurse averaged 45 minutes . At the 2-week follow-up visit , the nurse review ed the patient 's blood glucose log ; explained the algorithm step to which the patient had been assigned ; and used this information as the baseline for subsequent medication adjustments , meal planning , and exercise reinforcement . Patients receiving nurse case management  were also referred to a 5-week , 12-hour diabetes education program that included individual counseling by a dietitian , individual counseling by an exercise therapist , and group diabetes education classes . Subsequent in-person follow-up visits occurred quarterly . Patients in the nurse case management group  who were taking insulin  received weekly follow-up telephone calls . After the nurse review ed the blood glucose log and discussed glucose values with the patient , medication regimens were adjusted as needed and meal planning and exercise were reinforced . Patients treated with oral agents or diet and exercise  received follow-up telephone calls every 2 weeks . The nurse case manager met at least biweekly with the family medicine physician and the endocrinologist to review patient progress , medication adjustments , and other issues related to diabetes care . All medication adjustments or changes were communicated to the patients ' regular primary care physicians . Patients assigned to receive usual care were given blood glucose meters and strips , were encouraged to discuss enrollment in the diabetes education class with their physicians if they had not done so in the past year , and continued to receive diabetes care and follow-up from their primary care physicians . The 5-week diabetes education program is a st and ard , free-of-charge benefit for all HMO members with diabetes . All Jacksonville Health Care Group primary care physicians participate in an annual diabetes care seminar and undergo regular peer review of their adherence to published diabetes care st and ards . Tests to BACKGROUND To study the effects of two different structured shared care interventions , tailored to local needs and re sources , in an unselected patient population with type 2 diabetes mellitus . METHODS A three-year prospect i ve observational study of two interventions and st and ard care . The interventions involved extensive ( A ) or limited ( B ) task delegation from general practitioners to hospital-liaised nurses specialised in diabetes and included a diabetes register , structured recall , facilitated generalist-specialist communication , audit and feedback , patient-specific reminders , and emphasised patient education . The target population consisted of 2660 patients with type 2 diabetes treated in the primary care setting . Patients who were terminally ill or who had been diagnosed with dementia were excluded from the study . RESULTS The participation rates were high ( 90 % ) for patients , and none of the 64 GPs discontinued their participation in the study . Longitudinal analyses showed significant improvements in quality indicators for both intervention groups ( process parameters and achieved target values on the individual patient level ) ; in st and ard care , performance remained stable or deteriorated . Both patients and caregivers appeared satisfied with the project . CONCLUSION This study shows that structured shared care with task delegation to nurses , targeted at a large unselected general practice population , is feasible and can positively affect the quality of care for patients with type 2 diabetes OBJECTIVE To determine the effectiveness of specialist nurse delivered education in primary care to improve control of hypertension and hyperlipidaemia in patients with diabetes . DESIGN AND SETTING Practice -level r and omized controlled trial , Salford , Engl and . SUBJECTS From 44 practice s , 10 303 subjects presenting in general practice with raised blood pressure (= 140/80 mmHg ) , raised total cholesterol (= 5.0 mmol/l ) or both . INTERVENTIONS Practice s were r and omized to receive either the intervention for hyperlipidaemia or for hypertension ; practice s acted as control for the intervention not received . Specialist nurses arranged a schedule of visits with general practitioners and general practice nurses , reminding them of diabetes protocol s and clinical targets . They provided educational material s and protocol s used in secondary care for nurse and doctor interventions including stepping up pharmacotherapy when necessary . Practice s received a list of patients in their practice who were poorly controlled at their last annual review ; new and recalled patients were targeted . OUTCOME MEASURES At subsequent annual review , blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register for patients from participating practice s. RESULTS Overall , specialist nurse-led educational outreach to primary care was associated with no improvement in patients achieving target after 1 year-odds ratio ( OR ) : 1.03 ( 95 % CI 0.95 - 1.11 ; P = 0.52 ) . Similar results were achieved with hyperlipidaemia OR : 1.04 ( 95 % CI 0.88 - 1.23 ; P = 0.62 ) and hypertension OR : 1.01 ( 95 % CI 0.80 - 1.27 ; P = 0.93 ) . CONCLUSION This study provides evidence that the use of specialist nurses to perform educational outreach to improve target adherence to patients with diabetes in primary care is not effective Background Self-management support for people with type 2 diabetes is essential in diabetes care . Thus , mobile health technology with or without low-intensity theory-based health counseling could become an important tool for promoting self-management . Objectives The aim was to evaluate whether the introduction of technology-supported self-management using the Few Touch Application ( FTA ) diabetes diary with or without health counseling improved glycated hemoglobin ( HbA1c ) levels , self-management , behavioral change , and health-related quality of life , and to describe the sociodemographic , clinical , and lifestyle characteristics of the participants after 4 months . Methods A 3-armed r and omized controlled trial was conducted in Norway during 2011 - 2013 . In the 2 intervention groups , participants were given a mobile phone for 1 year , which provided access to the FTA diary , a self-help tool that recorded 5 elements : blood glucose , food habits , physical activity , personal goal setting , and a look-up system for diabetes information . One of the intervention groups was also offered theory-based health counseling with a specialist diabetes nurse by telephone for 4 months from baseline . Both intervention groups and the  control group were provided usual care according to the national guidelines . Adults with type 2 diabetes and HbA1c ≥7.1 % were included ( N=151 ) . There were 3 assessment points : baseline , 4 months , and 1 year . We report the short-term findings after 4 months . HbA1c was the primary outcome and the secondary outcomes were self-management ( Health Education Impact Question naire , heiQ ) , behavioral change ( diet and physical activity ) , and health-related quality of life ( SF-36 question naire ) . The data were analyzed using univariate methods ( ANOVA ) , multivariate linear , and logistic regression . Results Data were analyzed from 124 individuals ( attrition rate was 18 % ) . The groups were well balanced at baseline . There were no differences in HbA1c between groups after 4 months , but there was a decline in all groups . There were changes in self-management measured using the health service navigation item in the heiQ , with improvements in the FTA group compared to the control group ( P=.01 ) and in the FTA with health counseling group compared with both other groups ( P=.04 ) . This may indicate an improvement in the ability of patients to communicate health needs to their health care providers . Furthermore , the FTA group reported higher scores for skill and technique acquisition at relieving symptoms compared to the control group ( P=.02 ) . There were no significant changes in any of the domains of the SF-36 . Conclusions The primary outcome , HbA1c , did not differ between groups after 4 months . Both of the intervention groups had significantly better scores than the control group for health service navigation and the FTA group also exhibited improved skill and technique acquisition 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 practice s 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 r and omised controlled trials as the study design of choice . Other research design s such as controlled clinical trials , interrupted time series and controlled before and after design s 