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.

In a 12-month RCT of 186 diabetic patients, Clancy and colleagues concluded physician and RN co-led group visits can improve the quality of care for diabetic patients, but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes.¹² Results showed at both measurement points, HbA_1c, BP, and lipid levels did not differ significantly for patients attending group visits vs those in usual care. Similarly, Edelman and colleaguesfound that provider-run group medical appointments are a potent strategy for improving BP but not HbA_1c levels in DM patients in a RCT that compared a group medical appointment intervention with usual care among 239 primary care diabetic patients at the Durham VAMC in North Carolina and Hunter Holmes McGuire VAMC in Richmond, Virginia.¹⁰ Of note, the HbA_1c levels in the group medical clinics did improve from 9.2% at baseline to a final of 8.3%, whereas the HbA_1c level in the usual care group only improved from 9.2 to 8.6%.

Pharmacist-Led SMAs

In comparison to physician or nurse practitioner-led SMA, there also have been studies regarding pharmacist-led group medical appointments that have shown to be beneficial. Taveira and colleagues found that pharmacist-led group medical visits were feasible and efficacious for improving cardiac risk factors in patients with DM.⁸ This RCT with 118 VA patient participants showed a greater proportion of the intervention group vs the usual care alone group achieved a HbA_1c of < 7%, and a SBP < 130 mm Hg.

In a separate study, Taveira and colleagues found that pharmacist-led group SMA visits are effective for glycemic control in patients with DM and depression without a change in depression symptoms.⁹ This RCT compared standard care and VA Multidisciplinary Education in Diabetes and Intervention for Cardiac Risk Reduction in Depression vs standard care alone in 88 depressed patients with DM with HbA_1c > 6.5%. Also, Cohen and colleagues concluded that pharmacist-led group intervention program was an effective and sustainable collaborative care approach to managing DM and reducing associated cardiovascular risks.¹⁰ This study was a RCT that compared standard primary care alone to a 6-month pharmacist-led SMA program added to standard primary care. A total of 99 VA patients were included in the final analysis.

Other studies have looked at patient experiences involving SMAs. In a separate study, Cohen and colleagues explored the experiences of veterans who participated in SMAs.¹⁴ Veterans reported improvement in their overall health and well-being, improved self-management skills, and satisfaction with the SMA format.

Benefits to Veteran Patients

The SMA revealed the need for improved glycemic control in the participating patients. All the rural veteran patients included in the SMA had uncontrolled DM, which placed them at risk for many other health problems, such as renal failure, lower-limb amputations, blindness, cardiac disease, and stroke. In addition patients were given individual attention from several health care disciplines. Patients received one-on-one care from the physician or ARNP, nurse, pharmacist, dietitian, and psychologist in the same appointment. This arrangement benefited the patients in regard to their health, well-being, time, and money.

Limitations

Limitations of this study included its small sample size (18 patients), age of the patients, and the gender of patients. Patients average age was about 62 years, and most were aged in their 50s to 70s. Only 1 patient was in her 30s. Patients were predominantly male (17 men, 1 woman).

A second limitation was managing other PCP’s patients. It would be beneficial to see the outcomes of this same study if it were led by the patient’s PCP to find out whether the outcomes would be different regarding participation, no-show rates, and decrease in HbA_1c.

A third limitation was the absence of information on time and resource use. Clinical staff members took time to prepare and participate in the SMA, and follow-up afterward. However, comparing the SMA with a regular PCP appointment in which an uncontrolled diabetic patient may be referred to diabetic education classes led by nurse educators and/or dietitians, to an individual nutritionist, to an individual clinical pharmacist, and to a behavioral therapist, the SMA may be a time and resource saver.

Conclusion

The study shows the practicality of implementing an effective SMA using a group interdisciplinary team approach to care for rural veterans with DM. The DM SMA may assist in improving quality of care and improve diabetic patients’ blood glucose. The SMA also may benefit patients who are nonadherent by educating them more thoroughly and letting them express themselves or share life experiences with fellow veterans who have the same diagnoses. Future studies are needed to determine the efficacy of DM SMAs especially with patients’ own PCPs.