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Do primary health care nurses address cardiovascular risk in diabetes patients?
DIAB-6154; No. of Pages 9 Contents available at Diabetes Research and Clinical Practice Do primary health care nurses address cardiovascular risk in diabetes patients? Barbara Daly Timothy Kenealy Bruce Arroll , Nicolette Sheridan , a School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand b General Practice & Primary Health Care, School of Population Health, University of Auckland, New Zealand c Epidemiology and Biostatistics, School of Population Health, University of Auckland, New Zealand Aims: To identify factors associated with assessment and nursing management of blood Received 28 December 2013 pressure, smoking and other major cardiovascular risk factors by primary health care Received in revised form nurses in Auckland, New Zealand.
Methods: Primary health care nurses (n = 287) were randomly sampled from the total Accepted 30 August 2014 (n = 1091) identified throughout the Auckland region and completed a self-administered Available online xxx questionnaire (n = 284) and telephone interview. Nurses provided details for 86% (n = 265) of all diabetes patients they consulted on a randomly selected day.
Results: The response rate for nurses was 86%. Of the patients sampled, 183 (69%) patients had their blood pressure measured, particularly if consulted by specialist (83%) and practice Primary health care nurses (77%) nurses compared with district (23%, p = 0.0003). After controlling for demographic variables, multivariate analyses showed patients consulted by nurses who had identified stroke as a major diabetes-related complication were more likely to have their blood pressure measured, and those consulted by district nurses less likely. Sixteen percent of patients were current smokers. Patients consulted by district nurses were more likely to smoke while, those >66 years less likely. Of those who wished to stop, only 50% were offered nicotine replacement therapy. Patients were significantly more likely to be advised on diet and physical activity if they had their blood pressure measured ( p < 0.0001).
Conclusions: Measurement of blood pressure and advice on diet or physical activity were not related to patient's cardiovascular risk profile and management of smoking cessation was far from ideal. Education of the community-based nursing workforce is essential to ensure cardiovascular risk management becomes integrated into diabetes # 2014 Elsevier Ireland Ltd. All rights reserved.
cardiovascular (CV) events and total mortality has necessi- tated an integrated approach to managing people with type 2 diabetes based on their absolute CV risk . Smoking cessation The increasing prevalence of people with type 2 diabetes in and achieving guideline lipid and blood pressure targets New Zealand (NZ) and the associated increased risk of are essential in reducing CV events in people with diabetes.
* Corresponding author. Tel.: +64 9 923 9882; fax: +64 9 367 7158.
E-mail address: (B. Daly).
0168-8227/# 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin
DIAB-6154; No. of Pages 9 Cigarette use is a well-established risk factor for CV disease and total mortality People with type 2 Subjects, materials and methods diabetes who smoke have significantly more CV events , chronic kidney disease and its progression and other diabetes-related complications, particularly peripheral vas- cular disease and lower limb amputations . It is Sampling and details of the nurses has previously been recommended for all people who smoke, but especially described . Briefly, 35% of the total PHC nurses (n = 1091) in those with diabetes, to be asked about their motivation to the greater Auckland region were randomly selected and of stop and encouraged to do so at every consultation those 335 (88%) were working and invited to participate in the Blood pressure targets for people with diabetes <130/ survey – of whom 287 (86%) agreed. Of those, 210 were PNs, 49 80 mmHg have been recommended nationally and DNs, 19 DSN and nine CCM nurses. All participants completed internationally Hypertension has been linked with a telephone interview and 284 completed and returned a endothelial dysfunction increased risk of all diabetes- postal self-administered questionnaire on biographic and related complications and CV events . Several trials workplace details from 2006 to 8. Ethics approval was obtained using multiple antihypertensive agents showed risk reduc- from the Northern Regional Committee (NTX/05/10/128).
tions for all diabetes related end-points , myocardial infarction, stroke and all-cause mortality , Diabetes patients sampled although a recent meta-analysis showed no significant improvements in CV outcomes <140/90 mmHg compared During the telephone interview information was collected on with <130/80 mmHg .
