title: Shared medical appointments for patients with diabetes mellitus: a systematic review.
abstract: OBJECTIVE
  Shared medical appointments (SMAs) are an increasingly used system-redesign strategy for improving access to and quality of chronic illness care. We conducted a systematic review of the existing literature on SMA interventions for patients with diabetes in order to understand their impact on outcomes.
  
  
  METHODS
  MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from January 1996 through April 2012. PubMed search updated June 2013.
  
  
  METHODS
  English-language peer-reviewed publications of randomized controlled trials (RCTs), nonrandomized cluster controlled trials, controlled before-and-after studies, or interrupted time-series designs conducted among adult patients with diabetes. Two independent reviewers used prespecified criteria to screen titles and abstracts for full text review.
  
  
  METHODS
  Two different reviewers abstracted data and rated study quality and strength of evidence. When possible, we used random-effects models to synthesize the effects quantitatively, reporting by a weighted difference of the means when the same scale was used across studies, and a standardized mean difference when the scales differed. We measured heterogeneity in study effects using Forest Plots, Cochran's Q, and I(2), and explored heterogeneity by using subgroup analyses for categorical variables and meta-regression analyses for continuous or discrete variables. Outcomes not suitable to meta-analysis were summarized qualitatively.
  
  
  RESULTS
  Twenty-five articles representing 17 unique studies compared SMA interventions with usual care. Among patients with diabetes, SMAs improved hemoglobin A1c (∆ = -0.55 percentage points [95 % CI, -0.11 to -0.99]); improved systolic blood pressure (∆ = -5.2 mmHg [95 % CI, -3.0 to -7.4]); and did not improve LDL cholesterol (∆ = -6.6 mg/dl [95 % CI, 2.8 to -16.1]). Nonbiophysical outcomes, including economic outcomes, were reported too infrequently to meta-analyze, or to draw conclusions from. The A1c result had significant heterogeneity among studies, likely secondary to the heterogeneity among included SMA interventions.
  
  
  CONCLUSIONS
  Heterogeneity among the components of diabetes SMAs leads to uncertainty about what makes a particular SMA successful.
  
  
  CONCLUSIONS
  SMA interventions improve biophysical outcomes among patients with diabetes. There was inadequate literature to determine SMA effects on patient experience, utilization, and costs.
authors.affiliation: Durham Veterans Affairs Medical Center, 411 W Chapel Hill Street, Suite 512, Durham, NC, 27701, USA, dedelman@duke.edu.
authors.forename: David
authors.initials: D
authors.lastname: Edelman
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Gierisch
authors.forename: Jennifer R
authors.initials: JR
authors.lastname: McDuffie
authors.forename: Eugene
authors.initials: E
authors.lastname: Oddone
authors.forename: John W
authors.initials: JW
authors.lastname: Williams
mesh_terms: D001071:Appointments and Schedules; D001794:Blood Pressure / Q000502:physiology; D003920:Diabetes Mellitus / Q000097:blood / Q000191:economics / Q000503:physiopathology / Q000628:therapy*; D006442:Glycated Hemoglobin / Q000378:metabolism; D017048:Health Care Costs / Q000706:statistics & numerical data; D006801:Humans; D009936:Organizational Innovation; D017063:Outcome Assessment, Health Care; D017060:Patient Satisfaction; D011320:Primary Health Care / Q000191:economics / Q000458:organization & administration*
chemical_list: D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human
references.citation: PLoS Med. 2009 Jul 21;6(7):e1000097
references.pmid: 19621072
references.citation: Ann Pharmacother. 2011 Nov;45(11):1346-55
references.pmid: 22028418
references.citation: J Am Geriatr Soc. 2010 Jan;58(1):168-72
references.pmid: 20002506
references.citation: Nutr Metab Cardiovasc Dis. 2005 Aug;15(4):293-301
references.pmid: 16054554
references.citation: Diabetes Care. 2003 Jul;26(7):2032-6
references.pmid: 12832308
references.citation: J Am Geriatr Soc. 1997 May;45(5):543-9
references.pmid: 9158573
references.citation: Diabetes Care. 1999 Dec;22(12):2011-7
references.pmid: 10587835
references.citation: J Health Care Poor Underserved. 2005 May;16(2):315-27
references.pmid: 15937395
references.citation: CMAJ. 2013 Sep 17;185(13):E635-44
references.pmid: 23939218
references.citation: Ann Intern Med. 2010 Jun 1;152(11):689-96
references.pmid: 20513826
references.citation: Stat Med. 2002 Jun 15;21(11):1539-58
references.pmid: 12111919
references.citation: Diabetes Care. 2010 Apr;33(4):745-7
references.pmid: 20103547
references.citation: J Am Geriatr Soc. 2004 Sep;52(9):1463-70
references.pmid: 15341547
references.citation: Eff Clin Pract. 2001 Mar-Apr;4(2):49-57
references.pmid: 11329985
references.citation: J Gen Intern Med. 2007 May;22(5):620-4
references.pmid: 17443369
references.citation: Am J Manag Care. 2008 Jan;14(1):39-44
references.pmid: 18197744
references.citation: J Rural Health. 2005 Fall;21(4):317-21
references.pmid: 16294654
references.citation: Diabetes Educ. 2011 Nov-Dec;37(6):801-12
references.pmid: 22021025
references.citation: Diabetes Care. 2001 Apr;24(4):695-700
references.pmid: 11315833
references.citation: J Am Acad Nurse Pract. 2012 Dec;24(12):735-43
references.pmid: 23190131
references.citation: Arch Intern Med. 2011 Mar 14;171(5):453-9
references.pmid: 21403042
references.citation: Hypertens Res. 2011 Jun;34(6):714-21
references.pmid: 21307869
references.citation: Diabetes Care. 2001 Jun;24(6):995-1000
references.pmid: 11375359
references.citation: Qual Saf Health Care. 2007 Oct;16(5):349-53
references.pmid: 17913775
references.citation: Diabetes Educ. 2010 Jan-Feb;36(1):109-17
references.pmid: 19966072
references.citation: Am J Manag Care. 2011 Jun 01;17(6 Spec No.):e212-4
references.pmid: 21756014