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 . Method ological quality Quantitative papers selected for retrieval were assessed by two independent review ers for method ological validity prior to inclusion in the review using st and ardised 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 st and ardised data extraction tool from the Joanna Briggs Institute . The data extracted included specific details about the interventions , population s , 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 review ers . From these papers , five were included in the review , four r and omised 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 . Implication s 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 r and omised controlled trials are required to assess the efficacy of nurse‐led care including cost effectiveness UNLABELLED This review should be cited as : Renders CM , Valk GD , Griffin S. Wagner EH , Eijk JThM van , Assendelft WJJ . Interventions to improve the management of  diabetes mellitus  in primary care , outpatient and community setting s ( Cochrane Review ) . In : The Cochrane Library , Issue 2 , 2001 . Oxford : Up date Software . A substantive amendment to this systematic review was last made on 29 June 2000 . Cochrane review s are regularly checked and up date d if necessary . BACKGROUND Diabetes is a common chronic disease that is increasingly managed in primary care . Different systems have been proposed to manage diabetes care . OBJECTIVES To assess the effects of different interventions , targeted at health professionals or the structure in which they deliver care , on the management of patients with diabetes in primary care , outpatient and community setting s. SEARCH STRATEGY We search ed the Cochrane Effective Practice and Organisation of Care Group specialised register , the Cochrane Controlled Trials Register ( Issue 4 1999 ) , MEDLINE ( 1966 - 1999 ) , EMBASE ( 1980 - 1999 ) , Cinahl ( 1982 - 1999 ) , and reference lists of articles . SELECTION CRITERIA R and omised trials ( RCTs ) , controlled clinical trials ( CCTs ) , controlled before and after studies ( CBAs ) and interrupted time series ( ITS ) analyses of professional , financial and organisational strategies aim ed at improving care for people with Type 1 or Type 2 diabetes . The participants were health care professionals , including physicians , nurses and pharmacists . The outcomes included objective ly measured health professional performance or patient outcomes , and self-report measures with known validity and reliability . DATA COLLECTION AND ANALYSIS Two review ers independently extracted data and assessed study quality . MAIN RESULTS Forty-one studies were included involving more than 200 practice s and 48,000 patients . Twenty-seven studies were RCTs , 12 were CBAs , and two were ITS . The studies were heterogeneous in terms of interventions , participants , setting s and outcomes . The method ological quality of the studies was often poor . In all studies the intervention strategy was multifaceted . In 12 studies the interventions were targeted at health professionals , in nine they were targeted at the organization of care , and 20 studies targeted both . In 15 studies patient education was added to the professional and organisational interventions . A combination of professional interventions improved process outcomes . The effect on patient outcomes remained less clear as these were rarely assessed . Arrangements for follow-up ( organisational intervention ) also showed a favourable effect on process outcomes . Multiple interventions in which patient education was added or in which the role of the nurse was enhanced also reported favourable effects on patients ' health outcomes . REVIEW ERS ' CONCLUSION : Multifaceted professional interventions can enhance the performance of health professionals in managing patients with diabetes .  Organisational interventions that improve regular prompted recall and review of patients  ( central computerised tracking systems or nurses who regularly contact the patient ) can also improve diabetes management . The addition of patient-oriented interventions can lead to improved patient health outcomes . Nurses can play an important role in patient-oriented interventions , through patient education or facilitating adherence to treatment Objective To evaluate the effectiveness of biopsychosocial Self-Management Support ( SMS ) delivered by practice nurses in routine diabetes care . Design A pragmatic cluster-r and omised controlled trial within a hybrid effectiveness-implementation study design . Practice nurses were cluster-r and omised . Setting A regional care group in the Netherl and s consisting of 77 family practice s. The study involved practice nurses ( n=40 ) providing care to approximately 4000 patients with diabetes . Participants Patients with type 2 diabetes ( n=264 ) selected by a self-administered question naire aim ed at measuring emotional distress and diabetes-related reduced daily functioning . Intervention Practice nurses in the intervention arm ( n=19 ) were trained to integrate SMS into their routine consultations . SMS included detection of patients with emotional distress and reduced daily functioning , and supporting them when needed through problem solving and reattribution techniques . Practice nurses in the control arm ( n=21 ) provided usual care . Main outcome measures The primary outcome measure was a dichotomised score on a Visual Analogue Scale that measured the perceived effect of diabetes on daily functioning . Secondary measures included patients ’ diabetes-related distress , quality of life , autonomy and participation , self-efficacy , self-management and glycaemic control . Outcomes were measured at baseline and at 4-month and 12-month follow-ups . Results Only 16 of the 117 patients in the intervention arm ( 14 % ) who were found eligible by the posted research -driven screening question naire were detected by their practice nurses . Extra consultations for the self-management support were delivered to only 11 study participants . In the control arm , 147 patients received usual care . Multilevel analyses showed no significant differences in outcomes between the intervention and control arms . Conclusions SMS in its present form was not effective . The research -driven screening to select trial participants appeared to be inconsistent with nurse-led detection in routine practice . Adequate follow-up moments need to be built in to overcome barriers result ing from tension between the implementation and effectiveness parts of hybrid studies . Trial registration number Current Controlled Trials NTR2764 Background When depression accompanies diabetes , it complicates treatment , portends worse outcomes and increases health care costs . A collaborative care case-management model , previously tested in an urban managed care organization in the US , achieved significant reduction of depressive symptoms , improved diabetes disease control and patient-reported outcomes , and saved money . While impressive , these findings need to be replicated and extended to other healthcare setting s. Our objective is to comprehensively evaluate a collaborative care model for comorbid depression and type 2 diabetes within a Canadian primary care setting . Methods / design We initiated the TeamCare model in four Primary Care Networks in Northern Alberta . The intervention involves a nurse care manager guiding patient-centered care with family physicians and consultant physician specialists to monitor progress and develop tailored care plans .  Patients eligible for the intervention will be identified using the Patient  Health  Question naire-9 as a screen for depressive symptoms . Care managers will then guide patients through three phases : 1 ) improving depressive symptoms  , 2 ) improving blood glucose , blood pressure and cholesterol  , and 3 ) improving lifestyle behaviors .  