the nurses' diabetes management practices and on the Low-density lipoprotein (LDL)-cholesterol is a causal risk number of diabetes patients nurses had consulted on a factor for CV disease and lipid lowering randomised randomly selected day each nurse had worked over the past controlled trials (RCTs) have reported reductions in major CV seven days. Additional anonymous demographic and health events in people with diabetes . Further, practice-based information was gathered from each patient's record and on nurse-led lifestyle RCTs have also reported improved lipid nursing assessments and care provided during the consulta- levels in those with diabetes .
tion. On the randomly selected day, 58% of the 287 nurses In NZ, people with type 2 diabetes are managed within sampled did not consult any diabetes patients, while 42% had general practice or by independent primary health care consulted 308 diabetes patients and 41% (n = 117) were able to (PHC) providers. Practice nurses (PNs) are mostly employed provide information on 265 (86%) of those patients. Because of by general practitioners (GPs). PNs and are the largest of the the random sampling of nurses and day of the week, the four main PHC nursing groups involved in the care and patients sampled represent of all diabetes patients treated by management of people with diabetes. District nurses (DNs) PHC nurses at the time of the survey. During the telephone are the second largest group and provide hospital outreach interview specific questions were asked on nursing assess- services to patients at home or in community clinics ments and care. For example, all nurses were asked ‘during predominantly for wound care. The other two groups are this consultation did you take the patient's blood pressure?', specialist nurses (diabetes specialist nurses (DSN) and ‘what medication has this patients been prescribed?' and chronic care management (CCM) nurses). DSN provide ‘does this patient smoke?' – if yes ‘do they want to stop?'.
specialist diabetes care and are employed by secondary care services or Primary Health Organisations that provide Statistical analysis PHC to an enrolled population . CCM nurses either work in general practice or for independent care providers and PROC FREQ in SAS version 5.1 (SAS Institute, Cary, NC, 2012) provide specialist community-based care for people with was used to analyse data from the nurses. PROC CROSSTAB chronic care conditions Although DSN were not able to and PROC MULTILOG in SUDAAN (version 11 Research prescribe medications at the time of the study they typically Triangle Institute, 2012) was used to analyse patient data advise patients on titrating glycaemic mediations and all and correct for clustering effects by nurses who had consulted nurses are expected to discuss medication management more than one diabetes patient on the randomly selected day, with patients.
for calculation of relative risk (RR) and odds ratios (OR), GPs and PNs are expected to carry out 5-year CV risk respectively and generate adjusted Wald F P-values. The two assessments in all patients with type 2 diabetes and to specialist nurse groups (DSN and CCM nurses) were combined actively manage CV risk factors for those at high risk All for all analyses, due to the small numbers of CCM nurses, and PNs are expected to play a major role in the community referred to as specialist nurses.
management of diabetes, work more independently , identify patients at increased risk of diabetes-related complications (including CV events), initiate lifestyle changes, and for DSN and nurse practitioners to have prescribing rights .
Demographic and anthropological details of patients The aim of this paper is to report factors associated with the assessment and management of major CV risk factors for people with diabetes consulted by PHC nurses in community- Of the 117 nurses who provided data on their patients, 78 (38%) based settings.
PNs consulted 153 patients, 16 (57%) specialist nurses Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin
DIAB-6154; No. of Pages 9 consulted 65 patients and 23 DNs consulted 47 patients.
Demographic details on the 265 diabetes patients sampled are described in The majority of patients were aged over Of the 264 patients with information on smoking, 41 (16%) 50 years, most had type 2 diabetes and 16% smoked. Mean smoked tobacco and the status of nine patients was unknown.
systolic blood pressure (SBP) was 132 mmHg, diastolic blood In univariate analyses only age was negatively associated with pressure (DBP) 77 mmHg and mean total cholesterol was current smoking by patients; (relative risk (RR), 0.88; 95% 4.8 mmol/l and did not differ by nurse-group. While similar confidence interval (CI), 0.50–1.53) for those 51–66 years and proportions of patients consulted by specialist nurses (20%) (RR, 0.37; 95% CI, 0.16–0.85, p = 0.02) for those aged 67–93 and DNs (23%) were smokers, significantly more patients compared with patients aged <50 years. Patients consulted by consulted by DNs used tobacco compared with those DNs were more likely to smoke than those consulted by PNs consulted by PNs (11%, p = 0.039). Records for serum creatinine but did not quite reach significance (RR, 2.31; 95% CI, 1.18–4.53, and microalbumin levels were only available for 34% and 18% p = 0.054). shows after adjusting for demographic of patients respectively, with levels indicating some renal variables (sex, age and ethnicity) and nurse-group in multi- dysfunction for the majority of those patients.
variate analyses the negative association between age and current smoking strengthened for those aged over 66 years, while patients consulted by DNs were significantly more likely Table 1 – Demographic composition of diabetes patients to smoke compared with those consulted by PNs.
