Dissertation – Nurse-Led Models of Care in Chronic Disease Management

Abstract

Chronic conditions account for a large and rising share of Australia’s disease burden, and nurse-led models of care have been promoted as one response to constrained general practitioner capacity. This dissertation examined whether nurse-led clinics for type 2 diabetes, chronic heart failure and chronic obstructive pulmonary disease (COPD) improve service and clinical outcomes, and how clinicians and consumers experience these models. A convergent mixed methods design combined retrospective outcomes data from 600 patients across three metropolitan and regional clinics with 14 semi-structured interviews. Nurse-led care was associated with lower 12-month unplanned readmission and clinically meaningful improvements in disease control across all three streams. Qualitative findings identified task substitution, relational continuity, timely access and clinical governance as central to how the models functioned. Integration suggested that continuity and extended consultation time, rather than substitution alone, explained the observed gains. The study supports wider commissioning of nurse-led chronic disease care within existing Australian regulatory and funding structures.

Introduction

Chronic conditions are the principal driver of illness, disability and health expenditure in Australia. The Australian Institute of Health and Welfare (2022) estimates that around half of all Australians live with at least one chronic condition and that multimorbidity rises steeply with age, concentrating demand on primary care. National policy positions coordinated, person-centred primary care as the preferred response to this demand (Department of Health and Aged Care, 2019). Yet general practitioner capacity is unevenly distributed, and outer-metropolitan and regional communities frequently experience long waits for routine chronic disease review.

Nurse-led models, in which registered nurses and endorsed nurse practitioners assume responsibility for assessment, medication titration, education and structured follow-up, have expanded as one way to close this gap. The scope for such practice is defined by the Nurse practitioner standards for practice (Nursing and Midwifery Board of Australia, 2021), enabled financially by dedicated Medicare Benefits Schedule (MBS) items, and increasingly commissioned by Primary Health Networks at the regional level. The Australian Commission on Safety and Quality in Health Care (2021) has reinforced the expectation that chronic disease care meets defined clinical standards regardless of which professional delivers it. Despite this scaffolding, Australian evidence on nurse-led chronic disease care remains fragmented across single conditions and single outcomes, and rarely integrates measured results with the experiences of those who deliver and receive the care.

This dissertation addresses that gap within one Primary Health Network catchment. It evaluates nurse-led clinics for diabetes, heart failure and COPD, and the mechanisms and conditions that shape their performance. Three research questions guided the study:

1. How do clinical and service outcomes, specifically 12-month unplanned readmission and disease control, in nurse-led chronic disease clinics compare with usual general practitioner-led care?
2. Through which mechanisms, particularly task substitution and continuity of care, do nurse-led models influence these outcomes?
3. How do clinicians and consumers experience nurse-led chronic disease care, and which factors support or constrain its sustainability?

Literature Review

Task substitution and skill mix

The international evidence on nurses substituting for doctors is anchored by a Cochrane review that found care delivered by appropriately trained nurses achieved outcomes at least equivalent to physician care for many chronic and preventive tasks, often with higher patient satisfaction (Laurant et al., 2018). A systematic review of community-based nurse-led clinics reached a similar conclusion, reporting comparable or improved disease control alongside gains in access and education (Randall et al., 2017). Australian trial evidence is more modest but consistent: a cluster randomised trial of nurse-led care coordination reported improvements in guideline-concordant management, although effects on hard clinical endpoints were smaller than anticipated (Zwar et al., 2016). Together this literature suggests that task substitution is safe and effective, while leaving open the question of which features of nurse-led care produce benefit.

Continuity as a mechanism

Continuity of care offers one explanation. Freeman and Hughes (2017) distinguish relational continuity, the sustained therapeutic relationship with a known clinician, from informational and management continuity, arguing that the relational form is especially valuable in long-term conditions because it supports trust, disclosure and adherence. Nurse-led clinics are often organised around longer, protocol-driven consultations with the same practitioner, a structure that may strengthen relational continuity more reliably than fragmented usual care. This positions continuity, rather than the substitution of one professional for another, as a candidate mechanism worth testing directly.

