title: Nurse-led behavioral management of diabetes and hypertension in community practices: a randomized trial.
abstract: BACKGROUND
  Several trials have demonstrated the efficacy of nurse telephone case management for diabetes (DM) and hypertension (HTN) in academic or vertically integrated systems. Little is known about the real-world potency of these interventions.
  
  
  OBJECTIVE
  To assess the effectiveness of nurse behavioral management of DM and HTN in community practices among patients with both diseases.
  
  
  METHODS
  The study was designed as a patient-level randomized controlled trial.
  
  
  METHODS
  Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practices. Subjects were required to have inadequately controlled DM (hemoglobin A1c [A1c] ≥ 7.5%) but could have well-controlled HTN.
  
  
  METHODS
  All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years, for a total of 12 calls. Intervention patients received tailored DM- and HTN- focused behavioral content; control patients received non-tailored, non-interactive information regarding health issues unrelated to DM and HTN (e.g., skin cancer prevention).
  
  
  METHODS
  Systolic blood pressure (SBP) and A1c were co-primary outcomes, measured at 6, 12, and 24 months; 24 months was the primary time point.
  
  
  RESULTS
  Three hundred seventy-seven subjects were enrolled; 193 were randomized to intervention, 184 to control. Subjects were 55% female and 50% white; the mean baseline A1c was 9.1% (SD = 1%) and mean SBP was 142 mmHg (SD = 20). Eighty-two percent of scheduled interviews were conducted; 69% of intervention patients and 70% of control patients reached the 24-month time point. Expressing model estimated differences as (intervention--control), at 24 months, intervention patients had similar A1c [diff = 0.1 %, 95 % CI (-0.3, 0.5), p = 0.51] and SBP [diff = -0.9 mmHg, 95% CI (-5.4, 3.5), p = 0.68] values compared to control patients. Likewise, DBP (diff = 0.4 mmHg, p = 0.76), weight (diff = 0.3 kg, p = 0.80), and physical activity levels (diff = 153 MET-min/week, p = 0.41) were similar between control and intervention patients. Results were also similar at the 6- and 12-month time points.
  
  
  CONCLUSIONS
  In nine community fee-for-service practices, telephonic nurse case management did not lead to improvement in A1c or SBP. Gains seen in telephonic behavioral self-management interventions in optimal settings may not translate to the wider range of primary care settings.
authors.affiliation: Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA, dedelman@duke.edu.
authors.forename: David
authors.initials: D
authors.lastname: Edelman
authors.forename: Rowena J
authors.initials: RJ
authors.lastname: Dolor
authors.forename: Cynthia J
authors.initials: CJ
authors.lastname: Coffman
authors.forename: Katherine C
authors.initials: KC
authors.lastname: Pereira
authors.forename: Bradi B
authors.initials: BB
authors.lastname: Granger
authors.forename: Jennifer H
authors.initials: JH
authors.lastname: Lindquist
authors.forename: Alice M
authors.initials: AM
authors.lastname: Neary
authors.forename: Amy J
authors.initials: AJ
authors.lastname: Harris
authors.forename: Hayden B
authors.initials: HB
authors.lastname: Bosworth
mesh_terms: D000368:Aged; D001521:Behavior Therapy / Q000379:methods*; D003153:Community Health Services / Q000458:organization & administration; D016001:Confidence Intervals; D003924:Diabetes Mellitus, Type 2 / Q000175:diagnosis / Q000451:nursing* / Q000628:therapy*; D005260:Female; D005500:Follow-Up Studies; D015438:Health Behavior; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000451:nursing* / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D024802:Nurse's Role; D016017:Odds Ratio; D010349:Patient Compliance / Q000706:statistics & numerical data; D018570:Risk Assessment; D012720:Severity of Illness Index; D016037:Single-Blind Method; D018709:Statistics, Nonparametric; D016896:Treatment Outcome