Diabetes is a common, morbid and expensive disease among veterans. Achieving adequate glycemic control and blood pressure control can reduce the devastating complications of diabetes. Because the majority of patients do not achieve adequate control of blood sugar and blood pressure, innovative strategies to improve control are needed.One strategy with great potential for veterans receiving VA care is the group clinic. Group clinics have been developed over the last 5-10 years, and have been shown to improve clinical outcomes and reduce outpatient utilization in geriatric settings. Group medical clinics involve a cohort of 8-20 patients who have 1-2 hour group visits. These clinics are distinguished from traditional group education visits for diabetes by the fact that these visits involve one physician and one or more additional health care professionals, usually a nurse practitioner and/or a pharmacist, and are designed to make management changes for a number of people with the same disease in a short period of time. The effect of group medical clinics on blood sugar, blood pressure, and the cost of diabetes care, is unknown.
Our primary objectives in this project were to determine the effectiveness and cost-effectiveness of a group visit intervention in improving rates of control of diabetes and high blood pressure in patients with both illnesses.
We performed a two-site, randomized, controlled trial of group medical visits for diabetes management. Patients were patients in primary care at the Durham or Richmond VAMC's who had inadequate control of both their blood sugar and their blood pressure. We excluded patients with life-limiting illness. Patients randomized to the control arm received usual primary care. Patients randomized to the intervention arm were assigned to attend a group medical clinic every two months for one year. In the clinic, a primary care physician, with the assistance of a nurse and a pharmacist, measured blood pressure at the point of care, reviewed blood sugar logs, and then made all necessary medical changes for patients with diabetes. The primary outcomes were hemoglobin A1c and systolic blood pressure. Additional outcomes will be serum LDL-cholesterol, diabetes-specific quality of life, and health services utilization. Formative evaluation wasundertaken to determine the mechanism of the intervention and to prepare for more successful dissemination if the intervention is effective. Formal cost analysis will be performed and cost-effectiveness analysis will be undertaken. All outcomes were measured at baseline, and 6 and 12 months after the beginning of the intervention.
Because this is a blinded clinical trial, no interim analyses will be performed; primary analyses will be performed at the end of follow-up in late 2008.
Baseline characteristics of the 239 enrolled patients: mean age 62, 95% male, 60% African-American. Mean HbA1c at baseline 9.2%, mean blood pressure 152/83, mean BMI 33.9 kg/m2.
Attendance at the group intervention:
visits %attend % missed %missed
attended all visits 1 visit all visits Other
Durham 76% 38% 36% 11% 16%
Richmond 85% 62% 22% 0% 16%
Overall 81% 50% 29% 5% 16%
After adjusting for clustering, mean SBP at the end of the study was 7.3 mmHg lower in the GMC arm than in the control arm (p=0.01). After adjustment, mean A1c at the end of the study was 0.3% lower in the GMC arm (p=0.17). There was no difference between arms in adverse events except for lower rates of lightheadedness in the GMC arm (0.3 fewer events per person-year, p=0.002).
GMCs are a potent strategy for improving blood pressure in patients with diabetes. They are not significantly better than usual care in improving glycemic control in this population with well-established primary care.
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Diabetes, Outpatient, Primary care