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Shared Medical Appointments for Patients with Type 2 Diabetes

Melissa S. Hernandez, MD; Ruth Nutting, PhD, LCMFT; Andrew J. Vasey, MD; Susan K. Burbach, BSN-RN; Jason F. Shiffermiller, MD, MPH
Glycemic control in patients with type 2 diabetes was improved through a shared medical appointment program focusing on lifestyle education and behavior change.
Theme 2: Accountability. Patients confirmed that SMAs made managing diabetes easier. They identified accountability as a mechanism through which the SMAs acted. For example, 3-month follow-up appointments allowed this patient to focus on what she needed to do for shorter periods of time. “I can come in here every 3 months, I know I need to keep my blood sugars at such and such a level for 3 months, and I’ll check and say, ‘Oh good, I made it’. Ok, so I do the same thing for the next 3 months. That helps—baby steps.”

Theme 3: Lifestyle modification. SMA participants reported applying the education they received on diet (“Learning about good foods and foods that are good for diabetes was a big help…”) and exercise (“I’m not doing a lot, but I am doing more [exercise] than what I was doing before I started.”) Patients learned what lifestyle modifications to make and how to make them. One example: “I think that I’m realizing that I need to get a better balance of myself because I might go way far with doing good and eating, but not checking my sugars, or taking my insulin, but not exercising. So, balancing myself.”

Theme 4: Empowerment. Many participants struggled to recognize personal limitations during the pre-intervention period. The SMAs taught them to set boundaries, among other techniques, to deal with that issue. Patients reported using these techniques to help gain control of their diabetes. One stated, “I had to learn to take time for myself.” Another highlighted, “I’ve learned to say ‘No’ and set boundaries.”

Theme 5: Psychosocial well-being. Participating in SMAs appeared to positively impact the patient’s mood. One participant stated, “Coming to these meetings kinda cheers you up because you know there are other people in the same boat, so you’re not alone. That relieves my anxiety a little bit.” Another summed it up this way, “I feel better about myself … just everything improved.” Theme 6: Group dynamic. One patient summarized this benefit well. “When you get in a group like this and everybody starts talking about things that have happened to them, it makes it different. Not that we don’t appreciate the doctors and nurses, we do. They are what keep us alive. But it just hits and registers better … it supports everything they’re telling you, but in a different way.” Another patient identified the convenience of meeting with an interprofessional team as a benefit: “I like that team approach, where you can just sit down and don’t have to make 4 or 5 different appointments … I think that’s the most beneficial, but it all helps.”

Theme 7: Self-awareness. When asked about their ability to sustain diabetes control in the absence of SMAs, patients were able to identify their needs. One patient identified her need for a social support system: “I know for myself, I think I need it [SMAs] … because that’s the support we have in our group; not necessarily at home, but in our group.” Another patient expressed a need for a close relationship with her healthcare providers: “I would be fine, but I would have a lot of questions … I would have to find somebody to get me the answers.”

Theme 8: Future directions. Patients suggested several design elements that might enhance the effectiveness of our SMA. They recommended interactive demonstrations to teach cooking and exercise techniques, asked for virtual group interactions through social media, and wanted the opportunity to mentor new group members in a more meaningful way.


  We found that relatively small SMA groups, with a consistent membership of volunteer patients who met regularly over the course of a year, reduced A1C compared with pre-intervention levels. The improvement in glycemic control was not explained by an increase in insulin prescription or improvement in specific self-care activities as measured by The Diabetes Lifestyle Assessment Tool.

  We subsequently undertook a qualitative analysis to identify patient-generated explanations for the observed improvement in glycemic control. The qualitative analysis revealed 8 themes, which, taken together, begin to explain how improvements in glycemic control were achieved. Holding meetings every 3 months with a consistent, and eventually familiar, group of peers and providers was perceived to be beneficial. This structure helped patients to overcome initial fears, held them accountable, and allowed them to share insights with one another. Patients reported feeling empowered by our SMAs, and they reported actual lifestyle changes. Teaching the AADE7 Self-Care Behaviors™ and making behavioral health providers a central part of our SMA interprofessional team may have been responsible for those benefits.15 Finally, patients identified a few specific SMA design features that might enhance effectiveness. These included experiential demonstrations, a social media presence, and formal peer mentoring.

