Practice nurses key to improving type 2 diabetes care
The Diabetes and Cardiometabolic research group in the Department of General Practice has recently published the outcomes of the Stepping Up trial in the BMJ. The trial suggests practice nurses can play a stronger role in optimising medications for people with diabetes.
Achieving and maintaining blood glucose targets early in type 2 diabetes (T2D) improves long-term outcomes. It is also well known that there are barriers to early, stepwise progressive treatment intensification to achieve these targets in primary care, particularly when it comes to starting insulin. This can lead to delays in starting insulin and long periods of avoidable hyperglycaemia, with greater risk of vascular complications. Interventions have had limited success in overcoming this delay and changing clinical practice, in part because system level barriers are not addressed.
Our trial investigated the effectiveness of the Stepping Up model of care, a system innovation designed to support insulin initiation in primary care. The Stepping Up model is built around an enhanced, reconfigured role for practice nurses in leading the discussion with patients around starting insulin. A Credentialed Diabetes Educator, who took a support role rather than providing direct patient care, mentored the nurses. The Practice Nurse worked in liaison with the GP, and used simple clinical algorithms in starting and up titrating insulin as a part of routine primary care.
Our model of care intervention changed clinical practice, with more patients in intervention arm practices starting insulin, with an overall benefit in terms of HbA1c reduction, achieved without serious adverse events or any worsening in depressive symptoms. Our model of care is about “working smarter” with existing resources and has important implications for policymakers, funders, and practitioners seeking innovative ways to provide the best care for people with type 2 diabetes in primary care.
We are now working with stakeholders in partnership with the NW Melbourne PHN to implement the Stepping Up model of care more widely.
Read the full publication in the British Medical Journal here.