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RRP 08-246 – QUERI Project

RRP 08-246
Identifying Who Benefits from Diabetes Shared Medical Appointments
Susan R Kirsh, MD
Louis Stokes VA Medical Center, Cleveland, OH
Cleveland, OH
Funding Period: December 2008 - July 2009
Diabetes is a growing national problem and its management complexity challenges the acute care-orientated health care system. Since 2004, VHA has promoted the use of shared medical appointments (SMAs) or group appointments where a multidisciplinary team meets with a group of patients as a means to increase clinical capacity, reduce waiting times, and provide high quality care. Physician-led SMAs based on the chronic care model provide an efficient method to see patients and also produce good outcomes as previously demonstrated. While many patients who have participated in SMAs have benefitted, others did not. Some patients have improved at 3 months, but did not sustain that improvement over the course of a year.

The goal of this project was to collect preliminary data necessary to design a larger trial that elucidates who benefits and the mechanism(s) by which SMAs contribute to improved intermediate outcomes and self-management. The objectives are to (1) evaluate patient problem solving related to diabetes and patient self-care activities pre-post diabetes SMAs; (2) to identify other areas of SMAs that are beneficial or barriers to patient outcomes from qualitative interviews; and (3) provide preliminary data for the development of larger studies identifying who benefits from diabetes SMAs.

Patients participating in diabetes SMAs were asked to participate in this study. A total of 25 patients participated in the quantitative questionnaires measuring patients' self-care and problem solving skills related to diabetes. Twenty two participants completed a 3 month follow-up. Paired T-tests were utilized to identify significant changes in patient responses before and 3 months after their SMA. An additional eight patients were identified for participation in qualitative in-depth interviews. Qualitative methods were used to identify themes in patient interviews.

The 22 participants of the quantitative questionnaires showed significant improvements in the number of days they followed a healthful eating plan (t= -4.02, p<.001) and spaced out their carbs throughout the day (t = -2.417, p<.05). Other scales utilized in the study show trends of improvement in diabetes problem solving and self-care activities following engagement in at least one SMA although findings were not significant. Qualitative findings based on eight participants indicate that diet was a major theme mentioned by participants. Pariticpants identified peer support, and the information and education received from SMAs, including provider advice for self-management of diabetes. Behavioral changes were mentioned by several participants to occur over time and not instantaneous following an SMA, providing support for further long-term research identifying who benefits from SMAs.

By examining who benefits from diabetes shared medical appointments the VA may be better able to target SMAs to patients who receive the best benefits from them. Additionally identify who shows less benefits from SMAs can allow for alternative interventions or efforts to address their needs to enhance treatment and improve patient outcomes.

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