Shared Medical Appointments and Their Effects on Achieving Diabetes Mellitus Goals in a Veteran Population

For the primary endpoint, the SMA group had a 1.48% ± 0.02 (SD) reduction in A_1c compared with a 0.6% ± 0.02 (SD) decrease in the control group (P = .01). When evaluating mean changes in A_1c by the number of SMAs attended, it was noted that participation in ≥ 6 SMAs led to the greatest reduction in A_1c of 2.08%. In the SMA group, it was noted that patients with higher A_1c values at baseline demonstrated greater improvements in glycemic control compared with patients with lower baseline A_1c values. The mean change in A_1c, stratified by baseline A_1c, was -2.26% for those with baseline A_1c values ≥ 10% and -0.87% for those with baseline A_1c values < 10%.

In evaluating the format style, open- vs focused-session, it was observed that participation in focused sessions led to greater improvements in glycemic control. Furthermore, when stratified by provider, greater improvements in glycemic control were demonstrated when medication management was completed by a CPS vs a NP (Table 2). The average number of interventions per SMA patient was 3.1 ± 2.22 (SD). For the control group, the total number of interventions made was 86, with an average of 1.37 ± 1.51 (SD) per patient. The overall show rate was 49% ± 16 (SD), 52% ± 16 (SD) for open visits, and 46% ± 15 (SD) for focused visits. The mean change in ABW and BMI from baseline to endpoint was no different between the SMA and control groups (Table 3). The SMA group participants demonstrated a decrease in A_1c at 3 months postdischarge, and a moderate increase in A_1c was noted at 6 months postdischarge.

Discussion

Shared medical appointments provide an effective alternative to standards of care in order to obtain improvements in glycemic control. Consistent with previous studies, this study reported significant improvements in glycemic control in the SMA group vs the control group. This study also elucidated unique characteristics about SMAs that may have been correlated with clinical success.

Although the greatest improvements in glycemic control were noted for those who participated in ≥ 6 SMAs, it was observed that participation in only 1 SMA also led to improvements. For a site with limited staff and a high volume of patients waiting to participate in SMAs, it may be mutually beneficial to offer only 1 SMA per patient. In addition, patients with ≥ 10% A_1c at baseline demonstrated greater improvements in glycemic control compared to those with < 10% A_1c at baseline. The reasons the higher baseline A_1c subgroup responded to interventions more robustly are unclear and likely multifactorial. Nonetheless, factors such as psychosocial influences (eg, peer pressure to get healthy) may have increased motivation to prevent complications and improved medication adherence in the setting of closer follow-up. Additionally, hyperresponsiveness to drug therapy may have played a role. Regardless, for new SMA programs interested in making an immediate impact, it may be advantageous to initially select patients with very poorly controlled DM.

A unique aspect of the ABJ SMA was the variety of focused sessions offered. Previous studies did not demonstrate such a variety of focused sessions, nor did they evaluate the impact of a focused visit on the patient’s T2DM control. Participation in focused ABJ SMA sessions may have led to improved T2DM control, which may be attributed to the value patients assigned to specialty care and an increased motivation to get healthy.

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Another factor that may have led to improved T2DM control was CPS involvement with medication management. The presence of a NP was highly valued, both from a group discussion and medication management standpoint; still, it is a good idea to involve a CPS who has a strong command of DM pharmacotherapy. One shortcoming of this SMA program was the inability for patients to maintain glycemic improvements 6 months after discharge. This pitfall was likely the result of suboptimal coordination of care after SMA discharge and may be avoided by asking the medical administration service clerk to promptly schedule discharged SMA patients for a general medicine clinic T2DM follow-up.The SMA patients had more T2DM interventions within the same time frame compared with the control patients. Although not causative, the increased number of interventions in addition to the bolstered support of the SMA may have correlated with glycemic improvements.

An important finding of this study was the SMA show rate and how it compared with attendance rates found in other group models. The favorable ABJ SMA show rate could have been due to the rigorous attention paid to reminder letters and phone calls. The literature has not established a standard approach to increasing SMA show rates; however, the current data suggest that increased reminders may have increased attendance.