title: 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.
abstract: OBJECTIVE
  The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8-20) are seen by a multi-disciplinary team in a 1-2 h appointment. Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this quality improvement project was to improve intermediate outcome measures for diabetes (A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk.
  
  
  METHODS
  Primary care clinic at a tertiary care academic medical center.
  
  
  METHODS
  Patients with diabetes with one or more of the following: A1c >9%, SBP blood pressure >160 mm Hg and LDL-c >130 mg/dl were targeted for potential participation; other patients were referred by their primary care providers. Patients participated in at least one SMA from 4/05 to 9/05.
  
  
  METHODS
  Quasi-experimental with concurrent, but non-randomised controls (patients who participated in SMAs from 5/06 through 8/06; a retrospective period of observation prior to their SMA participation was used).
  
  
  METHODS
  SMA system redesign. ANALYTICAL METHODS: Paired and independent t tests, chi(2) tests and Fisher Exact tests.
  
  
  RESULTS
  Each group had up to 8 patients. Patients participated in 1-7 visits. At the initial visit, 83.3% had A1c levels >9%, 30.6% had LDL-cholesterol levels >130 mg/dl, and 34.1% had SBP >or=160 mm Hg. Levels of A1c, LDL-c and SBP all fell significantly postintervention with a mean (95% CI) decrease of A1c 1.4 (0.8, 2.1) (p<0.001), LDL-c 14.8 (2.3, 27.4) (p = 0.022) and SBP 16.0 (9.7, 22.3) (p<0.001). There were no significant differences at baseline between control and intervention groups in terms of age, baseline intermediate outcomes, or medication use. The reductions in A1c in % and SBP were greater in the intervention group relative to the control group: 1.44 vs -0.30 (p = 0.002) for A1c and 14.83 vs 2.54 mm Hg (p = 0.04) for SBP. LDL-c reduction was also greater in the intervention group, 16.0 vs 5.37 mg/dl, but the difference was not statistically significant (p = 0.29).
  
  
  CONCLUSIONS
  We were able to initiate a programme of group visits in which participants achieved benefits in terms of cardiovascular risk reduction. Some barriers needed to be addressed, and the operations of SMAs evolved over time. Shared medical appointments for diabetes constitute a practical system redesign that may help to improve quality of care.
authors.affiliation: Case Western Reserve University School of Medicine, Cleveland, OH, USA. susan.kirsh@va.gov
authors.forename: Susan
authors.initials: S
authors.lastname: Kirsh
authors.forename: Sharon
authors.initials: S
authors.lastname: Watts
authors.forename: Kristina
authors.initials: K
authors.lastname: Pascuzzi
authors.forename: Mary Ellen
authors.initials: ME
authors.lastname: O'Day
authors.forename: David
authors.initials: D
authors.lastname: Davidson
authors.forename: Gerald
authors.initials: G
authors.lastname: Strauss
authors.forename: Elizabeth O
authors.initials: EO
authors.lastname: Kern
authors.forename: David C
authors.initials: DC
authors.lastname: Aron
mesh_terms: D000046:Academic Medical Centers; D000368:Aged; D001071:Appointments and Schedules; D001794:Blood Pressure; D002318:Cardiovascular Diseases / Q000517:prevention & control* / Q000628:therapy; D016009:Chi-Square Distribution; D002908:Chronic Disease; D003920:Diabetes Mellitus / Q000517:prevention & control* / Q000628:therapy; D006442:Glycated Hemoglobin / Q000032:analysis; D006126:Group Processes; D019538:Health Care Surveys; D006787:Hospitals, Veterans; D006801:Humans; D008875:Middle Aged; D010044:Outpatient Clinics, Hospital; D011320:Primary Health Care / Q000379:methods*; D017064:Process Assessment, Health Care; D015397:Program Evaluation; D012307:Risk Factors; D017749:Total Quality Management
chemical_list: D006442:Glycated Hemoglobin