Our findings support evidence that the SMA model can improve glycemic control and facilitate ADA standards of care.7-10 Subjects’ enthusiasm for our particular SMA program is evidenced by the high adherence rate compared with other published studies.20-22 This may be related to our SMA design, which allowed for relatively small cohorts of patients that remained consistent over time. The improved sense of peer support that we found in qualitative analysis lends weight to this theory. Eisenstat et al also found that patients report high satisfaction with small group sizes of no more than 8 to 10 participants.14

  As mentioned previously, there are relatively few studies that specifically evaluate patient perceptions of diabetes SMAs. Our qualitative findings were similar to other research.11,12,23 Careyva et al found that 92% of patients learned more about how to manage their diabetes during group visits than through traditional models of care.12 In a focus group study of SMAs in a population of veterans, SMAs led to an increased sense of empowerment, peer support, awareness (ie, self-awareness and knowledge of the behaviors affecting their health), and overall health benefits.11 Participants developed deep connections with the others in the group, relating that to the connections they had felt in military units. Similarly, in our study, 1 participant described the group as “being like AA for diabetics.”

Our pre-post study of a SMA program carried out in a single clinic has a number of limitations. Although A1C levels in patients receiving usual care did not change significantly over the same time period, we could not rule out the possibility that unmeasured time-varying factors influenced our results. Only patients who remained participants in the SMA groups at the end of year 1 contributed to the quantitative analysis. This may have accentuated the A1C difference between the pre- and postintervention time periods.  

Also, our groups consisted largely of underserved women, and because all 4 of our SMA groups included 6 or fewer patients, we were not able to evaluate the effect of group size on outcomes. Therefore, our results may not apply to a more socially diverse population or to larger SMA group sizes. Small sample size limited our quantitative analysis of mood and self-care. We were unable to report the cost of instituting our SMA program, but we did conduct the program using existing staff and structure without external funding. Our qualitative findings are naturally subjective and should be substantiated with further study. Finally, we were not able to control for unmeasured characteristics (ie, self-efficacy, researcher behavior, and cultural differences) that can bias qualitative analysis.  

Implementation of SMAs in an Internal Medicine residency clinic was feasible and led to higher-quality care. Focus groups, but not surveys, proved an effective method for identifying the most beneficial aspects of our SMAs. Based on our findings, SMA design that allows a comfortable group dynamic to form can reduce barriers, provide accountability, and deliver meaningful education. Areas that require further study include group size, interprofessional team members, sustainability, and cost. 

Author information: The authors are all from the division of General Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska. The authors have no conflicts of interest to disclose.

Corresponding author contact data:
Jason Shiffermiller, MD, MPH 983331
Nebraska Medical Center Omaha, NE 68198-3331
Phone: 402-559-7299;
Fax: 402-559-8396

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  2. Centers for Disease Control and Prevention. National Vital Statistics Reports. Deaths: leading causes for 2014. CDC website. Published June 2016. Accessed September 22,2016.

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  8. Trento M, Gamba S, Gentile L, et al; ROMEO Investigators. Rethink organization to iMprove education and outcomes (ROMEO): a multicenter randomized trial of lifestyle intervention by group care to manage type 2 diabetes. Diabetes Care. 2010;33(4):745-747. doi: 10.2337/dc09-2024.

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11. 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.

  12. Careyva B, Salzman B, Plumb E, Kern S. Patient perceptions of a diabetes group visit experience. J Community Med Health Edu. 2012;2(135):2.

  13. NHS kidney care. Summary of the evidence on performance of the patient activation measure (PAM). The Health Foundation website. resources/patientactivation-1.pdf. Published May 2012. Accessed June 1, 2016.

  14. Eisenstat SA, Ulman K, Siegel AL, Carlson K. Diabetes group visits: integrated medical care and behavioral support to improve diabetes care and outcomes from a primary care perspective. Curr Diab Rep. 2013;13(2):177-187. doi: 10.1007/s11892-012-0349-5.

  15. American Association of Diabetes Educators. AADE7 self-care behaviors. AADE website. Published May 1999. Accessed September 29, 2015.

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  18. Full Circle Diabetes Program. Lifestyle Survey. Diabetes Initiative Archive website. Published June 2004. Accessed September 29, 2015.

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  20. 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. 

  21. Guirguis AB, Lugovich J, Jay J, et al. Improving diabetes control using shared medical appointments. Am J Med. 2013;126(12):1043-1044. doi: 10.1016/j.amjmed.2013.06.019.

  22. Dontje K, Forrest K. Implementing group visits: are they effective to improve diabetes self-management outcomes? J Nurse Pract. 2011;7(7):571-577.

  23. Clancy DE, Yeager DE, Huang P, Magruder KM. Further evaluating the acceptability of group visits in an uninsured or inadequately insured patient population with uncontrolled type 2 diabetes. Diabetes Educ. 2007;33(2):309-314.
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