Strategies for reducing the risks of cardiovascular disease (CVD) and type 2 diabetes aren't widely implemented despite well-publicized guidelines. Two new studies provide more evidence that nursing leadership is effective in helping patients manage these and other chronic conditions.

Results of the Community Outreach and Cardiovascular Health (COACH) trial demonstrate that intervention by a nurse-led team using individualized treatment regimens improves not only risk factor status in underserved populations but also patients' perceptions of the quality of the care they receive. At two urban community health centers, a total of 525 patients with CVD, hypercholesterolemia, hypertension, or type 2 diabetes were randomly assigned to receive either comprehensive CVD risk factor management by a team composed of an NP and a community health worker or "enhanced usual care." The team focused on behavioral modifications to bring about therapeutic lifestyle changes and adherence to medications and appointments. The NP served as the case coordinator for each study participant, and the community health worker assisted patients to overcome barriers to adherence and provided logs, pill organizers, and other aids to help patients follow complex regimens.

At 12 months, patients in the team-approach group had significantly greater improvements in total cholesterol, low-density lipoprotein cholesterol, triglyceride, blood pressure, and glycated hemoglobin levels, compared with those in the usual care group. In addition, patient perceptions of the quality of chronic illness care were significantly better in the team-approach group.

In a study of 214 patients with poorly controlled diabetes or coronary heart disease and coexisting depression, a team-based approach with nurses serving as care managers also proved effective. Patients were assigned to receive either a multicondition collaborative-care intervention or usual care over 12 months. The rates of initiation and adjustment of a number of types of drugs were several times higher among those receiving the intervention: antidepressant medications (six times higher), insulin (three times higher), antihypertensive and oral hypoglycemic agents (nearly two times higher), and lipid-lowering drugs (1.6 times higher). Medication adherence wasn't higher, but it was already high in both groups at baseline.

The COACH study authors say that their findings support the potential for nurse-led, patient-centered medical homes to improve the quality of care in underserved populations. Similarly, the authors of the second study say that a team-based, patient-centered approach can improve outcomes in patients with chronic illness and coexisting mood disorders in the primary care medical home setting.-Karen Rosenberg

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