(n = 265), consulted by PHC nurses and smoking status, Of the 41 patients who used tobacco, eight of 30 (27%) blood pressure, total cholesterol, microalbumin and patients who had been asked wished to stop, and of those, serum creatinine.
seven were advised on community support programmes Variable and level including referral to the government supported telephone ‘Quitline' counselling programme (n = 4), and four were advised to use nicotine replacement therapy (NRT), by more specialist nurses (n = 3), than PNs (n = 1). Significantly more patients who were current smokers were asked if they wished to stop if undergoing a special programme consulta- tion (diabetes annual review or chronic care consult) or if aged >66 years. No demographic or other factors (such as nurse group, post-registration qualification, time at current practice, knowledge of smoking as a risk factor for complications or NZ European/European place of consultation) were associated with nurses asking patients if they wished to stop smoking.
Other Pacific Island patients Type of diabetes (n = 263) Of the 146 (55%) patients with recorded total cholesterol levels, 71% were above the national recommended level of <4.0 mmol/l. In the univariate analyses only being male was Tobacco use (n = 264) associated with elevated cholesterol levels compared with female (RR, 2.33; 95% CI, 1.30–4.14, p = 0.003). After adjusting for all demographic variables in the multivariate analyses, elevated cholesterol was positively associated with being Biological variables male (OR, 3.75; 95% CI, 1.60–8.79, p = 0.003), while elevated Blood pressure (n = 214) SBP was inversely associated (OR, 0.46 95% CI, 0.21–0.99, p = 0.048) – separate data not shown.
Total cholesterol (mmol/L) (n = 146) Serum creatinine (mmol/L) (n = 89) Microalbumin (mg/L) (n = 47) During the nurse consultations, 183 (69%) of patients had their Variable and level blood pressure measured, and significantly more so if Total patients consulted and sampled consulted by specialist nurses (83%) and PNs (77%) compared District/home care nurses with those consulted by DNs (23%, p = 0.0003). An additional 31 patients had blood pressure levels recorded and reported. Of the 214 (81%) patients with recordings, 105 (49%) and 106 (50%) m: mean; CI: confidence interval; SBP: systolic blood pressure; DBP: diastolic blood pressure.
had a SBP > 130 mmHg and DBP > 80 mmHg, respectively.
a Geometric means -calculated from the antilog In multivariate analyses and controlling for demographic from multiplying & dividing the tolerance factor (antilog variables and nurse group, age and Maori ethnicity were from the mean.
associated with elevated SBP ).
b 78 practice, 23 district and 16 specialist nurses consulted at least Factors associated with measurement of patient's blood one patient sampled on the randomly selected day.
pressure are shown in Age, being consulted at home, Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin
DIAB-6154; No. of Pages 9 Table 2 – Multivariate odds ratios (OR) of patients being Table 3 – Multivariate odds ratios (OR) of patients having current smokers (n = 254).
elevated blood pressure (SBP > 130 mmHg), (n = 213).
1.10 (0.50–2.40) 1.01 (0.58–1.76) 0.70 (0.33–1.50) 1.51 (0.72–3.17) 0.23 (0.08–0.62) 3.56 (1.64–7.73) 0.99 (0.37–2.69) 2.30 (1.03–5.12) 0.96 (0.41–2.27) 1.46 (0.49–4.35) 0.37 (0.07–1.90) 0.89 (0.25–3.15) 3.53 (1.49–8.37) 1.75 (0.57–5.35) 1.69 (0.75–3.78) 0.57 (0.26–1.21) PN: practice nurses; DN: district nurses; SN: specialist nurses.
