title: Shared Medical Appointments: Impact on Clinical and Quality Outcomes in Veterans With Diabetes.
abstract: Managing diabetes poses substantial challenges to the over 29.1 million Americans afflicted, and is financially overwhelming to the US health care system. One potential strategy is utilizing a group approach to care delivery or shared medical appointment (SMA). The purpose of this 3-year retrospective VA study was to investigate differences in clinical and quality outcome measures in veterans with type 2 diabetes who used SMAs and those who received only usual care (UC) one-on-one with their doctor. This observational, 2-group cohort study used abstracted medical records from a large Midwestern Veterans Administration hospital. Clinical outcome metrics included hemoglobin A1c (hbA1c), systolic blood pressure, low-density lipoprotein cholesterol, and emergency department (ED) visits. Quality outcomes included Veterans' Administration (VA) Department of Defense clinical practice guidelines for the management of diabetes. A total of 988 total VA cases were examined retrospectively over 3 years: 371 cases had used SMAs and 617 were in the UC cohort, and had never attended a diabetes SMA. The study period used abstracted VA medical records from 2008 to 2010. There were no statistically significant differences in HbA1c, systolic blood pressure, and ED visits between groups; however, hbA1c for individuals who attended SMAs was 8.55 (standard deviation [SD] = 1.72) and UC was 7.49 (SD = 1.28) (P < .001). All clinical outcomes were worse at baseline for the SMA cohort. UC had mean ED visits/3 years (mean = 18.62, SD = 13.53, P < .001) versus SMA participants (mean = 27.97, SD = 14.00, P <. 001), revealing a propensity for high health care utilization. SMA providers had statistically significant differences over UC cases on quality measures, including ordering annual ophthalmology and podiatry examinations (P < .001) and prescribing aspirin and angiotension-converting enzyme inhibitors (ACE-I). SMAs may provide a venue for assessing and delivering quality care for patients with type 2 diabetes. More research is needed to ascertain effective strategies for diabetes disease management in high-risk patients.
authors.affiliation: Northwestern Memorial Hospital, Chicago, Illinois (Dr Harris); Cleveland VA Medical Center, Cleveland, Ohio (Drs Kirsh and Higgins); and Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio (Dr Higgins).
authors.forename: Marianne D
authors.initials: MD
authors.lastname: Harris
authors.forename: Susan
authors.initials: S
authors.lastname: Kirsh
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Higgins
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001071:Appointments and Schedules; D001794:Blood Pressure; D008078:Cholesterol, LDL / Q000097:blood; D015897:Comorbidity; D003924:Diabetes Mellitus, Type 2 / Q000628:therapy*; D019468:Disease Management; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006442:Glycated Hemoglobin; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000458:organization & administration; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration*; D019984:Quality Indicators, Health Care; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D014481:United States; D014493:United States Department of Veterans Affairs; D014728:Veterans
chemical_list: D008078:Cholesterol, LDL; D006442:Glycated Hemoglobin