title: Stabilization of glycemic control and improved quality of life using a shared medical appointment model in adolescents with type 1 diabetes in suboptimal control.
abstract: Declining glycemic control in type 1 diabetes (T1D) during adolescence persists despite treatment advances. Non-adherence, peer relations, diabetes burnout, risk taking, transition to autonomy, family conflict, and poor quality of life (QOL) are recognized barriers. Shared medical appointments (SMAs) in adolescent T1D may offer benefits, but data are limited. Our objective was to determine whether SMAs, with multi-component interventions utilizing multidisciplinary teams, improve glycemic control and psychosocial outcomes in poorly controlled adolescent T1D.
  
  
  
  SMAs focused on self-management, communication skills, goal setting, glucose pattern recognition, and peer/diabetes team support. SMAs included: individual history and physical, labs, surveys, multidisciplinary educational ice breakers, group session, and individual wrap up. Outcomes were QOL, adherence, and retrospective and prospective glycemic control. Three to six subjects and families came to 3 SMAs and 1 individual appointment every 3 months over 9 months.
  
  
  
  A total of 37 English speaking subjects, ages 12-16 yrs, with T1D ≥ 1 year, and hemoglobin A1c (HbA1c) 7.5-11% enrolled. Thirty-two subjects attended 75% of visits, meeting inclusion criteria.
  
  
  
  HbA1c worsened in the 9 months before study (ΔHbA1c= 0.7 ± 1.2; p < 0.01), but remained stable during study (ΔHbA1c = 0.01 ± 1.2; p > 0.05). There were significant improvements in overall QOL (p = 0.005), school function (p = 0.006), psychosocial function (p = 0.008), barriers (p = 0.02), adherence (p = 0.01), and communication (p = 0.02). Improvements in school function and communication reached clinical significance.
  
  
  
  SMAs are feasible replacements to individual appointments in adolescent T1D, stabilizing glycemic control and improving QOL. Randomized controlled trials with optimizations are needed to further explore and refine this intervention.
authors.affiliation: Department of General Pediatrics, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Baraka D
authors.initials: BD
authors.lastname: Floyd
authors.affiliation: Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Block
authors.affiliation: Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Bruce B
authors.initials: BB
authors.lastname: Buckingham
authors.affiliation: Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Trang
authors.initials: T
authors.lastname: Ly
authors.affiliation: Jaeb Center for Health Research, Tampa, FL, USA.
authors.forename: Nicole
authors.initials: N
authors.lastname: Foster
authors.affiliation: Department of Psychology, University of California Riverside, Riverside, CA, USA.
authors.forename: Robert
authors.initials: R
authors.lastname: Wright
authors.affiliation: Department of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Claudia L
authors.initials: CL
authors.lastname: Mueller
authors.affiliation: Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Korey K
authors.initials: KK
authors.lastname: Hood
authors.affiliation: Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA.
authors.forename: Avni C
authors.initials: AC
authors.lastname: Shah
mesh_terms: D000293:Adolescent; D002140:California; D015331:Cohort Studies; D003131:Combined Modality Therapy; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000178:diet therapy / Q000188:drug therapy*; D003927:Diet, Diabetic; D004351:Drug Resistance; D005240:Feasibility Studies; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D006943:Hyperglycemia / Q000517:prevention & control*; D007003:Hypoglycemia / Q000517:prevention & control*; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use; D008297:Male; D010348:Patient Care Team; D010353:Patient Education as Topic; D010379:Peer Group; D010865:Pilot Projects; D011788:Quality of Life; D000073278:Self-Management / Q000193:education*; D000074822:Treatment Adherence and Compliance
chemical_list: D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin; C517652:hemoglobin A1c protein, human
keywords: Interdisciplinary health team; patient care team; pediatrics; peer group; pilot study