Are community-based nurse-led self-management support interventions effective in chronic patients? Results of a systematic review and meta-analysis

The expansion of primary care and community-based service delivery systems is intended to meet emerging needs, reduce the costs of hospital-based ambulatory care and prevent avoidable hospital use by the provision of more appropriate care. Great emphasis has been placed on the role of self-management in the complex process of care of patient with long-term conditions. Several studies have determined that nurses, among the health professionals, are more recommended to promote health and deliver preventive programs within the primary care context. The aim of this systematic review and meta-analysis is to assess the efficacy of the nurse-led self-management support versus usual care evaluating patient outcomes in chronic care community programs. Systematic review was carried out in MEDLINE, CINAHL, Scopus and Web of Science including RCTs of nurse-led self-management support interventions performed to improve observer reported outcomes (OROs) and patients reported outcomes (PROs), with any method of communication exchange or education in a community setting on patients >18 years of age with a diagnosis of chronic diseases or multi-morbidity. Of the 7,279 papers initially retrieved, 29 met the inclusion criteria. Meta-analyses on systolic (SBP) and diastolic (DBP) blood pressure reduction (10 studies-3,881 patients) and HbA1c reduction (7 studies-2,669 patients) were carried-out. The pooled MD were: SBP -3.04 (95% CI -5.01--1.06), DBP -1.42 (95% CI -1.42--0.49) and HbA1c -0.15 (95% CI -0.32-0.01) in favor of the experimental groups. Meta-analyses of subgroups showed, among others, a statistically significant effect if the interventions were delivered to patients with diabetes (SBP) or CVD (DBP), if the nurses were specifically trained, if the studies had a sample size higher than 200 patients and if the allocation concealment was not clearly defined. Effects on other OROs and PROs as well as quality of life remain inconclusive

Are community-based nurse-led selfmanagement support interventions effective in chronic patients? Results of a systematic review and meta-analysis

The expansion of primary care and community-based service delivery systems is intended to meet emerging needs, reduce the costs of hospital-based ambulatory care and prevent avoidable hospital use by the provision of more appropriate care. Great emphasis has been placed on the role of self-management in the complex process of care of patient with long-term conditions. Several studies have determined that nurses, among the health professionals, are more recommended to promote health and deliver preventive programs within the primary care context. The aim of this systematic review and meta-analysis is to assess the efficacy of the nurse-led self-management support versus usual care evaluating patient outcomes in chronic care community programs. Systematic review was carried out in MEDLINE, CINAHL, Scopus and Web of Science including RCTs of nurse-led self-management support interventions performed to improve observer reported outcomes (OROs) and patients reported outcomes (PROs), with any method of communication exchange or education in a community setting on patients >18 years of age with a diagnosis of chronic diseases or multi-morbidity. Of the 7,279 papers initially retrieved, 29 met the inclusion criteria. Meta-analyses on systolic (SBP) and diastolic (DBP) blood pressure reduction (10 studies-3,881 patients) and HbA1c reduction (7 studies-2,669 patients) were carried-out. The pooled MD were: SBP -3.04 (95% CI -5.01-1.06), DBP -1.42 (95% CI -1.42-0.49) and HbA1c -0.15 (95% CI -0.32-0.01) in favor of the experimental groups. Meta-analyses of subgroups showed, among others, a statistically significant effect if the interventions were delivered to patients with diabetes (SBP) or CVD (DBP), if the nurses were specifically trained, if the studies had a sample size higher than 200 patients and if the allocation concealment was not clearly defined. Effects on other OROs and PROs as well as quality of life remain inconclusive

Is the task-shifting in self-management support effective? A systematic review and meta-analysis