We will employ the RE- AIM framework for a comprehensive and mixed- methods approach to our evaluation . Effectiveness will be assessed using a controlled “ on-off ” trial design , whereby eligible patients would be alternately enrolled in the TeamCare intervention or usual care on a monthly basis . All patients will be assessed at baseline , 6 and 12 months . Our primary analyses will be based on changes in two outcomes : depressive symptoms , and a multivariable , scaled marginal model for the combined outcome of global disease control ( i.e. , A1c , systolic blood pressure , LDL cholesterol ) . Our planned enrolment of 168 patients will provide greater than 80 % power to observe clinical ly important improvements in all measured outcomes . Direct costing of all intervention components and measurement of all health care utilization using linked administrative data bases will be used to determine the cost-effectiveness of the intervention relative to usual care . Discussion Our comprehensive evaluation will generate evidence to reliability , effectiveness and sustainability of this collaborative care model for patients with chronic diseases and depression . Trials registration Clintrials.gov Identifier : Aim : To verify if Group Care , a model to manage Type 2 diabetes ( T2DM ) by systemic continuing group education , can be administered by nurses and dieticians under pedagogic guidance , and improve metabolic control , quality of life , Locus of Control , and insulin resistance . Material and subjects : Twenty-five patients with non-insulin-treated T2DM were r and omized to Group Care and 24 to continued habitual individual care and education delivered by a diabetes specialist and pedagogist , respectively . Six nurses and 1 dietician received training by an accredited programme , a detailed operating manual and pedagogical supervision throughout the study . Follow-up was for 2 yr and included measurements of fasting blood glucose , glycated hemoglobin ( HbA1c ) , body mass index , waist circumference , lipids , creatinine , blood pressure , serum insulin , homeostasis model assessment ( HOMA ) index of insulin resistance , health behaviors , quality of life , state and trait anxiety , and Locus of Control . Results : One patient on Group Care and 3 controls dropped out . At the end of study , the patients on Group Care had lower HbA1c ( 7.6± 0.8 vs 8.4± 1.3 , p<0.05 ) , insulin ( 18.0± 9.6 vs 24.3± 13.7 , p<0.001 ) , HOMA index ( 6.9± 5.4 vs 9.2± 6.6 , p<0.05 ) , and fatalistic attitude ( 17.2± 5.9 vs 24.9± 4.2 , p<0.001 ) and better quality of life ( 65.0± 11.0 vs 78.4± 19.6 , p<0.001 ) than controls . Conclusions : Group Care delivered by trained nurses and dietitan is associated with better outcomes than those obtained by a medically and pedagogically qualified team . It may offer a model for health operators to re-organize clinical practice and for patients to improve lifestyle and strengthen the therapeutic alliance with their carers Background Despite the efforts of the healthcare community to improve the quality of diabetes care , about 50 % of people with type 2 diabetes do not reach their treatment targets , increasing the risk of future micro- and macro-vascular complications . Diabetes self-management education has been shown to contribute to better disease control . However , it is not known which strategies involving educational programs are cost-effective . Telehealth applications might support chronic disease management . Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high method ological quality . “ The COACH Program ” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions . It proved to be effective in patients with coronary heart disease after hospitalization . Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed . Methods / Design R and omized controlled trial in patients with type 2 diabetes . Patients were selected based on their medication consumption data and were recruited by their sickness fund . They were r and omized to receive either usual care plus “ The COACH Program ” or usual care alone . The study will assess the difference in outcomes between groups . The primary outcome measure is the level of HbA1c . The secondary outcomes are : Total Cholesterol , LDL-Cholesterol , HDL-Cholesterol , Triglycerides , Blood Pressure , body mass index , smoking status ; proportion of people at target for HbA1c , LDL-Cholesterol and Blood Pressure ; self-perceived health status , diabetes-specific emotional distress and satisfaction with diabetes care . The follow-up period is 18 months . Within-trial and modeled cost-utility analyses , to project effects over life-time horizon beyond the trial duration , will be undertaken from the perspective of the health care system if the intervention is effective . Discussion The study will enhance our underst and ing of the potential of telehealth in diabetes management in Belgium . Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions . Trial registration Belgian number : B322201213625 . Clinical Trials.gov Identifier : In recent years , great emphasis has been placed on the role of nonpharmacological self-management in the care of patients with diabetes . Studies have reported that nurses , compared to other healthcare professionals , are more likely to promote preventive healthcare seeking behaviors . The aim of this study was to investigate the effectiveness of a nurse-led diabetes self-management education on glycosylated hemoglobin . A two-arm parallel-group r and omized controlled trial with the blinded outcome assessors was design ed . One hundred forty-two adults with type 2 diabetes were r and omized to receive either usual diabetes care ( control group ) or usual care plus a nurse-led diabetes self-management education ( intervention group ) . Duration of the intervention was 12 weeks . The primary outcome was glycosylated hemoglobin ( HbA1c values ) . Secondary outcomes were changes in blood pressure , body weight , lipid profiles , self-efficacy ( efficacy expectation and outcome expectation ) , self-management behaviors , quality of life , social support , and depression . Outcome measures were assessed at baseline and at 12-week and 24-week postr and omizations . Patients in the intervention group showed significant improvement in HbA1c , blood pressure , body weight , efficacy expectation , outcome expectation , and diabetes self-management behaviors . The beneficial effect of a nurse-led intervention continued to accrue beyond the end of the trial result ing in sustained improvements in clinical , lifestyle , and psychosocial outcomes . This trial is registered with I RCT 2016062528627N1 BACKGROUND A new diabetes shared care service was introduced in North Dublin . It was design ed as a r and omized controlled trial with a complex intervention comprising education of participating practitioners , the introduction of a community-based diabetes nurse specialist , local agreement on clinical protocol s and structured communication across the primary - secondary care interface . OBJECTIVES Our aim was to assess the feasibility and effectiveness of a structured diabetes shared care service in a mixed health care system and to analyse the impact on total patient care . METHODS A Cluster r and omized controlled trial lasting 18 months was carried out in 183 patients with type 2 diabetes from 30 general practice s in North Dublin . Biophysical outcomes ( HbA1c , blood pressure , body mass index ) , psychosocial measures ( smoking status and Diabetes Clinic Treatment Satisfaction and Diabetes Well-being scores ) and process outcomes were collected . RESULTS There were significant improvements in diabetes care delivery and in psychosocial outcomes , but no significant improvements in biomedical outcomes . Process data collection revealed a significant increase in diabetes care-related activity for participating patients with an increase in structured annual review s and fewer patients defaulting from care . There were also significant improvements in information exchange between primary and secondary care . CONCLUSION Structured diabetes shared care , in a mixed health care system , can produce significant improvements in diabetes care delivery and in psychosocial outcomes for patients , with improved information exchange across the primary - secondary care interface INTRODUCTION The implementation of telemedicine often introduces major organizational changes in the affected healthcare sector . The objective of this study was to examine the organizational changes through the perception of the healthcare professionals regarding the implementation of a telemedical intervention . We posed the following research question : What are the key organizational factors in the implementation of telemedicine in wound care ? METHODS In connection with a r and omized controlled trial of telemedical intervention for patients with diabetic foot ulcers in the region of Southern Denmark , we conducted an organizational analysis . The trial was design ed as a multidisciplinary assessment of outcomes using the Model of ASsessment of Telemedicine ( MAST ) . We conducted eight semi-structured interviews including individual interviews with leaders , and an IT specialist as well as focus group interviews with the clinical staff . A qualitative data analysis of the