People with diabetes and RA have a 2-5 fold increased risk of cardiovascular disease. There is an increasing number of patients with RA and diabetes, therefore medical management of CV risks is increasingly being delegated to nurses and allied health professionals. The diabetes model of care appears to be ahead of the rheumatology model of care when it comes to monitoring patients for CVD.
In a session on cardiovascular risk assessment and management for patients with diabetes and RA, Danielle Moens discussed some of the issues common to both the diabetes model and the rheumatology model.
The medical tasks for nurses to monitor CVD in diabetes patients include CV screening, starting and regulating certain medications, and adjusting doses of other medications. The diabetes nurse specialist is able to prescribe glucose lowering medications independently. The nurses in this model are supported by a legal framework since The Netherlands issued legislation called the "health care protection act." All hospitals require CVD monitoring for patients with diabetes by a nurse specialist. To be a part of this program, nurses must be trained, certified and re-tested to maintain certification. Protocols are used to facilitate monitoring.
Research on task reallocation from the general practitioner to the nurse specialist showed that patients received a high quality of care from the nurse specialist. Clinical effectiveness was demonstrated though improved health status, and the costs remained the same or decreased with the nurse specialist.
The diabetes model shows that treatment by a nurse specialist delivers an equivalent quality of care and an improvement in glycemic control compared to treatment by general practitioners. In order for this program to work, proper training is needed, with cooperation between health care professionals, GPs and internists. An additional benefit of the diabetes model is that job satisfaction for the nurses increased. When asked if the nurses need to consult the doctors often, Ms. Moens explained that the physicians collaborate closely with the nurse specialists by working together at the same clinic.
For this to work for rheumatology care in Canada, we would require a legal framework for administering and adjusting medications. We would also require proper training on CV risk assessment and monitoring.
As an Advanced Clinician Practitioner in Arthritis Care (ACPAC) I can say that we currently can work in this manner under "medical delegation" in the rheumatology environment, alongside the rheumatologist. We have received some training in CVD monitoring but perhaps a specific CV assessment and management protocol would be helpful for ACPACs and nurse specialists to take on this expanded role.