PN: practice nurses; DN: district nurses; SN: specialist nurses.
and management by DNs were inversely associated, while whether the patients consulted had elevated SBP or total Ma-ori and Pacific Island ethnicity were positively associated, cholesterol or not – separate data not shown. There was no as were patients in a special programme review compared difference in ACE inhibitors prescribed between patients with with those having usual follow-up consultations. Nurses who and without elevated SBP or statins for those with or without held or were working towards gaining post-registration elevated total cholesterol. In addition, nurses planned to qualifications, and those who identified stroke (88% compared telephone 81 (31%) patients they had consulted, mostly to with 64%, p = 0.005) as a diabetes-related complication, were discuss follow-up visits, referrals and screening tests (54%).
more likely to measure a patient's blood pressure during the Of those, only 14% and 10% of PNs and specialist nurses consultation. Duration of the consultation, the first patient respectively, planned to discuss management of specific risk consultation following diagnosis, nurse's time at their current factors or lifestyle changes.
practice, post-registration diabetes education, knowledge of hypertension as a risk factor and heart disease as a Associations between nurse's knowledge of CV risk complication and patients prescribed antihypertensive medi- factors and management activities cation were not related to measurement of blood pressure.
In multivariate analyses, and adjusting for demographic and Nurses were significantly more likely to know and report other variables, only patients who had consulted nurses who patient's elevated total- or LDL-cholesterol if they had had identified stroke as a complication of diabetes remained identified the latter as a risk factor for diabetes-related associated with blood pressure being measured (OR, 3.20; 95% complications (64% compared with 43%, p = 0.03), and if they CI, 1.16–8.86, p = 0.03), while DNs were less likely to measure had identified smoking as a risk factor they were significantly blood pressure compared with PNs (OR, 0.10; 95% CI, 0.02–0.52, more likely to give specific advice related to patient's p = 0.006). In addition, patients who had their blood pressure individual risk profile (58% compared with 21%, p = 0.01). In measured were also more likely to receive advice on diet contrast, there were no significant associations between (OR, 6.47; 95% CI, 3.07–13.64, p < 0.0001) and physical activity nurse's knowledge of the following risk factors or diabetes- (OR, 2.39; 95% CI, 1.22–4.68, p = 0.01) – separate data not shown.
related complications and related management: hyperten- sion, heart or peripheral vascular disease and measuring Management related to cholesterol and blood pressure blood pressure or promoting physical activity.
Patients who had their blood pressure measured were also Proportion of patients prescribed CV and non-CV more likely to receive advice on diet and physical activity related medication () but not for patients with elevated total cholesterol (>4 mmol/L); (RR, 0.76; CI, 0.44–1.32 and RR, 0.82; CI, 0.46–1.46), outlines the proportion of patients prescribed respectively. Despite this, specific dietary advice aimed at cardiovascular-related medications which were known and reducing body weight (to reduce carbohydrate, fat and salt recorded for 257 (97%) patients. The most commonly pre- consumption, takeaways, portion sizes and regular meals) scribed were statins and angiotensin-converting enzyme was given by a similar proportion of nurses regardless of (ACE) inhibitors, outlined by nurse-group, and over half of Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin
DIAB-6154; No. of Pages 9 Table 4 – Univariate relative risk (RR) for patients having their blood pressure measured during the consultation (n = 265).
0.90 (0.75–1.07) 0.84 (0.70–1.01) 0.69 (0.55–0.86) 1.45 (1.14–1.84) 1.32 (1.03–1.70) 1.20 (0.89–1.62) 0.94 (0.83–1.06) 0.92 (0.81–1.05) Antihypertensive me 0.95 (0.80–1.12) Patient weight (kg) 1.00 (0.88–1.14) 0.93 (0.80–1.08) 1.16 (0.91–1.48) 0.30 (0.16–0.57) 1.08 (0.91–1.27) 1.26 (0.97–1.64) Knowledge of stroke as a complication 1.36 (1.14–1.63) 0.39 (0.24–0.64) No room – (cubicle/other) 0.93 (0.63–1.36) Type of consultation Get Checked/careplus 1.71 (1.44–2.02) 1.33 (1.02–1.74) 2.04 (1.49–2.80) 1.67 (1.31–2.14) SBP: systolic blood pressure; DBP: diastolic blood pressure; kg: kilograms; PN: practice nurses; DN: district nurses; SN: specialist nurses.
a Patients prescribed at least one of the following drugs: ACE inhibitor, Beta blocker, Calcium channel blocker or a thiazide diuretic.