interviews was performed in order to analyze the healthcare professionals and leaders perception of the organizational changes caused by the implementation of the intervention . RESULTS The telemedical setup enhanced confidence among collaborators and improved the wound care skills of the visiting nurses from the municipality . The effect was related to the direct communication between visiting nurses and specialist doctors . Focus on the training of the visiting nurses was highlighted as a key factor in the success to securing implementation . Concerns regarding lack of multidisciplinary wound care teams , patient responsibility and lack of patient interaction with the physician were raised . Furthermore , the need for clinical guidelines in future implementation was underlined . CONCLUSIONS Several influential factors were demonstrated in the analysis including visiting nurses wound care training , focus on management , economy , periods with absence from work and clinical care . However , the technology used here could provide an additional option to offer patients after an individual assessment of their health condition Background Co-morbid major depression is a significant problem among patients with type 2 diabetes mellitus and /or coronary heart disease and this negatively impacts quality of life . Subthreshold depression is the most important risk factor for the development of major depression . Given the highly significant association between depression and adverse health outcomes and the limited capacity for depression treatment in primary care , there is an urgent need for interventions that successfully prevent the transition from subthreshold depression into a major depressive disorder . Nurse led stepped-care is a promising way to accomplish this . The aim of this study is to evaluate the cost-effectiveness of a nurse-led indicated stepped-care program to prevent major depression among patients with type 2 diabetes mellitus and /or coronary heart disease in primary care who also have subthreshold depressive symptoms . Methods / design An economic evaluation will be conducted alongside a cluster-r and omized controlled trial in approximately thirty general practice s in the Netherl and s. R and omization takes place at the level of participating practice nurses . We aim to include 236 participants who will either receive a nurse-led indicated stepped-care program for depressive symptoms or care as usual .  The stepped-care program consists of four sequential but flexible treatment steps : 1 ) watchful waiting , 2 ) guided self-help treatment , 3 ) problem solving treatment and 4 ) referral to the general practitioner . The primary clinical outcome measure is the cumulative incidence of major depressive disorder as measured with the Mini International Neuropsychiatric Interview . Secondary outcomes include severity of depressive symptoms , quality of life , anxiety and physical outcomes . Costs will be measured from a societal perspective and include health care utilization , medication and lost productivity costs . Measurements will be performed at baseline and 3 , 6 , 9 and 12 months . Discussion The intervention being investigated is expected to prevent new cases of depression among people with type 2 diabetes mellitus and /or coronary heart disease and subthreshold depression , with subsequent beneficial effects on quality of life , clinical outcomes and health care costs . When proven cost-effective , the program provides a viable treatment option in the Dutch primary care system . Trial registration Dutch Trial Register In a r and omized clinical trial , quality of health care as reflected in patient outcomes and cost of health care was compared between two groups of high-risk childbearing women : women diagnosed with diabetes or hypertension in pregnancy . The control group ( N = 52 ) was discharged routinely from the hospital . The intervention group ( N = 44 ) was discharged early using a model of clinical nurse specialist transitional follow-up care . During pregnancy , the intervention group had significantly fewer rehospitalizations than the control group . For infants of diabetic women enrolled in the study during their pregnancy , low birth weight ( < or = 2,500 g ) was three times more prevalent in the control group ( 29 % ) than in the intervention group ( 8.3 % ) . The postpartum hospital charges for the intervention group were also significantly less than for the control group . The mean total hospital charges for the intervention group were 44 % less than for the control group . The mean cost of the clinical specialist follow-up care was 2 % of the total hospital charges for the control group . A net savings of $ 13,327 was realized for each mother-infant dyad discharged early from the hospital AIMS To investigate whether a secondary - primary care partnership education package could improve underst and ing of diabetes care among South Asians . METHODS In a pilot r and omized controlled trial , in the setting of eight general practice s r and omized to intervention or control , patients were invited to four or more rotating visits per year by one of a diabetes specialist nurse , dietician or chiropodist working with general practice staff . Participants were from lists of South Asian patients with known Type 2 diabetes in each ( general ) practice . RESULTS Patients and practice scores at baseline and 1-year follow-up , from an interview using a question naire on knowledge , awareness and self-management of diabetes . Responses were developed into educational packages used during intervention . Of the 411 patients listed at baseline only 211 were traced for interview ( refusal only 4 % ) . Mean age was 55.4 years , age of diabetes onset 47.1 years . Fourteen percent were employed and 35 % were able to communicate in English fluently . Only 118 could be traced and interviewed at 1 year , although there was no significant difference in demography between those who completed the study and those who did not . Despite a mean of four visits/patient , intervention had no impact on scores for diabetes knowledge , or awareness [ score change 0.14 , 95 % confidence interval ( CI ) -0.20 , 0.49 ] or self-management ( -0.05 , 95 % CI -0.48 , 0.39 ) between baseline and 1 year . CONCLUSIONS This form of secondary / primary care support did not transfer information effectively , and we suspect similar problems would arise in other similar communities . Different methods of clinician/patient information exchange need to be developed for diabetes in this South Asian group Background The diabetes of many patients is managed in general practice ; healthcare providers aim to promote healthful behaviors , such as healthful diet , adequate physical activity , and smoking cessation . These measures may decrease insulin resistance , improve glycemic control , lipid abnormalities , and hypertension . They may also prevent cardiovascular disease and complications of diabetes . However , professionals do not adhere optimally to guidelines for lifestyle counseling . Motivational interviewing to change the lifestyle of patients with type 2 diabetes is intended to improve diabetes care in accordance with the national guidelines for lifestyle counseling . Primary care nurses will be trained in motivational interviewing embedded in structured care in general practice . The aim of this paper is to describe the design and methods of a study evaluating the effects of the nurses ' training on patient outcomes . Methods / Design A cluster , r and omized , controlled trial involving 70 general practice s ( 35 practice s in the intervention arm and 35 in the control arm ) starting in March 2007 . A total of 700 patients with type 2 diabetes will be recruited . The patients in the intervention arm will receive care from the primary care nurse , who will receive training in an implementation strategy with motivational interviewing as the core component . Other components of this strategy will be adaptation of the diabetes protocol to local circumstances , introduction of a social map for lifestyle support , and educational and supportive tools for sustaining motivational interviewing . The control arm will be encouraged to maintain usual care . The effect measures will be the care process , metabolic parameters ( glycosylated hemoglobin , blood pressure and lipids ) , lifestyle ( diet , physical activity , smoking , and alcohol ) , health-related quality of life , and patients ' willingness to change behaviors . The measurements will take place at baseline and after 14 months . Discussion Applying motivational interviewing for patients with diabetes in primary care has been studied , but to our knowledge , no other study has yet evaluated the implementation and sustainability of motivating and involving patients in day-to-day diabetes care in general practice . If this intervention proves to be effective and cost-effective , large-scale implementation of this nurse-oriented intervention will be considered and anticipated . Trial registration Current Controlled Trials IS RCT N68707773 AIMS Chronic kidney disease patients overwhelm specialist services and can potentially be managed in the primary care ( PC ) . Opportunistic screening of high risk ( HR ) patients and follow-up in PC is the most sustainable model of care . A ' virtual consultation ' ( VC ) model instead of traditional face to face ( F2F ) consultations was used , aim ing to assess efficacy and safety of the model . METHODS Seventy patients were recruited from PC sites and hospital clinics and followed for 1 year . The HR patients ( eGFR < 30 mL/min/1.73m2 + /- albuminuria > 30 mg/mmol/L ) were r and omized to either VC or F2F .  