Comparative Effectiveness Study Shows Improvements Using Patient-Aligned Group Clinics for Diabetes Care

BACKGROUND:
Self-management skills are an essential means of reducing morbidity and health services use among older individuals with diabetes and comorbid conditions; however, the delivery of effective self-management education and support can be difficult in traditional primary care. This study evaluated the comparative effectiveness of two group self-management interventions for glycemic control among 87 Veterans with treated but uncontrolled diabetes. “Empowering Patients in Care” (EPIC) was a clinician-led, patient-centered group clinic consisting of four one-hour sessions on setting self-management action plans (e.g., diet, exercise, medications) and communicating about progress with action plans; each session included 10 minutes of 1:1 interaction with the study clinician. The comparison intervention consisted of 2 two-hour group education sessions with a diabetes educator and dietician, followed by an additional visit with the primary care provider. The effectiveness of both groups was compared using HbA1c levels and diabetes self-efficacy (i.e., confidence to perform self-care) immediately after the three-month interventions and at one-year follow-up. All participants received usual primary care post-intervention until the one-year follow-up. Study participants were recruited between 8/07 and 3/08; and all were receiving routine primary care at one VAMC.

FINDINGS:

• Veterans who participated in the primary care-based EPIC intervention had significantly greater improvements in HbA1c levels immediately following the active intervention; these differences remained at one-year follow-up. Thus, primary care-based diabetes group clinics that include patient-aligned approaches to goal-setting (e.g., action plan) for medication management, and diet and exercise changes can significantly improve HbA1c levels.
• Diabetes self-efficacy measures improved immediately after the intervention in both groups, but were significantly higher in the EPIC intervention group. Self-efficacy was associated with individual changes in HbA1c levels.
• At 1 year, differences in HbA1c levels between groups remained the same (i.e., there was no return to baseline, but also no further improvements). Self-efficacy levels dropped in both groups at 1 year; but the drop in the EPIC intervention participants was less than the diabetes education participants, resulting in modest (non-significant) differences between the groups at one year.

LIMITATIONS:

• This study was limited to older Veterans and was a relatively small sample.
• The duration of the EPIC intervention sessions exceeded the length of instruction in the traditional group; however, with the exception of content on goal setting and formulating action plans, the EPIC group received the same or less content about diabetes education than the traditional group.

AUTHOR/FUNDING INFORMATION:
This study was partly supported through HSR&D’s Houston Center for Quality of Care and Utilization Studies (HCQCUS). Drs. Naik and Petersen are part of HCQCUS.

Naik A, Palmer N, Petersen N, et al. Comparative Effectiveness of Goal-Setting in Diabetes Group Clinics: Randomized Clinical Trial. Archives of Internal Medicine March 14, 2011;171(5):453-59.