Evaluating the Effectiveness of Diabetes Shared Medical Appointments (SMAs) as Implemented in Five Veterans Affairs Health Systems: a Multi-site Cluster Randomized Pragmatic Trial

Michele Heisler,Adam S Tremblay,John F Chardos,Wen-Chih Wu,Jeffrey Cass,Donna M Zulman,Lorrie A Strohecker,Jennifer Burgess,Alexander B Guirguis

doi:10.1007/s11606-020-06570-y

Abstract

ObjectiveTo examine whether diabetes shared medical appointments (SMAs) implemented as part of usual clinical practice in diverse health systems are more effective than usual care in improving and sustaining A1c improvements.Research Design and MethodsA multi-site cluster randomized pragmatic trial examining implementation in clinical practice of diabetes SMAs in five Veterans Affairs (VA) health systems was conducted from 2016 to 2020 among 1537 adults with type 2 diabetes and elevated A1cs. Eligible patients were randomly assigned to either: (1) invitation to participate in a series of SMAs totaling 8–9 h; or (2) continuation of usual care. Relative change in A1c (primary outcome) and in systolic blood pressure, insulin starts, statin starts, and anti-hypertensive medication classes (secondary outcomes) were measured as part of usual clinical care at baseline, at 6 months and at 12 months (~7 months after conclusion of the final SMA in four of five sites). We examined outcomes in three samples of SMA participants: all those scheduled for a SMA, those attending at least one SMA, and those attending at least half of SMAs.ResultsBaseline mean A1c was 9.0%. Participants scheduled for an SMA achieved A1c reductions 0.35% points greater than the control group between baseline and 6-months follow up (p = .001). Those who attended at least one SMA achieved reductions 0.42 % points greater (p < .001), and those who attended at least half of scheduled SMAs achieved reductions 0.53 % points greater (p < .001) than the control group. At 12-month follow-up, the three SMA analysis samples achieved reductions from baseline ranging from 0.16 % points (p = 0.12) to 0.29 % points (p = .06) greater than the control group.ConclusionsDiabetes SMAs as implemented in real-life diverse clinical practices improve glycemic control more than usual care immediately after the SMAs, but relative gains are not maintained. Our findings suggest the need for further study of whether a longer term SMA model or other follow-up strategies would sustain relative clinical improvements associated with this intervention.Trial RegistrationClinicalTrials.gov ID NCT02132676

Highlights

Health burdens and costs of type 2 diabetes mellitus (T2DM)—a leading cause of morbidity and mortality—continue to soar
From May 2016 to May 2018, we identified from electronic health records (EHR) patients who had (1) two outpatient visits or one hospitalization with a diabetes-related ICD-10 code in the prior 12 months; or (2) at least one prescription for a glucose control medication; and (3) an A1c ≥ 7.5% if age < 70 or ≥ 8.0% if age 70+ years within 6 months prior to enrollment
Participants were more likely than non-participants to be nonwhite, have higher levels of education, report poorer health, 6,401 PaƟents IdenƟfied as Eligible for shared medical appointments (SMAs) through EHR Data

Summary

Introduction

Health burdens and costs of type 2 diabetes mellitus (T2DM)—a leading cause of morbidity and mortality—continue to soar. One of three US adults without diabetes at age 45 is projected to develop T2DM.[1] Success of diabetes treatments depends on patients’ initiating and sustaining key behaviors—taking medications, eating healthily, being physically active, self-monitoring. Many patients need self-management support.[2,3] Health systems seek models to improve diabetes self-management support and clinical management that are more low-cost and scalable than offering frequent one-on-one visits with providers. One potentially effective and efficient model for providing integrated medical care and self-management support is diabetes shared medical appointments (SMAs). SMAs bring groups of patients together with an interdisciplinary team of providers for a series of 60–120-min sessions. Session leaders encourage participants to set behavioral goals and steps to meet these goals (“action planning”),[4] discuss key areas of JGIM

Results

Discussion

Conclusion