Patients were monitored in 6 monthly follow-up cycles by a Clinical Nurse Specialist . The specialist team provided virtual or clinical support and included a Nephrologist , Endocrinologist , Cardiologist and Renal ' Palliative ' Supportive Care . RESULTS Sixty one ( 87 % ) patients were virtually tracked or consulted with 14 ( 23 % ) being HR . At 12 months , there was no difference in outcomes between VC and F2F patients . All patients were successfully monitored . General practitioners reported a high level of satisfaction and supported the model , but found software integration challenging . Patients found the system attractive and felt well managed . Specialist consults occurred within a week , and if a second specialist opinion was required , it took another 2 weeks . CONCLUSIONS The programme demonstrated safe , expedited and efficient follow up with a clinical and web based programme . Support from the general practitioners and patients was encouraging , despite logistical issues . Ongoing evaluation of VC services will continue and feasibility to larger networks and more chronic diseases remains the long term goal OBJECTIVE Specialist care is reportedly associated with favorable therapeutic results , although detailed outcomes of recent large-scale prospect i ve surveys of specialist care have yet to be published . The goal of this study was to eluci date the effects of one year 's specialist care on the management of type 2 diabetes . PATIENTS AND METHODS A multi-centered , prospect i ve observational study was undertaken . 754 type 2 diabetes patients , who made their first visit to one of eleven participating outpatient clinics specializing in diabetes care , were enrolled .  Routine structured diabetes care according to established guideline , including diabetes self-management education , was provided to all patients at each clinic visit . Parameters relating to glycemic control , serum lipids , blood pressure , patient follow-up status and others were followed for twelve months . RESULTS The HbA(1C ) level had improved significantly from 8.4+/-2.2 % at baseline to 6.8+/-1.2 % after six months and was 7.0+/-1.3 % after twelve months ( mean+/-SD ) . The higher the baseline HbA(1C ) level , the greater the subsequent improvement . Moreover , the most dramatic improvements in HbA(1C ) levels were seen within the first three months . The proportion of patients satisfying all of the therapeutic goals was extremely low at baseline and remained at less than 10 % after twelve months of specialist care . CONCLUSIONS Diabetic patients under specialist care  experienced substantial improvement , especially in glycemic control , as early as a few months after the first visit . However , 35 percent of patients dropped out during the 12-month study period and this is one area that needs to be improved AIMS AND OBJECTIVES To determine whether the management of  type 2 diabetes mellitus  in a primary care setting can be safely transferred to practice nurses . BACKGROUND Because of the increasing prevalence of type 2 diabetes mellitus and the burden of caring for individual patients , the dem and type 2 diabetes mellitus patients place on primary health care re sources has become overwhelming . DESIGN R and omised controlled trial . METHODS The patients in the intervention group were cared for by practice nurses who treated glucose levels , blood pressure and lipid profile according to a specified protocol . The control group received conventional care from a general practitioner . The primary outcome measure was the mean decrease seen in glycated haemoglobin ( HbA1c ) levels at the end of the follow-up period ( 14 months ) . RESULTS A total of 230 patients was r and omised with 206 completing the study . The between-group differences with respect to reduction in HbA1c , blood pressure and lipid profile were not significant . Blood pressure decreased significantly in both groups ; 7.4/3.2 mm Hg in the intervention group and 5.6/1.0 mm Hg in the control group . In both groups , more patients met the target values goals for lipid profile compared to baseline . In the intervention group , there was some deterioration in the health-related quality of life and an increase in diabetes-related symptoms . Patients being treated by a practice nurse were more satisfied with their treatment than those being treated by a general practitioner . CONCLUSION Practice nurses achieved results , which were comparable to those achieved by a general practitioner with respect to clinical parameters with better patient satisfaction . RELEVANCE TO CLINICAL PRACTICE This study shows that diabetes management in primary care can be safely transferred to practice nurses Background In the presence of type 2 diabetes ( T2DM ) or coronary heart disease ( CHD ) , depression is under diagnosed and under treated despite being associated with worse clinical outcomes . Our earlier pilot study demonstrated that it was feasible , acceptable and affordable for practice nurses to extend their role to include screening for and monitoring of depression alongside biological and lifestyle risk factors . The current study will compare the clinical outcomes of our model of practice nurse-led collaborative care with usual care for patients with depression and T2DM or CHD . Methods This is a cluster-r and omised intervention trial . Eighteen general practice s from regional and metropolitan areas agreed to join this study , and were allocated r and omly to an intervention or control group . We aim to recruit 50 patients with co-morbid depression and diabetes or heart disease from each of these practice s. In the intervention group , practice nurses ( PNs ) will be trained for their enhanced roles in this nurse-led collaborative care study . Patients will be invited to attend a practice nurse consultation every 3 months prior to seeing their usual general practitioner . The PN will assess psychological , physiological and lifestyle parameters then work with the patient to set management goals . The outcome of this assessment will form the basis of a GP Management Plan document . In the control group , the patients will continue to receive their usual care for the first six months of the study before the PNs undergo the training and switch to the intervention protocol . The primary clinical outcome will be a reduction in the depression score . The study will also measure the impact on physiological measures , quality of life and on patient attitude to health care delivered by practice nurses . Conclusion The strength of this programme is that it provides a sustainable model of chronic disease management with monitoring and self-management assistance for physiological , lifestyle and psychological risk factors for high-risk patients with co-morbid depression , diabetes or heart disease . The study will demonstrate whether nurse-led collaborative care achieves better outcomes than usual care OBJECTIVE Despite good evidence and clinical practice guidelines , studies document that treatment of type 2 diabetes is less than optimal . Lack of re sources or limited access may put patients in rural communities at particular risk for suboptimal care . RESEARCH DESIGN AND METHODS We conducted a prospect i ve , before/after study with concurrent controls to assess the effectiveness of a multidisciplinary diabetes outreach service ( intervention ) for improving the quality of care for rural patients with type 2 diabetes . Our intervention consisted of six monthly visits by a traveling team of specialist physicians , nurses , dieticians , and a pharmacist . The core of this service was specialist-to-rural primary care physician academic group detailing . Two comparable regions in Northern Alberta were r and omly allocated to control or intervention . Data were collected before and 6 months after intervention in a representative volunteer sample . The primary outcome was a 10 % improvement in any one of the following : blood pressure , total cholesterol , or HbA(1c ) . RESULTS Our analysis included 200 intervention and 179 control subjects ; 14 subjects were at all three primary outcome targets at baseline . The intervention was associated with a trend toward improvement in primary outcome at 6 months ( 44 % intervention vs. 37 % control ; odds ratio 1.32 , 95 % CI 0.87 - 1.99 ) . The intervention was associated with a significant improvement in blood pressure ( 42 % intervention vs. 25 % control , P = 0.004 ) ; however , there were only small , nonsignificant changes in cholesterol or HbA(1c ) . The intervention was associated with a significant increase in satisfaction with diabetes care . Multivariate adjustment for baseline differences between intervention and control subjects did not affect any of the main results . CONCLUSIONS A diabetes outreach service has the potential to improve the quality of diabetes care for rural patients . Future studies need to involve longer timelines and larger sample sizes BACKGROUND There is a need for r and omized , prospect i ve trials of case management interventions with re source utilization analyses . OBJECTIVES To determine whether algorithm-driven telephone care by nurses improves lipid control in patients with diabetes . DESIGN Prospect i ve , r and omized , controlled trial . PARTICIPANTS Adults with diabetes at a federally funded community health center were r and omly assigned to intervention ( n = 381 ) or usual-care ( n = 381 ) groups . INTERVENTIONS Nurses independently initiated and titrated lipid therapy and promoted behavioral change through motivational interviewing and self-management techniques . Other parameters of diabetes care were addressed based on time constraints . MAIN MEASURES The primary outcome was the proportion of patients with a low-density lipoprotein ( LDL ) less than 100 mg/dL. Secondary outcomes included the number of hospital admissions , total hospital charges per patient , and the proportion of patients meeting other lipid , glycemic , and blood pressure guidelines . KEY RESULTS The percent of patients with an LDL < 100 mg/dL increased from 52.0 % to 58.5 % in the intervention group and decreased from 55.6 % to 46.7 % in the control group ( P < .01 ) . Average cost per patient to the healthcare system was less for the intervention group ( $ 6600 vs $ 9033 , P = .03 ) . Intervention patients trended toward fewer hospital admissions ( P = .06 ) . The intervention did not affect glycemic and blood pressure outcomes . CONCLUSIONS Nurses can improve lipid control in patients with diabetes in a primarily indigent population through telephone care using moderately complex algorithms , but a more targeted approach is warranted . Telephone-based outreach may decrease re source utilization , but more study is needed The purpose of this study is to examine effects of a nurse-physician collaborative approach to care of patients with type 2 diabetes and to determine possible effect sizes for use in computing sample sizes for a larger study . Forty patients from a family practice clinic with type 2 diabetes were r and omly assigned to control or experimental groups . The control group received st and ard care , whereas the experimental group received st and ard care plus home visits from a nurse , as well as consultation with an exercise specialist and /or nutritionist . Follow-up continued for 3 months . Clinical end points included st and ard measures of diabetes activity as well as quality -of-life indicators .  Focus group interviews were used to explore patients ’ responses to the program . Although findings were not statistically significant , a trend toward small to moderate positive effect sizes was found in glycosylated hemoglobin and blood pressure . Quality oflife measures also showed a trend toward small to moderate , but nonsignificant , improvements in physical functioning , bodily pain , vitality , social and global functioning , energy , impact of diabetes , and health distress . Focus group interviews indicated a very positive response from patients , who expressed feelings of empowerment . In this study , patients treated with  nurse-physician collaboration  demonstrated small , but nonsignificant , improvements in blood chemistry after only 3 months . Physical and social functioning , energy , and bodily pain also showed a small improvement . Changes in awareness of effects of diabetes on health and an expressed sense of self-efficacy suggest that effects could be sustainable over the longer term AIMS AND OBJECTIVES To evaluate the usability of the educational needs assessment tool  in clinical practice , from a practitioner and patient perspective and to establish whether patients perceive that they are getting an equally good or equally inadequate education service for their needs . BACKGROUND The educational needs assessment tool was developed to enable patients with Rheumatoid Arthritis to assess their education needs prior to a consultation with a health professional . The educational needs assessment tool has been translated into nine language s and measurement properties have been established , however , its usability in clinical practice has not been studied . DESIGN A qualitative study embedded into a multicentre RCT in which patients had been r and omised into either educational needs assessment tool-focused education ( Experimental Group ) or usual care ( control group ) . METHODS Both groups were seen by a clinical nurse specialist . Sixteen patients and four clinical nurse specialists were recruited from the Rheumatology Outpatient Departments of three Acute Hospitals within the U K. Data were collected by interviews with patients and clinical nurse specialist . Analysis followed the Framework approach . RESULTS Patients and clinical nurse specialist found completion of the  educational needs assessment tool straightforward , comprehensive and easy to use . Completing the educational needs assessment tool helped patients to focus on what they needed to know from the clinical nurse specialist . Patients in both the control group and the experimental group felt supported and reassured by their clinical nurse specialist and perceived that they received a good and adequate education provision . CONCLUSION This study provides useful insights into the ability of the  educational needs assessment tool  to assess the educational needs of patients with rheumatoid arthritis in routine clinical practice . RELEVANCE TO CLINICAL PRACTICE The educational needs assessment tool would be useful as a structured guide for nurses when assessing and meeting individual patient educational needs . This has the potential to improve patient-centred care , involve patients more actively in their care and enhance the long-term effects of patient education provision Context Many patients have both diabetes and depression . Some hypothesize that treating depression might improve diabetes outcomes . Contribution In this r and omized trial , 12 months of depression care management for depressed patients with diabetes improved depression-related outcomes and increased the frequency of exercise . However , care management did not affect diet , diabetes medication adherence , glucose testing , or glycemic control . Caution s The study sample had reasonably good diabetes control at baseline . Whether patients with poorly controlled diabetes would benefit from depression care is not known . The Editors Major depression and dysthymic disorder affect 5 % to 10 % of older adults seen in primary care setting s ( 1 - 3 ) .  