patients were prescribed other non-cardiovascular medica- Ma-ori and Pacific patients and those consulted by nurses who tions – primarily for pain, arthritis (including gout) and had identified stroke as a major complication of diabetes were depression ).
more likely to have their blood pressure measured, while those consulted by DNs were less likely. Reflecting the latter group's focus on wound management and the difficulty in carrying extra equipment into people's homes. Nurses were more likely to ask patients who smoked if they wished to stop, This is the first report identifying factors associated with if they were attending special programme consultations.
people with diabetes having their blood pressure measured Nurses could only access total cholesterol levels and blood and receiving advice on smoking cessation by PHC nurses.
pressure recordings for 55% and 81% of patients consulted, Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin
DIAB-6154; No. of Pages 9 Table 5 – Proportion of diabetes patients prescribed cardiovascular-related medication (n = 265), by nurse group.
Variable and level Total sample of patients CV risk management medications ACE inhibitor (n = 252) Aspirin (n = 253) Beta blocker (n = 251) Diuretic/furosemide (n = 252) Calcium channel blockers (n = 254) Warfarin (n = 251) Digoxin (n = 251) Other-mostly for angina (n = 254) Non-diabetes nor CV medication CV: cardiovascular; ACE: angiotensin-converting enzyme.
P-value showing significance of variation in percentages in subgroups, from the chi-square value and either a Fisher or Pearson exact tests used with small cell numbers.
respectively. Of those, 71% and 49% had total cholesterol and smoking cessation rates and decreases unpleasant withdrawal SBP above the recommended levels and were no more likely symptoms GPs and PHC nurses are in an ideal position to to receive advice on diet or physical activity by the consulting target diabetes patients who smoke. Despite several smoking nurse compared with patients with levels below that cessation initiatives implemented in primary care settings in recommended. Knowledge of stroke as a complication of NZ, a recent update showed that the proportion of patients diabetes was probably a marker for more in-depth diabetes receiving advice to quit smoking (28–62%) remained well below knowledge and extensive clinical experience as only 14% of the national 90% target set for 2012 Further, attempts to quit nurses reported this knowledge, although significantly more smoking in NZ compare poorly with international trends, with DSN (36%) did so compared with PNs (13%) and DNs (8%) .
less than 60% of current smokers attempting to quit in one year, The proportion of patients prescribed a statin was similar to compared with over 80% in other developed countries The that reported in the large audit of patients with diabetes in proportion of patients in primary care given advice to quit West and South Auckland 66% in 2006 and internationally smoking by their GP and other healthcare providers was also proportions ranged from 61% to 74% lower compared with those in Australia as is the proportion Tobacco smoking was less common among patients using NRT (particularly in males and Pacific and Ma-ori sampled (16%) compared with the 18% of adult New populations) despite it being heavily subsidised .
Zealanders who currently smoke and was similar for A more effective PHC systems approach and management Pacific patients (18%), and European patients (13%) but far is required to reduce the proportion of patients with major CV fewer for Ma-ori patients (35%), compared with those in an risk factors and substantially increase the number of smoking audit of 5917 diabetes patients enrolled in general practices in cessation attempts by patients. PHC nurses need to be able to West and South Auckland . The discrepancy in the prescribe NRT and ensure patients have easy access to proportion of Ma-ori patients who were current smokers in prescriptions for essential pharmaceutical therapy to assist this study compared to those in the audit study in West and those who wish to stop smoking.
South Auckland maybe explained by fewer patients smoking Nurses planned to telephone about a third of patients in the higher socio-economic central Auckland area. In the consulted mainly for follow-up appointments, rather than for current study, no Ma-ori patients from the central Auckland health promotion or goal setting on reducing CV risk factors; area were current smokers, while 15% and 30% from the despite the latter being highly recommended and shown in Waitemata (North and West Auckland) and Counties-Manu- those with diabetes to increase smoking cessation rates kau (South Auckland) DHBs respectively, were current adherence to a non-atherogenic diet and physical activity and promote healthy lifestyle behaviours Further, twice the proportion of sampled patients were Type 2 diabetes should be contextualised as a CV disease smokers compared with diabetes patients exiting large inter- and nursing management should shift from the current national intensive glucose control trials . In addition, glucocentric approach to managing CV risk factors – smoking both the ACCORD and ADVANCE trials reported reductions in cessation (including registering as Quit Card providers), diet smoking prevalence during the trial periods of around 4% over (with specific recommendations based on the national guide- 3.5 years and 6% over 5 years, respectively lines and related to patient's risk profile) and physical activity.
