The effectiveness of nurse- and pharmacist-directed care in diabetes disease management: a narrative review.

People with diabetes have a marked increase in morbidity and mortality. The American Diabetes Association has recommended evidence-based process and outcome measures to improve diabetes care. However, these are not met in the majority of patients under our current medical care system. There have been many (mostly unsuccessful) approaches to improving these outcomes including reminding patients about appointments, feeding back information on the patient to the physician, even when specific treatment recommendations for the individual patient were included, case management (when the case manager could not make treatment decisions), education of physicians and multifaceted quality improvement interventions in the practice setting. One approach has consistently been successful; case management when a nurse or pharmacist had the authority to make independent treatment decisions. In randomized clinical trials, Hb A1c levels were lowered approximately three times as much by nurses or pharmacists following approved detailed treatment algorithms (under the supervision of a physician) compared to usual care. Given the approaching epidemic of diabetes, our medical care system should strongly consider this approach to improving diabetes care to forestall the devastation of diabetic complications and the overwhelming costs of caring for these patients.