Late-life depression  is often chronic or recurrent ( 4 - 6 ) and is associated with substantial suffering , functional impairment , and diminished health-related quality of life ( 7 ) . Diabetes mellitus affects 7.8 % of all adults and almost 1 in 5 of those age 60 years and older ( 8) . Individuals with diabetes mellitus have a 2-fold higher rate of major depression than those without diabetes ( 9 , 10 ) . Depression adversely affects the course of coexisting medical illness , contributing to increased symptom burden , functional impairment , and mortality ( 11 , 12 ) . For patients with diabetes mellitus , depression is associated with decreased glycemic control and increased number of micro- and macrovascular complications ( 13 , 14 ) . The mechanism of effect is not understood but may be related to depression-induced abnormalities in neuroendocrine and neurotransmitter function or decreased self-care behaviors ( 15 - 20 ) . Integrating evidence -based depression care for persons with diabetes may improve both depression and diabetes outcomes . Three small r and omized , controlled trials have studied the effect of treatment for  depression on affective and glycemic outcomes in patients with depression and diabetes mellitus ( 21 - 23 ) . These studies have consistently shown improvements in affective outcomes , but effects on glycemic control have been mixed . Primary care physicians are well positioned to provide integrated care for depression and diabetes mellitus but face many barriers . Controlled trials report that  treatment for depression  is efficacious in approximately 70 % of persons who complete treatment compared with 30 % of those who receive placebo ( 24 ) . However , these results are difficult to replicate in routine primary care practice . Barriers to high- quality care include suboptimal recognition ; inconsistent treatment with lack of close follow-up and monitoring ; and organizational barriers , such as brief visits , poor integration with specialty mental health care , competing clinical priorities , and lack of decision support systems ( 25 - 27 ) . Simple interventions , such as depression screening and physician education , have little impact on these barriers and patient outcomes ( 28 - 30 ) . Treatment models that use a depression specialist working collaboratively with primary care physicians have shown clinical ly important improvement in patient outcomes ( 31 - 37 ) . We recently reported robust effects of such a model for older adults with major depression or dysthymia ( 37 ) . In this preplanned analysis , we evaluate the effects on affective and diabetes-specific outcomes . If effective care for depression also benefits adherence to self-care regimens , functional status , and other medical illness outcomes , it would add powerful quality -of-care and economic incentives for the dissemination and maintenance of these models . In addition , if effective care for depression improves self-care behaviors , it may also positively affect other chronic medical illnesses with important self-care components . For this prespecified subgroup analysis , we focused on older adults with clinical depression and coexisting diabetes mellitus . We hypothesized that the collaborative care intervention would improve affective symptoms , functional status , self-care behaviors , and glycemic control . In addition , we hypothesized that effects on glycemic control would be greatest for patients with baseline hemoglobin A1c values of 8.0 % or greater . Methods The Improving MoodPromoting Access to Collaborative Treatment ( IMPACT ) study is a multisite r and omized , controlled trial of a collaborative care intervention program for late-life depression in primary care ( 37 , 38 ) . Institutional review boards at participating sites approved study protocol s , and all participants gave written informed consent . Patients Seven study sites representing 8 diverse health care organizations with a total of 18 primary care clinics in 5 states participated in the study . From July 1999 to August 2001 , depressed older adults were recruited through referrals from primary care practitioners and other clinic staff or through systematic depression screening with a 2-item depression screener adapted from the Primary Care Evaluation of Mental Disorders ( 39 ) . Of the 2190 patients referred to the study , 308 ( 14 % ) declined the initial eligibility screening or additional interviews , 54 ( 3 % ) had incomplete initial screenings , and 202 ( 9 % ) were ineligible because they were younger than 60 years of age or they did not plan to use the participating clinic over the coming 12 months . Of the 32908 patients approached for screening , 5246 ( 16 % ) declined the initial screening or follow-up interviews . A total of 1791 ( 5 % ) of the initial screenings were incomplete and 23233 ( 71 % ) of those screened were not eligible because they did not have one of the core depression symptoms ( 95 % ) or because of logistic reasons such as lack of transportation or access to a telephone ( 5 % ) . The remaining 1626 ( 74 % ) of those referred and 2638 ( 8 % ) of those screened completed a computer-assisted structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders , fourth edition ( DSM-IV ) , to assess whether patients met research diagnostic criteria for major depression or dysthymia ( 40 ) . Inclusion criteria were age 60 years or older , plans to use one of the participating clinics as the main source of general medical care in the coming year , and a diagnosis of current major depression or dysthymic disorder according to the structured clinical interview for DSM-IV . Otherwise eligible persons were excluded because of a current drinking problem ( a score of 2 on the CAGE question naire ) ( 41 ) , a history of bipolar disorder or psychosis ( 38 ) , ongoing treatment with a psychiatrist , or severe cognitive impairment defined by a score less than 3 on a 6-item cognitive screener ( 42 ) . We identified 2102 eligible older adults with major depression or dysthymic disorder , of whom 1801 ( 86 % ) enrolled in the study . As part of the structured baseline interview , enrolled patients were asked Has a doctor or another health care worker diagnosed you with or treated you for high blood sugar or diabetes in the past 3 years ? The 417 patients who endorsed this question are the focus of the diabetes-specific analyses . After the baseline interview , we r and omly assigned participants to the IMPACT intervention or usual care . The r and omization was stratified by recruitment method ( screening or referral ) and clinic . R and omization information was contained in a set of numbered , sealed envelopes for each stratum that were used sequentially for newly enrolled patients at each clinic ( 38 ) . Diagnoses were communicated to enrolled patients and their primary care physicians . Intervention Patients in the intervention group received a 20-minute educational videotape and a booklet about late-life depression and were encouraged to have an initial visit with a depression care manager at the primary care clinic ( 43 , 44 ) . Care managers were nurses or psychologists who were trained for the study as a depression clinical specialist ( 38 , 45 ) . During the initial visit , the depression clinical specialist conducted a clinical and psychosocial history , review ed the educational material s , and discussed patient preferences for  depression treatment ( antidepressant medications or psychotherapy ) . New patients and patients needing treatment plan adjustments were discussed with a supervising team psychiatrist and a liaison primary care physician during a weekly team meeting . The depression clinical specialist then worked with the patient and his or her regular primary care provider to establish a treatment plan according to an evidence -based treatment algorithm ( 38 ) . The IMPACT algorithm suggested an initial choice of an antidepressant ( usually a selective serotonin reuptake inhibitor ) or a course of Problem-Solving Treatment in Primary Care ( PST-PC ) , which consisted of 6 to 8 brief sessions of structured psychotherapy for depression , delivered by the depression clinical specialist in primary care ( 46 - 49 ) . For patients who were already receiving antidepressant medications but who were still depressed , the recommendation for partial responders was to increase the dose or augment the antidepressant with a trial of PSTPC ; the recommendation for nonresponders was to switch to a different medication or use a trial of PSTPC . Depression clinical specialists also encouraged patients to increase behavioral activation and referred them to additional health or social services , as clinical ly indicated . The intervention did not specifically address diabetes mellitus or other coexisting medical illnesses . As care managers , depression clinical specialists attempted to follow patients for up to 12 months ; they monitored treatment response with the Primary Care Evaluation of Mental Disorders Patient Health Question naire ( 50 ) and a Web-based clinical information system ( 51 ) . During the acute treatment phase , in-person or telephone follow-up contacts were suggested at least every other week . Patients who recovered from depression ( 50 % reduction