Improving Glycemic Control

Group Visits Are Cost-Effective Way to Improve Glycemic Control

Diabetes care can be rushed during a typical office visit, frustrating both patients and physicians. Shared medical appointments (SMAs) are now being used to allow for more comprehensive care as well as social support, with the latest research showing significant improvements in glycemic control with this model of care, as reported in the American Journal of Medicine.

“SMAs are effective and can help to improve compliance with medications and dietary regimens,” said senior author Jeffrey D. Kravetz, MD, Associate Professor of Medicine at Yale School of Medicine in New Haven, CT. “The patients who attended the visits truly enjoyed the camaraderie of the group visits. They were able to share helpful tips and support each other with new medication trials.  For example, if a patient needed to start insulin, they could hear from their peer that ‘it wasn’t so bad’ and this would improve compliance,” said Dr. Kravetz, who is also a physician at the VA Connecticut Healthcare System, West Haven, CT.

Study Design

Patients at the West Haven Veterans Affairs Medical Center who agreed to SMAs were asked to attend a joint visit every 6 to 12 weeks for up to 4 visits over a 1-year period. At each visit, approximately 3 to 8 patients met for 90-minutes and underwent individual assessment by a pharmacist for medication adjustments, discussed goal-setting behavior with a health psychologist, consulted with a dietitian, and received education from a registered nurse.

A total of 60 patients attended at least 1 group visit, 40 attended 2 visits, 19 attended >3 visits.

Improved Glycemic Control Found

Patients who attended at least 2 group visits showed a significant decrease in A1C from baseline to 1 year (8.99% vs 8.32%; P=0.06). A subgroup of patients with A1C >9% (n=15) also experienced a significant decrease in A1C after 2 visits (10.75% to 9.51%; P=0.02). Participants who attended ≥3 visits showed a trend toward a greater reduction in A1C level; this difference was significant among the subgroup of patients with A1C >9% (10.94% to 9.97%; P=0.055).

“Although the number of patients in this study is relatively small, the findings point to what we see in our clinical practice—an improvement in A1C with SMAs,” commented Patricio Aycinena, MD, an endocrinologist at the Cleveland Clinic who also uses this model of care. “While results can vary for patient to patient, most patients [attending SMAs] will improve. And remember that every 1% decrease in A1C is equal to an approximately 25% or more decrease in the rate of complications,” Dr. Aycinena said.

“Further studies are needed to determine long-term benefits of this type of health care delivery model,” commented Iris Sanchez, DNP, FNP, ADM, CDE. “While [previous] studies tended to focus on biometric outcome measures, a focus on quality of life, diabetes self-management skills, and patient satisfaction with health care providers could yield clinical significance. Prospective cohort studies with patients in the Veterans Administration would provide valuable information to determine which process measures are more meaningful to improving diabetes outcomes,” she said.

Positive Peer Pressure

Patients reported that the SMAs were helpful and improved compliance, although this was not objectively measured, Dr. Kravetz said. “Patients would see that their peers would be compliant with medications and diet and be persuaded to do so themselves,” Dr. Kravetz said. “Patients would share their dietary indiscretions and then hear direct feedback from their peers. Some would stop drinking soda or snacking because their peers influenced them,” he said.

“People love it!,” said Steven V. Edelman, MD, who leads SMA groups for diabetes care at the University of California, San Diego (UCSD). “They jump in there and give each other suggestions on techniques, skills, phone apps, restaurants that have diabetic-friendly foods, all kinds of other issues. In the type 1 group, patients talk about different pumps, continuous glucose monitoring, and how to handle their diabetes during exercise,” said Dr. Edelman, who is Professor of Medicine at UCSD.

Interestingly, Dr. Edelman finds it helpful to include his most difficult patients in group visits. “Those are the patients who start conforming when they see themselves in comparison to others,” he explained.

SMA Models at Other Diabetes Clinics

At the UCSD, the 90-minute visits are lead by Dr. Edelman, along with a registered nurse who takes vitals and adds notes to each patient’s medical records, and a facilitator to keep the visits moving at a good pace. Dr. Edelman divides patients into groups of 10 by type of diabetes, gender, and age (ie, <40 years and ≥ 40 years).

Dr. Edelman puts the patients’ vitals and glucose monitoring data on screen so that the group can analyze the data together. “We don’t do a comparison to browbeat people. It is a really good strategy for people who have poor glucose control; instead of a doctor yelling at them, they just see themselves among their peers. That seems to be to more powerful in turning these people around,” he said.

“I have a lot of fun. Humor is important during the visits and [patients] all love it,” Dr. Edelman said. “With my older male patients with type 2 diabetes, we talk about erectile dysfunction. I ask if anyone is having problems and what medication they are taking for it. It is a good discussion, you just have to open up and talk about it matter-of-factly,” he said.

The Cleveland Clinic uses a model that includes a physician, a certified diabetes educator/diabetes care coordinator as a facilitator, and one or two medical assistant to take vitals and add notes to medical records. Groups include 6 to 8 patients and meet for 90 minutes every 4 months.

Dr. Aycinena finds the social component of the groups to be one of the most important aspects. “People don’t feel alone. They find themselves with other people who are struggling the same way,” he said.

“At the beginning, patients can be hesitant about joining an SMA so I usually propose ‘If you like the SMA you can stay, or we can go back to one-on-one visits.’ I would say that 80% stay in the group,” Dr. Aycinena said, adding that patients tend to stay in the same groups for years.

Cost- and Time-Effective Care

All of the clinicians said that SMAs allowed them to see more patients than they could in individual appointments. The added time allows for more comprehensive care, they said. Plus, with a team member charting during the visit, there is no paperwork to complete afterward.

One drawback is that “at this time, there are no documentation and billing codes to demonstrate the amount of time required for SMAs, which might be a barrier to primary care practices implementing them,” Dr. Sanchez noted. “The lack of billing codes also hinders the ability to track national trends on diabetes outcomes,” she said.

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