Nurse Practitioners vs MD Providers in Diabetes Care
Nurse Practitioners vs MD Providers in Diabetes Care
Demographically, patients differed from 2004–2005 to 2006–2009. In 2004, the patient was apt to be male, overweight, and over 60. After the establishment of the diabetic clinic, patients were often female, overweight, and in 2006–2007, over 60, but in 2008–2009 younger than 50. Hours of operation in 2004 were in the evening, possibly explaining the increased male attendance. The diabetic clinic was held during daytime hours, when more women may have been able to attend.
Ophthalmology and podiatry referrals were somewhat more frequent when the patient attended the NP diabetic clinic in 2008–2009 but not in 2006–2007. This may be explained by the diabetic clinic just being established in 2006 and the patients beginning to be seen every 3 months. These referrals were made by the provider, and the patient made the appointment with the podiatrist or ophthalmologist. When seen, the podiatrist or ophthalmologist wrote a summary of findings and sent it to the clinic, documenting the follow-through of the referral. For the study, the provider making the referral was the variable used.
When analyzing data for HDL goals, the patients seen by the NP were more likely to attain the goal, but not to a level of significance. However, the HDL goal of 50 mg/dL or greater for women was applied, despite gender in this study, possibly skewing data for this variable, as more women were seen in the later subsets than in 2004–2005.
In examining patient feet, the NP excelled in foot sensation testing, reaching a level of significance. Foot inspection was independently associated with the NP. Microfilament testing is done at least every year and documented on the chart on foot diagrams.
Prior research supports this study of the NP reaching goals for referrals, but research also demonstrates goal attainment of A1C, HDL, and LDL, which this study did not support. One reason for this discrepancy may be the influx of patients over the 4 years the diabetic clinic was studied. The sample size (n) in 2004 was 52 and 262 in 2006–2009. With the increase in patient numbers, the operations of the free clinic were stretched financially. Less efficacious statins were substituted for the more efficacious medications because of cost and availability. Drugs for hyperlipidemia and diabetes were ordered through patient assistance programs (PAP) beginning in 2006. The PAP program requires reauthorization every 6 months to a year, which proved to be a burden to the clinic with the influx of patients. This necessitated a dedicated, paid position to keep up with the medications and paperwork required, another financial burden to the clinic.
BP is an important part in the care of the patient with diabetes. The literature reflects this fact, but this variable was omitted from this study. As this was a retroactive chart review, the variable was not able to be controlled. Accuracy of readings by different providers, the size of the cuff selected, and at what point in the visit the BP was measured would have confounded the results.
Limitations of this retroactive chart review were determined to be the accuracy of handwritten documentation and the patients' desire to control their diabetes. It was assumed that increased interest and follow-up by the provider would translate to increased desire on the patient's part. This was not necessarily borne out by this study when objectively measured.
Discussion
Demographically, patients differed from 2004–2005 to 2006–2009. In 2004, the patient was apt to be male, overweight, and over 60. After the establishment of the diabetic clinic, patients were often female, overweight, and in 2006–2007, over 60, but in 2008–2009 younger than 50. Hours of operation in 2004 were in the evening, possibly explaining the increased male attendance. The diabetic clinic was held during daytime hours, when more women may have been able to attend.
Ophthalmology and podiatry referrals were somewhat more frequent when the patient attended the NP diabetic clinic in 2008–2009 but not in 2006–2007. This may be explained by the diabetic clinic just being established in 2006 and the patients beginning to be seen every 3 months. These referrals were made by the provider, and the patient made the appointment with the podiatrist or ophthalmologist. When seen, the podiatrist or ophthalmologist wrote a summary of findings and sent it to the clinic, documenting the follow-through of the referral. For the study, the provider making the referral was the variable used.
When analyzing data for HDL goals, the patients seen by the NP were more likely to attain the goal, but not to a level of significance. However, the HDL goal of 50 mg/dL or greater for women was applied, despite gender in this study, possibly skewing data for this variable, as more women were seen in the later subsets than in 2004–2005.
In examining patient feet, the NP excelled in foot sensation testing, reaching a level of significance. Foot inspection was independently associated with the NP. Microfilament testing is done at least every year and documented on the chart on foot diagrams.
Prior research supports this study of the NP reaching goals for referrals, but research also demonstrates goal attainment of A1C, HDL, and LDL, which this study did not support. One reason for this discrepancy may be the influx of patients over the 4 years the diabetic clinic was studied. The sample size (n) in 2004 was 52 and 262 in 2006–2009. With the increase in patient numbers, the operations of the free clinic were stretched financially. Less efficacious statins were substituted for the more efficacious medications because of cost and availability. Drugs for hyperlipidemia and diabetes were ordered through patient assistance programs (PAP) beginning in 2006. The PAP program requires reauthorization every 6 months to a year, which proved to be a burden to the clinic with the influx of patients. This necessitated a dedicated, paid position to keep up with the medications and paperwork required, another financial burden to the clinic.
BP is an important part in the care of the patient with diabetes. The literature reflects this fact, but this variable was omitted from this study. As this was a retroactive chart review, the variable was not able to be controlled. Accuracy of readings by different providers, the size of the cuff selected, and at what point in the visit the BP was measured would have confounded the results.
Limitations of this retroactive chart review were determined to be the accuracy of handwritten documentation and the patients' desire to control their diabetes. It was assumed that increased interest and follow-up by the provider would translate to increased desire on the patient's part. This was not necessarily borne out by this study when objectively measured.
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