Background Nurses play a key role in primary care, especially in long term care programs for patients with chronic diseases. The taskshifting from medical doctors to appropriately trained nurses could be a possible way to reduce doctors\u2019 workload and direct cost of care, keeping quality, health outcomes and patient satisfaction constant. Systematic review and meta-analysis was carried out to assess the effectiveness of nurse-led selfmanagement interventions in community setting. Methods Most important biomedical databases were searched for Randomized Control Trials (RCTs) of nurse-led self-management interventions performed in community setting on patients with a diagnosis of chronic disease or multimorbidity. Primary outcomes of the studies were our outcomes of interest. Pooled mean difference (MD), along with 95% confidence interval (CI) was calculated, as appropriate. Results Globally, 29 RCTs were included involving 10,240 participants. Six studies reported as outcomes the levels of HbA1c, 10 the systolic (SBP) and diastolic blood pressure (DBP). The pooled MD showed a reduction in HbA1c and in SBP in the experimental groups. Meta-analyses of subgroups showed a statistically significant effect of the interventions for SBP among diabetic patients (MD -2.56, 95% CI -4.82\u2014-0.31). A reduction of the DBP was found on the overall group (MD - 1.42, 95% CI -1.42\u2014-0.49) and in the subgroup of patients with cardiovascular diseases (-2.09, 95% CI -4.11\u2014-0.07). All-cause mortality was found significantly lower in two studies out of four. Quality of life in the experimental groups was significantly higher than in the control group only in one RCT out of three. Conclusions The results support the effectiveness of a nurse-led approach in the management of clinical outcomes in chronic patients. In particular, the nurse-led approach has positive effects on the DBP and SBP control and Hb1AC level in patients with cardiovascular diseases or diabetes. Key messages: Task-shifting from doctors to nurses in educational and selfmanagement programs in community settings can improve clinical outcomes in chronic patients. Further research to evaluate cost-effectiveness of taskshifting interventions in the management of chronic patients is strongly neede

Definitions of setting and interventions.

<p>Definitions of setting and interventions.</p

Flow diagram of the study selection process.

<p><i>From</i>: Moher D, Liberati A, Tetzlaff J, Altman DG, The PRISMA Group (2009). Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. PLoS Med 6(7): e1000097. doi: <a href="http://dx.doi.org/10.1371/journal.pmed1000097" target="_blank">10.1371/journal.pmed1000097</a>.</p

Definitions of setting and interventions.

<p>Definitions of setting and interventions.</p

Meta-analysis of the reduction of blood pressure levels stratified by level and training of employed nurses; type and duration of the intervention; study size; attrition rate; allocation concealment.

<p>Meta-analysis of the reduction of blood pressure levels stratified by level and training of employed nurses; type and duration of the intervention; study size; attrition rate; allocation concealment.</p

Comparison of the effect of nurse-led support interventions and usual care on the reduction of some Observer Related Outcomes (OROs): Systolic Blood Pressure, Diastolic Blood Pressure and Hb1Ac*.

<p>*Only for diabetic patients.</p

Il ruolo del supporto al self management da parte del medico di medicina generale e dell’infermiere nel trattamento di pazienti cronici

Introduzione In letteratura è stato riportato un impatto positivo del ruolo guida dell’infermiere nel trattamento della cronicità nell’ambito dell’assistenza primaria. L’obiettivo del presente lavoro è quello di comparare l’efficacia del supporto al Self Management (SMS) effettuato dal medico di medicina generale rispetto a quello effettuato dall’infermiere relativamente agli outcome di salute nei pazienti cronici o affetti da multicronicità. Metodi E’ stata condotta una revisione sistematica della letteratura attraverso l’interrogazione dei seguenti database: Medline, CINAHL, Web of Science e Scopus. Sono stati inclusi gli articoli in lingua inglese pubblicati dal 2000 al 2014. E’ stata inoltre condotta la valutazione della qualità metodologica attraverso il “Cochrane Collaboration’s tool for assessing risk of bias”. Risultati 22 studi su 7153 hanno soddisfatto i criteri di inclusione per un totale di 7317 pazienti. Gli studi sono stati stratificati per patologia: diabete (5), patologie cardiovascolari (11), broncopneumopatia cronica ostruttiva - BPCO (3), multicronicità (3). E’ stata evidenziata, attraverso i diversi parametri descritti nei documenti e gli strumenti di misurazione delle capacità di autogestione, una maggiore efficacia dell’intervento infermieristico rispetto a quello del MMG. Rispettivamente nell’80% degli studi per patologia cardiovascolare, nel 66% per la BPCO, nel 50% per il diabete. Nessuna differenza di efficacia tra intervento MMG ed infermiere si è riscontrata nel caso della multicronicità. Conclusioni Tali risultati evidenziano un ruolo determinante dell’infermiere nel supporto all’autogestione dei pazienti cronici, determinando una diversa distribuzione delle abilità tra i professionisti e caratterizzando il fenomeno di task shifting

Findings of the impact of nurse led-self management interventions on Observer Related Outcomes (OROs) and Patient Related Outcomes (PROs).

<p>Findings of the impact of nurse led-self management interventions on Observer Related Outcomes (OROs) and Patient Related Outcomes (PROs).</p