People with chronic illnesses such as diabetes and rheumatoid arthritis have an increased risk of cardiovascular disease. In addition to more generic risk factors such as lack of exercise, obesity and smoking, these disorders have a direct detrimental effect on blood vessels by accelerating the process of atherosclerosis. People with diabetes have a two- to five- fold increased risk of cardio - vascular diseases (CVD) which can be prevented or delayed by treating the risk factors for these diseases timely. This cardiovascular risk management (CVRM) has long been an important topic in diabetes care and our department is involved in the development of national guidelines of CVRM.
Traditionally, the majority of people with diabetes were treated in the Netherlands in secondary care. Due to the progressive increase in the number of patients, questions arose on how the organization of diabetes care should be adjusted and what implications this trend would have to the CVRM guidelines. What is the role of the re-allocation of tasks, how should the CVRM be defined and executed? Next to the organizational changes, also the legal aspects should be reviewed.
Consequently, In the Maastricht University Hospital, the treatment of diabetes has changed over the last 15 years. Tasks of medical specialists were delegated to nurses, both working in secondary (most complex patients) and primary care (less complex patients).
The increased risk of CVD is the consequence of the abnormalities such as hyperglycemia, dyslipidemia and hypertension. In addition, there are secondary risk factors such as obesity, smoking and lack of exercise, a multifactorial treatment is therefore necessary to reduce the risk of CVD. This treatment takes place on two levels, the general measures with the aim to alter lifestyle and the pharmacological treatment of CVD risk actors. The counseling and treatment of many patients is based on task reallocation from doctor to nurse, except patients in with complex complications e.g. renal failure, or co-morbidities, e.g. heart failure. The care model in our hospital consists of nursing tasks as providing information, lifestyle advice, education, encourage self-care and medical tasks, starting up antidiabetic medication, adjust antihypertensive medication, adjust cholesterol-lowering medication, performing the three - monthly monitoring and the year control. The diabetes nurse is acting according to a protocol, which describes all tasks, procedures and process aspects in detail, with the medical specialist ultimately responsible.
Research showed that this new approach led to high quality care at a comparable cost (Vrijhoef,2002 and Steuten, 2007).The clinical effectiveness two years after the introduction of the care program has significantly improved especially when looking at disease-related health status, therapy adherence and self-care behavior.Another study, in another Dutch Centre, the ZODIAC-study, also shows that quality of care can be improved by reallocation of tasks. The ZODIAC- study is a prospective observational study of quality of diabetes care in a shared care setting. The study started in 1998 and ran until 2008. The participants were people with type 2 diabetes mellitus in different age groups. In the period 1998-2008, the number of participating patients with type 2 diabetes mellitus increased from 1622 to 27 438.All quality indicators improved for hypertension, dyslipidemia, quit smoking and exercise. The body mass index remained unchanged.
Reallocation of tasks, in which roles and tasks are delegated from doctors to specialized nurses can result in improved quality of care with better glycemic, lipid and blood pressure -control. These improvements are probably related to more strict application of diabetes and CVRM protocols by specialized nurses. The redefined care by specialized nurses, however, requires a legal framework. Moreover, close cooperation between doctors and nurses are conditional, through clear protocols and by clear demarcation of the responsibilities. The results we achieved for people with diabetes are certainly useful for people with rheumatoid arthritis. Not only quality of care improved, but job satisfaction of caregivers as well because of new challenges and responsibilities
Disclosure of Interest None declared