Program Profile

Shared Medical Appointments for Glycemic Management in Rural Veterans

Fed Pract. 2016 June;33(6):45-49

References

1. Kirsh S, Watts S, Schaub K, et al. VA shared medical appointments for patients with diabetes: maximizing patient & provider expertise to strengthen care management. U.S. Department of Veterans Affairs website. http://www.queri.research.va.gov/tools/diabetes/shared-med-appt.pdf. Published December 2008. Accessed May 10, 2016.

2. American Diabetes Association. Statistics about diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/diabetes-statistics. Updated April 1, 2016. Accessed May 14, 2016.

3. Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care. 1999;22(12):2011-2017.

4. Trento M, Passera P, Tomalino M, et al. Group visits improve metabolic control in type 2 diabetes: a 2-year follow-up. Diabetes Care. 2001;24(6):995-1000.

5. Kirsh S, Watts S, Pascuzzi K, et al. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Health Care. 2007;16(5):349-353.

6. Sanchez I. Implementation of a diabetes self-management education program in primary care for adults using shared medical appointments. Diabetes Educ. 2011;37(3):381-391.

7. Guirguis AB, Lugovich J, Jay J, et al. Improving diabetes control using shared medical appointments. Am J Med. 2013;126(12):1043-1044.

8. Taveira TH, Friedmann PD, Cohen LB, et al. Pharmacist-led group medical appointment model in type 2 diabetes. Diabetes Educ. 2010;36(1):109-117.

9. Taveira TH, Dooley AG, Cohen LB, Khatana SA, Wu WC. Pharmacist-led group medical appointments for the management of type 2 diabetes with comorbid depression in older adults. Ann Pharmacother. 2011;45(11):1346-1355.

10. Cohen LB, Taveira TH, Khatana SA, Dooley AG, Pirraglia PA, Wu WC. Pharmacist-led shared medical appointments for multiple cardiovascular risk reduction in patients with type 2 diabetes. Diabetes Educ. 2011;37(6):801-812.

11. Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Diabetes Care. 2001;24(4):695-700.

12. Clancy DE, Huang P, Okonofua E, Yeager D, Magruder KM. Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med. 2007;22(5):620-624.

13. Edelman D, Fredrickson SK, Melnyk SD, et al. Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial. Ann Intern Med. 2010;152(11):689-696.

14. Cohen S, Hartley S, Mavi J, Vest B, Wilson M. Veteran experiences related to participation in shared medical appointments. Mil Med. 2012;177(11):1287-1292.

Results

Eighteen patients met the inclusion criteria (Table). Participants mean age was 62 years with most aged 50 to 70 years. Most participants were male (94%) and white (61%). Thirty-nine percent of the participants were African American. Twelve group appointments were held from November 2010 through April 2013. The mean enrollment per session was 5.8 patients (range 3-9). The median number of sessions each patient participated in was 3 (range 1 to 10).

SMA Outcomes

Among the 18 participants, the absolute change in HbA_1c was -2.2% ± 2.0, representing a relative decrease in HbA_1c of 18.2%. The study criterion for success was either a relative decrease of HbA_1c by 13.5% or an absolute decrease in HbA_1c of 1.5%. Of 18 patients participating in SMA, 14 (78%) patients achieved this goal. Of the 4 patients that were not successful, 2 patients had a relative HbA_1c increase of 13% and 14%, respectively, 1 patient had no change at all, and 1 patient had a 9% relative decrease (Figure). Fourteen patients had improvement in their HbA_1c after the first appointment, 2 patients had improvement after the second appointment, 1 patient had improvement after the fourth appointment, and 1 patient had no improvement.

In this population of rural veterans with poorly controlled diabetes, participation in SMAs was associated with marked improvement in measures of glucose control. Fourteen of the 18 (78%) veterans who participated in the DM SMA exhibited clinically significant decreases in HbA_1c and achieved the defined goal.

Discussion

The effectiveness of DM SMAs has been documented in several previous studies. Sadur and colleagues found that a 6-month cluster visit group model of care for adults with DM improved glycemic control by 1.3% in the intervention subjects vs 0.2% in the control subjects in a randomized, controlled trial (RCT) with 185 participants.³ The intervention group received multidisciplinary outpatient diabetes management delivered by a diabetes nurse educator, a psychologist, a nutritionist, and a pharmacist in cluster visit settings of 10 to 18 patients per month for 6 months.

Metabolic Control

In another RCT trial of 112 patients, Trento and colleagues found that physician-led group consultations may improve metabolic control in the medium term by inducing more appropriate health behaviors.⁴ The consultations are feasible in everyday clinical practice without increasing working hours. After 2 years, HbA_1c levels remained stable in patients seen in groups but had worsened in control subjects.

In a quasi-experiment with concurrent but nonrandomized controls, Kirsh and colleagues concluded that SMAs for DM constitute a practical system redesign that may help improve quality of care.⁵ Participants included 44 veterans from a VA primary care clinic who attended at least 1 physician-led SMA from April 2005 to September 2005 and from May 2006 to August 2006. Results showed levels of HbA_1c, low-density lipoprotein cholesterol (LDL-C), and systolic BP (SBP) fell significantly postintervention with a mean decrease of HbA_1c 1.4%, LDL-C 14.8 mg/dL, and SBP 16.0 mm Hg. The reductions in HbA_1c and SBP were greater in the intervention group relative to the control group. The LDL-C reduction also was greater in the intervention group; however, the difference was not statistically significant.

Similarly, Sanchez concluded that patients who participated in a physician and nurse practitioner-led SMA using the diabetes self-management education (DSME) process had improvements in their HbA_1c, self-management skills, and satisfaction.⁶ The study was considered a quality improvement project. Data were collected on 70 patients who were 96% Mexican American and received DSME via SMA during a 3-month span. The average HbA_1c on visit 1 was 7.95%, 7.48% on visit 2, and 7.51% on visit 3. There were 34 patients with a decrease in HbA_1c on visit 2 and 12 patients with a decrease in HbA_1c on visit 3. Also, in a study on the effectiveness of SMAs in DM care, Guirguis and colleagues found that veterans showed an average decline in HbA_1c whether they attended 1, 2, 3, or 4 SMAs.⁷ However, the decline was only statistically significant (P = .02) for those who had a baseline HbA_1c > 9% prior to the study.

In contrast, other studies found no significant difference in improvement of DM patients in a SMA vs DM patients not in a SMA. Wagner and colleagues found periodic primary care sessions organized to meet the complex needs of diabetic patients improved the process of diabetes care and were associated with better outcomes.¹¹ Primary care practices with a total of 700 patients were randomized within clinics to either a chronic care clinic (intervention) group or a usual care (control) group. Each chronic care clinic consisted of an assessment; individual visits with the primary care physician, nurse, and clinical pharmacist; and a group educational/peer support session. Although they found that the primary care group sessions improved the process of DM care and were associated with better outcomes, the mean HbA_1clevels and cholesterol levels were comparable between the 2 groups.