Open Access Research article

Primary care nurses: effects on secondary care referrals for diabetes

Christel E van Dijk1*, Robert A Verheij1, Johan Hansen1, Lud van der Velden1, Giel Nijpels23, Peter P Groenewegen14 and Dinny H de Bakker15

Author Affiliations

1 NIVEL, Netherlands Institute of Health Services Research, Utrecht, The Netherlands

2 Department of Public and Occupational Health, VU University Medical Center, Amsterdam, The Netherlands

3 Department of General Practice, VU University Medical Center, Amsterdam, The Netherlands

4 Utrecht University, Department of Sociology, Department of Human Geography, Utrecht, The Netherlands

5 Tilburg University, Scientific Centre for Transformation in Care and Welfare (TRANZO), Tilburg, The Netherlands

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BMC Health Services Research 2010, 10:230  doi:10.1186/1472-6963-10-230

Published: 6 August 2010



Primary care nurses play an important role in diabetes care, and were introduced in GP-practice partly to shift care from hospital to primary care. The aim of this study was to assess whether the referral rate for hospital treatment for diabetes type II (T2DM) patients has changed with the introduction of primary care nurses, and whether these changes were related to the number of diabetes-related contacts in a general practice.


Healthcare utilisation was assessed for a period of 365 days for 301 newly diagnosed and 2124 known T2DM patients in 2004 and 450 and 3226 patients in 2006 from general practices that participated in the Netherlands Information Network of General Practice (LINH). Multilevel logistic and linear regression analyses were used to analyse the effect of the introduction of primary care nurses on referrals to internists, ophthalmologists and cardiologists and diabetes-related contact rate. Separate analyses were conducted for newly diagnosed and known T2DM patients.


Referrals to internists for newly diagnosed T2DM patients decreased between 2004 and 2006 (OR:0.44; 95%CI:0.22-0.87) in all practices. For known T2DM patients no overall decrease in referrals to internists was found, but practices with a primary care nurse had a lower trend (OR:0.59). The number of diabetes-related contacts did not differ between practices with and without primary care nurses. Cardiologists' and ophthalmologists' referral rate did not change.


The introduction of primary care nurses seems to have led to a shift of care from internists to primary care for known diabetes patients, while the diabetes-related contact rate seem to have remained unchanged.