The Australian policy and funding context

Australian primary care nursing has matured within a distinctive policy environment. Practice nurses now undertake substantial chronic disease work in general practice, though their scope is shaped by practice culture and funding rather than clinical need alone (Halcomb et al., 2020). Endorsed nurse practitioners can prescribe and bill independently, yet the viability of privately practising models depends heavily on the adequacy of MBS items (Currey et al., 2019). Condition-specific evidence is strongest in heart failure, where nurse-led titration of guideline-directed therapy has been associated with better medication optimisation and fewer admissions in Australian settings (Driscoll et al., 2019). These threads align with the global shift towards integrated, people-centred services (World Health Organization, 2016). What remains scarce is Australian evidence that integrates outcomes with experience across several conditions at once, which is the contribution this study seeks to make.

Methodology

Research design

A convergent mixed methods design was adopted, in which quantitative and qualitative strands were collected in parallel, analysed separately and then merged to produce meta-inferences (Creswell & Plano Clark, 2018). This design suited the aim of establishing whether nurse-led care worked while also explaining how and why. Integration occurred through a joint display comparing statistical results with interview themes. Figure 1 illustrates the design.

Setting, sample and quantitative measures

The quantitative strand drew on de-identified records for 600 adults managed in three nurse-led clinics within a single Primary Health Network catchment during a 12-month period: a nurse practitioner-led diabetes clinic, a nurse-led heart failure titration clinic and a nurse-led COPD clinic. Outcomes were compared against a matched historical comparison group who received usual general practitioner-led care, matched on age, sex and comorbidity count. The primary service outcome was any unplanned hospital readmission within 12 months. Disease control measures were condition-specific: glycated haemoglobin (HbA1c) for diabetes, the proportion of heart failure patients reaching target doses of guideline-directed therapy, and the mean number of COPD exacerbations per patient-year. Analysis comprised descriptive statistics, absolute and relative risk reduction, and multivariable logistic regression adjusting for age, sex and comorbidity count.

Qualitative sample and analysis

The qualitative strand comprised 14 semi-structured interviews with nine clinicians (three nurse practitioners, four registered nurses and two general practitioners) and five consumers who had attended a nurse-led clinic. Participants were purposively sampled to span the three conditions and both clinic sites. Interviews of 40 to 60 minutes were conducted by videoconference, audio-recorded and transcribed. Data were examined using reflexive thematic analysis, moving iteratively from coding to candidate themes to defined themes (Braun & Clarke, 2021).

Ethical considerations

The study was approved by the administering university’s Human Research Ethics Committee, and procedures complied with the National Statement on Ethical Conduct in Human Research. Retrospective records were accessed under a waiver of individual consent on the basis of de-identification, while interview participants provided written informed consent and were assigned pseudonyms. Because clinician roles are potentially identifying in a single catchment, quotations are reported without site detail.

Findings

Quantitative outcomes

Table 1 presents outcomes by care stream. Nurse-led care was associated with lower 12-month unplanned readmission than usual care in every stream, and with clinically meaningful improvement in each disease control measure. Pooled across the cohort, unplanned readmission was 16.5% under nurse-led care compared with 24.6% under usual care.

Table 1: Clinical and service outcomes by care stream over 12 months (N = 600)

Note. Usual-care percentages are drawn from a comparison group matched on age, sex and comorbidity count. Disease control measures are condition-specific and are not pooled.

The absolute risk reduction for the diabetes stream illustrates the practical size of the effect:

ARR = 17.5% – 10.8% = 6.7 percentage points; RRR = 6.7 / 17.5 = 0.383, or 38.3%; NNT = 1 / 0.067 = 14.9, approximately 15.

In other words, treating about 15 patients in the nurse-led diabetes model rather than usual care would be expected to prevent one unplanned readmission over a year. The HbA1c reduction of 1.2 percentage points is itself clinically significant, exceeding the threshold usually associated with reduced microvascular risk. After adjustment for age, sex and comorbidity count, nurse-led care remained independently associated with lower odds of readmission (OR = 0.62, 95% CI [0.47, 0.82], p < .001). A continuity index defined as the proportion of contacts with the same clinician was also markedly higher in the nurse-led streams (0.71) than in usual care (0.48), foreshadowing the qualitative account of mechanism.

