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Edelman D (Durham VAMC), Fredrickson SK
(Richmond VAMC), Melnyk SD
(Durham VAMC), Coffman CJ
(Durham VAMC), Jeffreys AS
(Durham VAMC), Jackson GL
(Durham VAMC), Harris AC
(Durham VAMC), Stewart H
(Richmond VAMC), Hamilton NS
(Durham VAMC), Weinberger M
(Durham VAMC)
Objectives:
Group medical visits are widely used but poorly tested in the management of diabetes and hypertension. Our objective was to test the effectiveness of group medical visits in the management of diabetes and hypertension.
Methods:
239 patients receiving primary care at the Durham or Richmond VAMC with poorly controlled diabetes (Hemoglobin A1c (A1c) > = 7.5%) and blood pressure (BP) (systolic BP > = 140 or diastolic BP > = 90) were randomized within the VAMC to receive either group medical visits or usual care. The same patients met with the same pharmacist and general internist at each visit; however, there were different physicians and pharmacists across groups. Each session included group education and structured group interactions moderated by a registered nurse or certified diabetes educator. Additionally, individual medication adjustments were made by the pharmacist and physician to manage A1c and BP. Each group met every two months for a year. A1c and systolic BP (SBP) were measured at baseline, 6, and 12 months. Linear mixed modeling (LMM) was used to compare changes in A1c and systolic BP between the intervention and control arms, adjusting for clustering within group medical clinics.
Results:
Mean baseline SBP and A1c were 152.9mmHg (SD 14.2) and 9.2% (SD 1.4), and were comparable between study arms; 89% of patients had complete follow-up. Intervention patients had greater observed improvements in SBP than controls at both 6 months (14.5 vs. 7.2 mmHg) and 12 months (14.1 vs. 6.2 mmHg). After adjusting for baseline and clustering, the difference between arms in systolic BP at 12 months was 7.2 mmHg (p = 0.02 by LMM). Intervention patients also had greater observed improvements in A1c than controls at both 6 months (0.6% vs. 0.4%) and 12 months (0.9% vs. 0.5%). After adjustment, the difference at 12 months was 0.3% (p = 0.20 by LMM).
Implications:
Group medical visits are a potent strategy for improving blood pressure in patients with diabetes. They are not significantly better than VA usual care in improving glycemic control.
Impacts:
Group medical visits are better for managing BP than A1c, probably due to multi-factorial challenges in improving glycemic control among refractory patients in a VA population.
