VA Ann Arbor Healthcare System
Diabetes Shared Medical Appointments and Lower A1c
Short-term Shared Medical Appointments (SMA) within routine clinical care demonstrated improved A1c in Veterans with Type-2 diabetes, according to a study published in the Journal of General Internal Medicine. A1c is a measure of blood sugar control that, when elevated, significantly increases the risks of serious complications from diabetes.
Shared Medical Appointments bring groups of patients together with a team of providers for a series of one to two-hour sessions.
“There are usually 2 clinicians that head these SMA's with 8-10 people. We designed ours so that they’re very much about encouraging the participants to share their experiences. The discussions and topics covered were very driven by the participants,” said Dr. Michele Heisler, a research scientist at the Center for Clinical Management Research at the VA Ann Arbor Healthcare System and lead author of the study.
The first-ever rigorous evaluation of SMA’s as actually implemented in real clinical practice was conducted at five different VA healthcare systems including Ann Arbor, Palo Alto, Providence, Sacramento, and West Haven.
The results show that real-life, diverse clinical practices significantly improved glycemic control more than usual care immediately after the conclusion of the series of SMA's, but those relative gains were not maintained months after the SMA's ended.
SMA's for those with Type 2 diabetes achieved A1c reductions 0.35% greater--and 0.53% greater among those who attended at least half of the SMA's-- than the control group after 6 months. These are big enough differences to make a significant difference in risk of complications. However, at the 12-month follow up, while A1c reductions from the baseline ranged from 0.16% points to 0.29% points greater than the control group, these were not statistically significantly different.
More about the Patients
Participants for the evaluation were identified using one of two conditions:
- Patients who had two outpatient visits or one hospitalization with a diabetes-related condition in the past 12 months;
- At least one prescription for a glucose control medication and;
- an A1c of at least 7.5% and less than 70 years in age OR;
- an A1c of at least 8.0% and greater than 70 years in age.
Patients were also offered an option to participate in a Peer Support (P2P) program in conjunction with their SMA’s. The P2P program matched SMA participants with another and encouraged them to make weekly phone calls with each other outside of the SMA sessions. However, only a small number of Veterans elected to participate in this option.
Dr. Heisler noted, “The reductions of 0.4% points in A1c for the participants who attended at least one SMA group achieved, and the more than 0.5% points of those who attended at least half of the sessions achieved, are about what we physicians hope our patients achieve after starting a good diabetes medication.”
“It is important to emphasize that these sessions are not lecture-type diabetes education. The key is that the facilitators are encouraging discussion and learning among the SMA participants--they are feeling empowered and motivated by helping each other with strategies and specific steps to meet health goals they set for themselves."
Addressing Long-Term Solutions
Improvements in A1c at 12 months among participants who attended at least half of the SMA sessions approached statistical significance, but did not achieve it, according to the study.
The authors had hypothesized that offering participants the P2P program at the first SMA in the series might be an effective and scalable approach to maintaining the gains observed after 6 months. However, a low number of participants elected to take part in this option for the study. Uptake in the P2P may have been better if offered later in the SMA series, once the participants established more rapport and trust amongst each other.
There remains great need to test long term interventions, but Dr. Heisler and other researchers feel this model has a future in addressing diabetic care.
“We think that this is a really important model both for the V.A. and for other health systems. One possibility to maintain improvements is to continue the group SMA's rather than just holding them for a short period of time as we did in this evaluation.” concluded Dr. Heisler.