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
Over 29 million Americans are currently living with diabetes, a disease that ranks among the top 10 causes of death.1,2 Although the quality of care provided to these patients has improved, it remains suboptimal.3 Patient education and engagement are significant shortcomings: nearly half of patients report receiving no diabetes education at the time of their diagnosis.3 In traditional models of care, such barriers as limited time, lack of access to an interprofessional team, and patient reluctance to discuss self-care behaviors with a physician account for failure to deliver diabetes education.4 A redesign of clinic visits to make them more collaborative and patient-centered is warranted.5
The shared medical appointment (SMA) model optimizes patient and provider time through an interprofessional, team-based approach.6 Over the last 20 years, SMAs have been shown to reduce glycated hemoglobin (A1C),7,8 blood pressure,7 and low-density lipoprotein cholesterol8; boost adherence to the American Diabetes Association (ADA) standards of care9,10; and decrease hospitalization.7 Although existing literature supports the role of SMAs in improving objective outcomes, there has been less attention on patient-centered outcomes, such as satisfaction with SMAs and their components.7,11,12 The patient perspective is important to understand, as patient activation is imperative to chronic disease management.13
Since no standard exists for the format, components, or the team of healthcare providers involved, there is significant variability in the design of diabetes SMA interventions. A recent systematic meta-analysis concluded that heterogeneity among interventions makes it difficult to evaluate which group-visit components lead to successful SMA interventions.7 We undertook a mixed-methods study exploring how and why an SMA program achieved success.
Research Design and Methods Setting and Participants
This study, approved by the university’s Institutional Review Board, took place at a Joint Commission–certified Primary Care Medical Home (PCMH), in which integrated care is provided to an underserved population. This PCMH serves as the continuity clinic for Internal Medicine residents who receive training at the affiliated academic medical center.
Patients with poorly controlled type 2 diabetes, which we defined as having an A1C greater than 8.0%, were invited to participate in the project. Patients were excluded if they lived in long-term care facilities, had cognitive impairment/dementia, and or did not speak English.
We designed a hybrid SMA structure by combining elements from other models and creating a more fundamental role for the behavioral medicine provider.14 Four SMA group cohorts were offered. Participants were invited to join whichever meeting time was most convenient for them. In an effort to maintain cohesiveness, new patients were added to the groups only once per year. Patients signed a Health Insurance Portability and Accountability Act document prior to participation, which informed them that protected health information would be shared within their group. Four senior Internal Medicine resident physicians led each of the 4 groups. A nurse diabetes educator, social worker, pharmacist, nursing staff, and behavioral medicine provider were present at every visit. The SMA sessions lasted 120 minutes and were held quarterly. Participants were required to meet with their primary resident physician for a traditional clinic visit outside of the SMA program at least once per year.
The SMA meetings were divided into 4 sections: intake, education, break-out, and closing. The education sessions followed the AADE7 Self-Care Behaviors™ curriculum, created by the American Association of Diabetes Educators, and covered nutrition, exercise, mental health, foot care, and other topics.15 During the breakout session, patients met one-on-one with the pharmacist, social worker, medical assistant, Internal Medicine resident, diabetes educator, and behavioral health provider. They then reconvened in a group led by the resident physician and attended by all interprofessional team members to collaboratively review lab work, glycemic control, barriers to adherence, and any changes in diabetes management. During this part of the SMA, each patient had the opportunity to ask questions of the group, share experiences, and participate in the development of their own care plans. Immediately following SMA visits, the resident physician presented all assessments and plans to an attending physician.
We conducted a mixed methods study. We began by performing a quantitative pre-post study of clinical outcomes and survey responses at the conclusion of the first year of the program. Focus groups were convened at the conclusion of the second year to explore patient insights into how the SMA visits influenced their diabetes management.
Data Collection and Outcome Measures Quantitative
At each visit, we administered the Patient Health Questionnaire-9 (PHQ-9) to screen for and monitor depression.16,17 Self-management behaviors and knowledge were assessed by The Diabetes Lifestyle Assessment Tool, a publicly available, but nonvalidated, measure of diet, activity, self-monitoring, and medication adherence, among other domains.18 This assessment was administered at the first group session of the first year and at the final session of the first year. In addition to collecting A1C measurements from SMA participants, we collected contemporaneous A1C values for all clinic patients receiving usual care. Process measures were extracted from the electronic health record.