Of concern, only 50% of patients who wished to stop smoking Findings from the glucose intensive type 2 diabetes trials show were advised on NRT – the use of which approximately doubles a lack of benefit in lowering HbA1c levels on CV outcomes Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin DIAB-6154; No. of Pages 9 (with the exception of metformin in overweight patients) important to ensure CV risk factor management becomes an and one trial found an increased mortality rate . The lack of integral part of diabetes management.
improvements in CV outcomes from the intensive glucose trials and in contrast the reduction in CV events reported from the blood pressure and LDL-cholesterol lowering trials Conflict of interest ; in those with type 2 diabetes and CV disease, and the large cohort studies reporting increased CV events and total The authors declare that they have no conflict of interest.
mortality in those who use tobacco has led to broadening the management of those with type 2 diabetes to include improving CV risk factors and smoking cessation. In the current survey, nurses weighed 58% of patients and gave advice on diet and physical activity to 70% and 66% of patients, Funding for this survey was provided by ‘Novo Nordisk', the respectively Despite this, only 20% of those nurses gave Charitable Trust of the Auckland Faculty of the Royal New advice related to each patient's risk profile and only 12% Zealand College of General Practitioners, and the New Zealand advised patients to reduce body weight despite a mean body Ministry of Health.
weight of 92 kg . Lifestyle changes, that include weight loss We wish to thank the practice, district and specialist nurses in conjunction with a cardioprotective diet have been who participated in this survey and enabled this study to shown to reduce both systolic and diastolic blood pressures . The inclusion of the mnemonic ‘ABC' (A1c, blood pressure and cholesterol), promoted in North America and adapted to include smoking and physical activity in health promotion may assist PHC nurses when educating patients in their management of diabetes.
Study limitations include a lack of available data on total cholesterol, serum creatinine and microalbumin, and smok- ing status for patients consulted by DNs. Further, we cannot conclude that patients' blood pressures were not measured by physicians on the day of the PN or SN consultations and smoking status may have been known to physicians managing patients consulted by DNs. During the survey period, the PREDICT programme for calculating patients CV risk by PNs and GPs, based on the Framingham CV risk scores, was introduced into several general practices in Auckland and was expected to increase nursing manage- ment and assessment CV risk factors However, there is limited evidence about the use of these databases and programmes by PNs, although one report showed PNs completed 8% of patients CV risk assessments using PREDICT and another reported a fourfold increase in its use after software installation and related education .
Despite the study limitations, this is a representative and large comprehensive cross-sectional survey of PHC nurses  Peto R, Lopez AD, Boreham J, Thun M, Heath CJ. Mortality from smoking in developed countries 1950–2000: indirect and the diabetes patients they consult with, in the largest estimates from national vital statistics. Oxford University city in NZ. It is the first study to document predictors for Press; 1994 (2004 update on measuring blood pressure and management of tobacco use by nurses working in community settings.
In conclusion, patients were more likely to have their blood pressure measured by nurses who identified stroke as a diabetes-related complication and if patients were of Maori or Pacific Island ethnicity. Only special programme consultations were associated with nurses asking patients who smoked if they wished to stop. A large proportion of patients had modifiable CV risk factors (elevated blood pressure and total cholesterol) and twice the proportion smoked compared with those exiting large international type 2 diabetes intensive glucose trials. The main findings highlight the need for improved management of CV risk factors, particularly smoking to ensure PHC nurses play a major role in improving patient outcomes. Continuation of funding for post-graduate education and development of the PHC nursing workforce is Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin DIAB-6154; No. of Pages 9  Ministry of Health. Investing in health: Whakatohutia Te Oranga Tangata: a framework for activating primary health care nursing in New Zealand; 2003 [cited 13.03.13] Available  Daly B, Arroll B, Kenealy T, Sheridan N, Scragg R.
Management of diabetes by primary health care nurses in Auckland, New Zealand, J Prim Health Care [in press].
Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin DIAB-6154; No. of Pages 9 Please cite this article in press as: Daly B, et al. Do primary health care nurses address cardiovascular risk in diabetes patients?. Diabetes Res Clin
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