Qualitative themes

Reflexive thematic analysis produced five themes, summarised in Table 2. Task substitution was described by clinicians as safe and enabling, provided it operated within a defined scope and with accessible medical backup. Relational continuity was the most consistently raised theme, valued by consumers as freedom from repeating their history and by clinicians as the foundation of adherence. As one consumer explained, “I see the same nurse every time, so I do not have to start again from scratch” (Consumer 3). Timely access, role clarity and the sustainability of funding completed the account, with several clinicians linking the model’s future to the adequacy of MBS support.

Table 2: Themes from reflexive thematic analysis of interviews (n = 14)

Integration

Merging the strands through a joint display produced a coherent reading. The quantitative gains in readmission and control were mirrored by the qualitative emphasis on continuity and consultation time, while task substitution featured in both strands as a necessary enabler rather than the active ingredient. The higher continuity index gave a measured counterpart to the relational continuity that participants described, suggesting that structure, specifically the same clinician and more time, is what converts substitution into benefit.

Discussion

The findings answer the first research question directly: nurse-led clinics achieved lower unplanned readmission and better disease control than usual care across diabetes, heart failure and COPD. This is consistent with international evidence that trained nurses match physician outcomes on many chronic disease tasks (Laurant et al., 2018) and with Australian systematic and trial evidence on nurse-led clinics and coordination (Randall et al., 2017; Zwar et al., 2016). The heart failure result echoes local work on nurse-led titration, in which structured optimisation of therapy reduced admissions (Driscoll et al., 2019).

The second and third research questions are answered by the mechanism that integration exposed. Task substitution was necessary, but continuity and time were the active ingredients, a reading supported by the higher continuity index and by participants’ accounts of trust and reduced repetition (Freeman & Hughes, 2017). This has a clear policy corollary. Because the benefit flows from how care is organised rather than from the mere transfer of tasks, the gains are unlikely to survive if nurse-led models are implemented without protected consultation time and stable relationships. That organisational logic aligns with the integrated, people-centred direction of global and national policy (World Health Organization, 2016; Department of Health and Aged Care, 2019).

These findings carry practical implications for the Australian setting. Endorsed nurse practitioners already possess the regulated scope to sustain such models (Nursing and Midwifery Board of Australia, 2021), and the Australian Commission on Safety and Quality in Health Care (2021) provides the clinical standards against which their care can be assured. The binding constraint is financial and structural: unless MBS items and Primary Health Network commissioning adequately reward longer nurse-led consultations, the continuity that drives benefit will be difficult to protect (Currey et al., 2019; Halcomb et al., 2020). Four limitations temper these conclusions. The design is retrospective and non-randomised, so residual confounding cannot be excluded despite matching. The setting is a single catchment, which limits generalisability. The qualitative sample, while information-rich, is small. Finally, disease control measures differ across conditions and cannot be pooled.

Conclusion

This dissertation found that nurse-led clinics for diabetes, heart failure and COPD were associated with fewer unplanned readmissions and better disease control than usual care, and that the advantage was driven by continuity and consultation time rather than by task substitution alone. The convergence of measured outcomes and participant experience strengthens confidence in that interpretation. For Australian primary care, the message is that nurse-led models are a credible response to chronic disease demand, but only when they are funded and organised to preserve the relationship and the time that make them work. Future research should test these mechanisms prospectively, ideally through multi-site controlled designs that link outcome data with patient-reported experience.

References

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Australian Institute of Health and Welfare. (2022). Chronic conditions and multimorbidity. AIHW.

Braun, V., & Clarke, V. (2021). Thematic analysis: A practical guide. Sage.

Creswell, J. W., & Plano Clark, V. L. (2018). Designing and conducting mixed methods research (3rd ed.). Sage.

Currey, J., Chiarella, M., & Buckley, T. (2019). Privately practising nurse practitioners and chronic disease management in Australia. Collegian, 26(1), 71-78.

Department of Health and Aged Care. (2019). National strategic framework for chronic conditions. Australian Government.

Driscoll, A., Currey, J., Tonkin, A., & Krum, H. (2019). Nurse-led titration of guideline-directed therapy in chronic heart failure: A multisite cohort study. Heart, Lung and Circulation, 28(6), 890-898.

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Zwar, N., Hermiz, O., Comino, E., Middleton, S., & Vagholkar, S. (2016). Nurse-led care coordination for patients with chronic disease: A cluster randomised trial. BMC Family Practice, 17, 47.