MIAMI BEACH — Group medical visits that combine education and individualized medication adjustment significantly improved hypertension among primary care patients with poorly controlled diabetes, compared with usual care, according to a randomized, controlled trial. This intervention, however, did not significantly improve glycemic control.
Although group medical clinics are widely used, this is the first study to assess the effectiveness of group medical clinics at simultaneously controlling blood pressure and glycemia, Dr. David Edelman said.
He and his colleagues randomized 239 patients with poorly controlled diabetes receiving primary care at the Durham Veterans Affairs Medical Center or the Richmond VA Medical Center, both in North Carolina. At baseline, all participants had a hemoglobin A1c level of 7.5% or more and hypertension, defined as blood pressure above 140 mm Hg systolic or 90 mm Hg diastolic. Mean age of the patients was 62 years, 59% were African American, and 96% were men.
A total of 133 patients received the group intervention and 106 got usual care. Mean systolic blood pressure at baseline was 152 mm Hg in the intervention cohort and 154 mm Hg in the usual care group; mean HbA1c was 9.2% in both groups. The intervention was in addition to usual care, Dr. Edelman said at the annual meeting of the Society of General Internal Medicine.
In the intervention arm, a nurse or certified diabetes educator facilitated a group educational session every 2 months for 1 year.
During these sessions, a primary care doctor and a pharmacist met in a separate room to review blood pressure and HbA1c measurements and to make individual medication adjustments. Following the group discussion, each patient met individually with either the primary care doctor or pharmacist. Qualitative data indicated that patients “really liked the additional access to a health care provider,” said Dr. Edelman, an investigator at the Center for Health Services Research in Primary Care at the Durham VA Medical Center. He is also on the general internal medicine faculty at Duke University.
A total of 89% of patients completed follow-up. Intervention patients had significantly greater improvements in systolic blood pressure, compared with controls. At 6 months, the intervention patients had a mean 14.5 mm Hg decrease in systolic blood pressure, compared with 7.2 mm Hg for usual care patients. At 12 months, mean decreases were 14.1 mm Hg in the intervention patients and 6.2 mm Hg in the usual care group.
After adjustments, there was a statistically significant overall decrease of 7.2 mm Hg between groups, favoring the group medical clinic participants. Most of the difference was seen in the first 6 months, Dr. Edelman said.
The HbA1c findings were “not as promising.” There was an average 0.9% improvement in the intervention group, “which we would have patted ourselves on the back for, had we not had a control group, which saw 0.6% improvement,” Dr. Edelman said. It might be easier to treat and change blood pressure than to treat and change HbA1c, especially in patients with poorly controlled diabetes, he said. “It could be these refractory patients are a special challenge.”
“We are working on the possibility of co-intervention” to explain the disparity in results, Dr. Edelman said. Because the primary care physicians were not blinded to group assignment, “it's possible that when they found a patient randomized to control [and] wildly out of control … they may have prescribed something else. It's reasonable and possible [that] there was more co-intervention on HbA1c than [on] blood pressure.”
The study was funded by the Department of Veterans Affairs, and Dr. Edelman did not disclose any conflicts of interest.
To watch a video interview of Dr. Edelman, go to www.youtube.com/user/ClinicalEndoNews
Group intervention improved blood pressure, but not glycemic control, Dr. David Edelman said in a video interview.
Source Damian McNamara/Elsevier Global Medical News