A Systematic Review: Effects of Nurse-Managed Protocols in the Outpatient Management of Adults with Chronic Conditions
Medical management of chronic illness consumes 75% of every healthcare dollar spent in the United States; thus, the provision of economical and accessible, yet high-quality care is a major concern. Diabetes, hypertension, hyperlipidemia, and cardiovascular disease are prime examples of chronic diseases that cause substantial morbidity and mortality, and require long-term medical management. VA is developing protocols and policies that expand the nurse's role as a member of Patient Aligned Care Teams (PACTs) as one strategy to address the need to improve the management of these chronic illnesses. A protocol includes a series of actions set by current clinical guidelines or standards of practice that are implemented by nurses to manage a patient's condition.
The VA Evidence-Based Synthesis Program located in Durham, NC conducted a systematic review of the literature to describe the effects of nurse-managed protocols for the outpatient management of adults with high-impact, chronic conditions, such as type 2 diabetes, hypertension, hyperlipidemia, and congestive heart failure (CHF). Investigators conducted a review of the literature from January 1, 1980 through December 12, 2012 for peer-reviewed publications that evaluated interventions using nurse-managed protocols compared with usual care in studies targeting adults with the aforementioned conditions. This evidence report is based on 31 articles, reporting on 29 unique studies (26 were randomized controlled trials). Results are presented in the Summary, which is followed by three key questions that provide more detailed information.
Results from this systematic review and meta-analysis suggest that nurse-managed protocols have positive effects on the outpatient management of adults with moderate severity of type 2 diabetes, hypertension, hyperlipidemia, and CHF. The most robust finding is that nurse-managed protocols had a positive impact on the biophysical outcomes of chronically ill patients (e.g., decrease in mortality and fewer hospitalizations for CHF patients). Additionally, interventions delivered by telephone demonstrated greater effects for total and LDL cholesterol. There was insufficient evidence to determine fidelity to treatment protocols or adverse events associated with nurse-managed protocols.
Key Question #1
For adults with chronic medical conditions, do nurse-managed protocols compared with usual care improve the following outcomes?
- Nursing staff experience (e.g., satisfaction)
- Treatment adherence
- Quality measures such as:
- Biophysical markers (e.g., laboratory or physiological markers of health status such as HbA1c and blood pressure)
- Process-of-care measures used by VA, National Quality Forum, or National Committee for Quality Assurance
- Resource utilization
- All studies used a registered nurse (RN) who had autonomy to titrate medications and, in most studies, initiate medications per protocol.
- For patients with elevated cardiovascular risk, interventions using nurse-managed protocols had a small to moderate positive effect on improving HbA1c, blood pressure, and hyperlipidemia, but effects varied substantially across studies.
- Nurse-managed protocols using an RN compared with usual care also were associated with more patients reaching target goals in total cholesterol and blood pressure.
- For patients with CHF, nurse-managed protocols using an RN were associated with lower all-cause mortality, more patients being prescribed an angiotensin-converting enzyme inhibitor or angiotensin receptor blocking (ACE/ARB) agent, and decreased CHF-related hospitalizations compared with usual care.
- Effects on nursing staff satisfaction were not reported.
- Effects on treatment adherence were reported infrequently, but showed a pattern of improved adherence to lifestyle goals.
- The educational preparation or additional training needed to assume this expanded nurse role was not well reported.
Moreover, subgroup analyses showed some differences between in-person and telephone-based care studies. For example, interventions delivered primarily by telephone showed significantly greater effects for total and LDL cholesterol in patients with elevated cardiovascular risk, and greater mortality reductions in patients with CHF.
Key Question #2
In studies of nurse-managed protocols, how well do participating nurses adhere to the protocol?
- Indirect evidence (e.g., improved outcomes) suggests that nurses adhere to protocols, but direct evidence (e.g., through fidelity checks) is insufficient to establish how well nurses adhere to protocols when engaged in delivering nurse-managed care.
- Only 2 of 29 included studies reported direct nurse adherence to treatment protocols. Thus, the available data is insufficient to establish how well nurses adhere to protocols when engaged in delivering nurse-managed care.
Key Question #3
Are there adverse effects associated with the use of nurse-managed protocols?
- Adverse events were reported in only one study.
- Evidence was insufficient to establish if there are adverse effects associated with the use of nurse-managed protocols.
Only one fair-quality U.S. study on diabetes in a health maintenance organization reported on adverse events. Severe low blood glucose events were identical (1.5%) at baseline and increased similarly: 2.9% in the control group compared with 3.1% in the intervention group.
There were evidence gaps due to insufficient information on the effects of nurse-managed protocols where the investigators recommend future research, including the following areas: patients with complex disease or multiple chronic conditions; narrowly focused (e.g., BP) or multi-target interventions (e.g., HbA1c, lipids); patient and staff satisfaction and experience; and fidelity to the intervention protocol, to name a few.
A Cyberseminar session on this ESP Report will be held on Tuesday, January 28, 2014 from 11:00am to 12:15pm (ET).
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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers — and to disseminate these reports throughout VA.
Shaw RJ, McDuffie JR, Hendrix CC, Edie A, Lindsey-Davis L, Williams JW Jr. Effects of Nurse-Managed Protocols in the Outpatient Management of Adults with Chronic Illness. VA-ESP Project #09-010; 2013.
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