执业护士与初级保健医生提供的糖尿病护理
Diabetes Mellitus Care Provided by Nurse Practitioners vs Primary Care Physicians.
作者信息
Kuo Yong-Fang, Goodwin James S, Chen Nai-Wei, Lwin Kyaw K, Baillargeon Jacques, Raji Mukaila A
机构信息
Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas.
Department of Preventive Medicine and Community Health, University of Texas Medical Branch, Galveston, Texas.
出版信息
J Am Geriatr Soc. 2015 Oct;63(10):1980-8. doi: 10.1111/jgs.13662.
OBJECTIVES
To compare processes and cost of care of older adults with diabetes mellitus cared for by nurse practitioners (NPs) with processes and cost of those cared for by primary care physicians (PCPs).
DESIGN
Retrospective cohort study.
SETTING
Primary care in communities.
PARTICIPANTS
Individuals with a diagnosis of diabetes mellitus in 2009 who received all their primary care from NPs or PCPs were selected from a national sample of Medicare beneficiaries (N = 64,354).
MEASUREMENTS
Propensity score matching within each state was used to compare these two cohorts with regard to rate of eye examinations, low-density lipoprotein cholesterol (LDL-C) and glycosylated hemoglobin (HbA1C) testing, nephropathy monitoring, specialist consultation, and Medicare costs. The two groups were also compared regarding medication adherence and use of statins, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (for individuals with a diagnosis of hypertension), and potentially inappropriate medications (PIMs).
RESULTS
Nurse practitioners and PCPs had similar rates of LDL-C testing (odds ratio (OR) = 1.01, 95% confidence interval (CI) = 0.94-1.09) and nephropathy monitoring (OR = 1.05, 95% CI = 0.98-1.03), but NPs had lower rates of eye examinations (OR = 0.89, 95% CI = 0.84-0.93) and HbA1C testing (OR = 0.88, 95% CI = 0.79-0.98). NPs were more likely to have consulted cardiologists (OR = 1.29, 95% CI = 1.21-1.37), endocrinologists (OR = 1.64, 95% CI = 1.48-1.82), and nephrologists (OR = 1.90, 95% CI = 1.67-2.17) and more likely to have prescribed PIMs (OR = 1.07, 95% CI = 1.01-1.12). There was no statistically significant difference in adjusted Medicare spending between the two groups (P = .56).
CONCLUSION
Nurse practitioners were similar to PCPs or slightly lower in their rates of diabetes mellitus guideline-concordant care. NPs used specialist consultations more often but had similar overall costs of care to PCPs.
目的
比较由执业护士（NP）护理的老年糖尿病患者与由初级保健医生（PCP）护理的患者的护理流程和成本。
设计
回顾性队列研究。
地点
社区初级保健机构。
参与者
从医疗保险受益人的全国样本中选取2009年诊断为糖尿病且其所有初级保健均由NP或PCP提供的个体（N = 64,354）。
测量指标
在每个州内使用倾向得分匹配法，比较这两组在眼科检查率、低密度脂蛋白胆固醇（LDL-C）和糖化血红蛋白（HbA1C）检测率、肾病监测、专科会诊以及医疗保险费用方面的情况。还比较了两组在药物依从性以及他汀类药物、血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂（用于诊断为高血压的个体）的使用情况，以及潜在不适当药物（PIM）的使用情况。
结果
执业护士和初级保健医生在LDL-C检测率（优势比（OR）= 1.01，95%置信区间（CI）= 0.94 - 1.09）和肾病监测率（OR = 1.05，95% CI = 0.98 - 1.03）方面相似，但执业护士的眼科检查率（OR = 0.89，95% CI = 0.84 - 0.93）和HbA1C检测率（OR = 0.88，95% CI = 0.79 - 0.98）较低。执业护士更有可能咨询心脏病专家（OR = 1.29，95% CI = 1.21 - 1.37）、内分泌专家（OR = 1.64，95% CI = 1.48 - 1.82）和肾病专家（OR = 1.90，95% CI = 1.67 - 2.17），并且更有可能开具潜在不适当药物（OR = 1.07，95% CI = 1.01 - 1.12）。两组之间调整后的医疗保险支出无统计学显著差异（P = 0.56）。
结论
执业护士在糖尿病指南一致性护理率方面与初级保健医生相似或略低。执业护士更频繁地使用专科会诊，但与初级保健医生的总体护理成本相似。
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