Informed by the results of the quantitative analysis, we developed a semi-structured focus group agenda through an iterative process. It contained 6 open-ended questions with 3 subquestions (TABLE 1). The purpose was to reveal patients’ insights into which features, or parts, of our SMA provided the greatest value. In addition to asking how SMAs were most valuable, questions investigated the effect of SMAs on a variety of factors, including adherence and mood. Two researchers attended each focus group: 1 moderator and 1 transcriber. The focus group interviews were recorded and transcribed verbatim by the moderator. Our qualitative data comprises the 4 transcripts.
Statistical Analysis Quantitative
At the conclusion of the first year, SMA attendance, survey responses, A1C, and process measures were analyzed; pre- and postintervention values were compared; and demographics and retention were examined using descriptive statistics. Paired survey responses and A1C levels were analyzed with the Wilcoxon signedrank test, abstracted data from chart reviews were analyzed using the Chi-squared test, and students’ t-tests were used to analyze A1C values in clinic patients receiving usual care. We set alpha equal to 0.05 for all comparisons.
A phenomenological method was employed to analyze focus group interviews.19 We attempted to minimize bias by having the researcher begin with a reflection on her own experience with SMAs. Each focus group transcript was then reviewed 3 times in order to identify noteworthy patient statements. Statements that pertained to patient perception of, and satisfaction with, SMAs were excerpted and coded, and then clustered into common themes. From each theme, a textural description was written identifying “what” SMA subjects experienced and a structural description was created identifying “how” the subjects experienced SMAs. Finally, a composite description incorporating the textural and structural descriptions, as well as participant examples, was generated. A second researcher reviewed themes and descriptions for clarity.
Results Quantitative Primary Outcomes
Of 214 eligible patients, 21 accepted the invitation to participate and were enrolled in the study. Group sizes ultimately ranged from 4 to 6 patients, the average participant age was 57 years, female subjects outnumbered males 16 to 5, and the majority of subjects were unmarried. Four of 21 subjects (19%) were uninsured, and 13 of 21 (62%) were enrolled in Medicare or Medicaid. Details of the demographic analysis are presented in TABLE 2. The first SMA visits occurred in May of 2013. Eighteen of the 21 subjects (86%) who attended the first SMA were still participating at the end of year 1. The mean A1C in SMA participants decreased from 10.1 % to 7.9% over the course of the first year (P = .003). This represents an absolute reduction of 2.2 percentage points in A1C and a relative reduction of 21.8 %. A1C in non-SMA clinic patients with diabetes (usual care) decreased from 7.5% (n = 109) to 7.0% (n = 117) (P = .079) over a similar time period. Overall, PHQ-9 scores in SMA participants decreased during the first year, but did not reach statistical significance (P = .11). Using The Diabetes Lifestyle Assessment Tool, we were unable to detect any impact of SMAs on diet, exercise, glucose monitoring, medication adherence, or social support.
Quantitative Secondary Outcomes
The proportion of patients taking insulin remained nearly unchanged over the year, decreasing from 20 (95%) to 19 (90%) of the 21 subjects (P = .549). Statin prescription and angiotensin converting enzyme/angiotensin receptor blockers prescription increased numerically, but did not change significantly, as seen in TABLE 3. Urine albumin/creatinine was measured and foot examination was documented in every patient during the intervention year, representing increases in both measures compared with the baseline year (P = .017 and P <.001, respectively). Influenza vaccination was administered more commonly in the intervention year (18/21 subjects, 86%) than in the baseline year (10/21 subjects, 48%; P = .009).
Qualitative Four focus groups were held in April 2015, with a total of 15 participants. Twelve of these participants were female and 3 were male. Focus group size ranged from 2 to 5 participants, and each interview lasted no longer than 27 minutes. From the 4 focus group interviews, 107 significant statements were extracted and, through thematic analysis, categorized into 8 main themes (TABLE 4).
Theme 1: Barriers to adherence. Participants recalled a number of perceived barriers from the pre-intervention period. Denial of the importance of diabetes, if not the diagnosis itself, was common. One patient remembered saying to herself after diagnosis, “I’m not a diabetic. I’m just pretending I’m not.” Another stated, “Nobody else in your family has to make changes, so they give you crap about making changes.” Fear of needles was the barrier for a third patient. 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.