in the Patient Health Question naire score and <3 of 9 symptoms of major depression ) were engaged in developing a relapse prevention plan and were then AIMS To examine the clinical outcomes of screening for gestational diabetes mellitus ( GDM ) in primary care versus secondary care , in the Irish healthcare system . DESIGN AND METHODS A parallel group r and omised controlled trial ( RCT ) of screening for GDM in primary versus secondary care was used to examine ( i ) prevalence , ( ii ) gestational week of screen , ( iii ) time to access specialist care  , and ( iv ) maternal and neonatal outcomes . In total 781 women were recruited for screening in primary care ( n=391 ) or secondary care ( n=390 ) . RESULTS The prevalence of GDM and gestational week of screen were similar in both locations . There was a trend towards a longer time to access diabetes care in primary care ( 24days ) versus secondary care ( 19days ) , a difference of 5days ( p=0.09 ) . Women screened in primary care also showed a trend towards a higher rate of large for gestational age ( LGA ) infants ( 20 % ) than those screened in secondary care ( 14.7 % ) , ( p=0.09 ) . There were no differences between groups in maternal outcomes . CONCLUSIONS This RCT suggests that screening for GDM in secondary care may be associated with potentially faster time to access specialist antenatal diabetes care and possibly lower LGA rates . Further research is needed to clarify these findings and to improve the delay in accessing specialist care requires an urgent focus . Further research is needed to test these findings in other health systems AIMS To evaluate patient outcomes for a novel integrated primary /specialist model of community care for complex Type 2 diabetes mellitus management compared with outcomes for usual care at a tertiary hospital for diabetes out patients . METHODS This was a prospect i ve open controlled trial performed in a primary and tertiary care setting in Australia . A total of 330 patients with Type 2 diabetes aged > 18 years were allocated to an intervention ( n=185 ) or usual care group ( n=145 ) . The intervention arm was a community-based model of care led by a general practitioner with advanced skills and an endocrinologist partnership . Usual care was provided via the hospital diabetes outpatient department . The primary end point was HbA(1c ) concentration at 12 months . Secondary end points included serum lipids and blood pressure . RESULTS The mean change in HbA1c concentration in the intervention group was -9 mmol/mol ( -0.8 % ) at 12 months and in the usual care group it was -2 mmol/mol ( -0.2 % ) ( 95 % CI -5,1 ) . The percentage of patients in the intervention group achieving the HbA(1c ) target of ≤53 mmol/mol ( 7 % ) increased from 21 to 42 % ( P<0.001 ) ; for the usual care group there was a 1 % increase to 39 % of patients attaining this target ( P=0.99 ) . Patients in the intervention group experienced significant improvements in blood pressure and total cholesterol compared with those in the usual care group . The percentage of patients achieving clinical targets was greater in the intervention group for the combined target of HbA(1c ) concentration , blood pressure and LDL cholesterol . CONCLUSIONS A community-based , integrated model of complex diabetes care , delivered by general practitioners with advanced skills , produced clinical and process benefits compared with a tertiary diabetes outpatient clinic AIMS AND OBJECTIVES To examine the effect of a hospital-based clinic intervention on glycaemic control self-efficacy and glycaemic control behaviour of Chinese patients with type 2 diabetes mellitus ( DM ) . BACKGROUND Self-efficacy expectations are related to self-management of diabetes and , in conjunction with environmental support , are better predictors of behaviour than are knowledge and skills . Enhancing self-efficacy in patients with DM has been shown to have a positive effect on behavioural change and positively influence long-term glycaemic control . DESIGN A r and omised controlled trial study consisting of two-group pretest-post-test . METHODS One hundred and fifty-seven patients with type 2 DM were r and omly divided into two groups : ( 1 ) the experimental group ( 77 patients ) receiving one-month hospital-based clinic intervention and ( 2 ) the control group ( 80 patients ) receiving usual care . Data collection instruments used in this study were Diabetes Management Self-Efficacy Scale and Summary of Diabetes Self-Care Activities Measure . Outcomes were determined by changes in glycaemic control self-efficacy and glycaemic control behaviour of patients with type 2 DM . RESULTS The findings revealed that the experimental group showed statistically significant improvement in glycaemic control self-efficacy and glycaemic control behaviour immediately and four months after the intervention ( F = 26.888 , df = 1 , 155 , p < 0.05 and F = 18.619 , df = 1 , 155 , p < 0.05 , respectively ) . CONCLUSIONS One-month hospital-based clinic intervention could be useful in improving glycaemic control self-efficacy and glycaemic control behaviour . RELEVANCE TO CLINICAL PRACTICE Nurses can learn and use the sources of self-efficacy to enhance patients ' self-efficacy on their glycaemic control in clinical care . The health education is most important in nursing care and should be considered while organising the hospital-based clinic intervention BACKGROUND Type 2 diabetes is a serious and growing problem in Taiwan where it is the fifth leading cause of death , and health care costs are 4.3 times higher than for people without diabetes . OBJECTIVES The purpose of this study was to determine whether participation in a motivational interview for  people with type 2 diabetes would improve their self-management , psychological and glycemic outcomes . DESIGN A r and omized controlled trial to assess the effects of the motivational interviewing intervention . SETTING S Participants were drawn from the diabetes outpatient clinic of a large teaching hospital in South Taiwan . PARTICIPANTS A sample of 250 type 2 diabetes people . METHODS Type 2 diabetes people were r and omly allocated into either the motivational interview group or the usual care group from baseline to 3 months follow-up . The intervention was based on motivational interviewing which encompassed a variety of interviewing techniques , and reflected each person 's readiness stage to change . The control group was provided with usual care by nursing staff . RESULTS A total of 250 type 2 diabetic participants were r and omized . The retention rate in the intervention group was 83 % ( n=104 ) . The motivational interview did improve participants significantly in self-management , self-efficacy , quality of life , and HbA1c among diabetes people with appropriate baseline value ( < 121.24 , < 174.57 , < 107.18 , and > 7.62 , respectively ) but not in depression , anxiety and stress ( F=0.13 , p=0.72 ) compared to the control group at 3 months follow-up . CONCLUSION The findings provided important evidence concerning the positive effect of motivational interventions in self-management , psychological and glycemic outcomes . This research provided evidence for future clinical practice s in diabetes care
Where reported , emergency admissions and quality of life were not found to be significantly different between groups .
No information was found regarding BMI , mortality , long term diabetic complications , adverse effects , or costs .
REVIEW ER 'S CONCLUSIONS The presence of a diabetes specialist nurse / nurse case manager may improve patients ' diabetic control over short time periods , but from currently available trials the effects over longer periods of time are not evident .
There were no significant differences overall in hypoglycaemic episodes , hyperglycaemic incidents , or hospital admissions .
Quality of life was not shown to be affected by input from a diabetes specialist nurse/nurse case manager
BACKGROUND The patient with diabetes has many different learning needs relating to diet , monitoring , and treatments .
In many health care systems specialist nurses provide much of these needs , usually aim ing to empower patients to self-manage their diabetes .
The present review aims to assess the effects of the involvement of specialist nurse care on outcomes for  people with diabetes  , compared to usual care in hospital clinics or primary care with no input from specialist nurses .
OBJECTIVES To assess the effects of diabetes specialist nurses / nurse case manager in diabetes on the metabolic control of patients with type 1 and type 2 diabetes mellitus .