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IIR 03-084 – HSR&D Study

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IIR 03-084
Can Group Visits Improve Outcomes of Veterans with Diabetes
David Edelman MD MHS
Durham VA Medical Center, Durham, NC
Durham, NC
Funding Period: December 2005 - January 2009

BACKGROUND/RATIONALE:
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.

OBJECTIVE(S):
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.

METHODS:
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.

FINDINGS/RESULTS:
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:

%overall
visits %attend % missed %missed
attended all visits 1 visit all visits Other
Site
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).

IMPACT:
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.

PUBLICATIONS:

Journal Articles

  1. Coffman CJ, Edelman D, Woolson RF. To condition or not condition? Analysing 'change' in longitudinal randomised controlled trials. BMJ open. 2016 Dec 30; 6(12):e013096.
  2. Edelman D, Dolor RJ, Coffman CJ, Pereira KC, Granger BB, Lindquist JH, Neary AM, Harris AJ, Bosworth HB. Nurse-led behavioral management of diabetes and hypertension in community practices: a randomized trial. Journal of general internal medicine. 2015 May 1; 30(5):626-33.
  3. Edelman D, Gierisch JM, McDuffie JR, Oddone E, Williams JW. Shared medical appointments for patients with diabetes mellitus: a systematic review. Journal of general internal medicine. 2015 Jan 1; 30(1):99-106.
  4. Crowley MJ, Melnyk SD, Ostroff JL, Fredrickson SK, Jeffreys AS, Coffman CJ, Edelman D. Can group medical clinics improve lipid management in diabetes? The American journal of medicine. 2014 Feb 1; 127(2):145-51.
  5. Crowley MJ, Melnyk SD, Coffman CJ, Jeffreys AS, Edelman D. Impact of baseline insulin regimen on glycemic response to a group medical clinic intervention. Diabetes Care. 2013 Jul 1; 36(7):1954-60.
  6. Edelman D, Fredrickson SK, Melnyk SD, Coffman CJ, Jeffreys AS, Datta S, Jackson GL, Harris AC, Hamilton NS, Stewart H, Stein J, Weinberger M. Medical clinics versus usual care for patients with both diabetes and hypertension: a randomized trial. Annals of internal medicine. 2010 Jun 1; 152(11):689-96.
Journal Other

  1. Jackson GL, Edelman D, Olsen MK, Smith VA, Maciejewski ML. Benefits of participation in diabetes group visits after trial completion. JAMA internal medicine. 2013 Apr 8; 173(7):590-2.
Conference Presentations

  1. Jackson GL, Bosworth HB, Powers BJ, Maciejewski ML, Edelman D. Do the Economic Benefits of Participation in Disease Management Trials Persist After Trial Completion? Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA.
  2. Jackson GL, Olsen MK, Smith V, Edelman D, Bosworth HB, Powers BJ, Kaufman M, Maciejewski ML. Do the Economic Benefits of Participation in a Diabetes Group Visits Trial Persist After Trial Completion? Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.
  3. Smith V, Maciejewski ML, Jackson GL, Edelman D, Olsen MK. A comparison of longitudinal cost modeling techniques. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; National Harbor, MD.
  4. Datta SK, Coffman CJ, Jeffreys AL, Weinberger M, Edelman D. Effectiveness, Intervention Cost, and Health Care Utilization Associated with Group Medical Visits for Diabetes and Hypertension: A Randomized Controlled Trial. Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA.
  5. Edelman D, Datta SK, Coffman CJ, Jeffreys AL, Weinberger M. Cost and Utilization Associated with Group Medical Clinics for Diabetes and Hypertension. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN.
  6. Edelman D, Fredrickson SK, Melnyk SD, Coffman CJ, Jeffreys AL, Jackson GL, Harris AC, Weinberger M. Effectiveness of Group Medical Clinics in Diabetes and Hypertension: A Two-Site Randomized Controlled Trial. Paper presented at: Society of General Internal Medicine Annual Meeting; 2009 May 2; Miami, FL.
  7. Fredrickson S, Coffman CJ, Weinberger M, Jeffreys AL, Jackson GL, Melnyk SD, Harris AC, Edelman D. Group Medical Visits Improve Lipid Profiles in Patients with Diabetes and Hypertension. Paper presented at: Society of General Internal Medicine Annual Meeting; 2009 May 1; Miami, FL.
  8. Edelman D, Fredrickson SK, Melnyk SD, Coffman CJ, Jeffreys AL, Jackson GL, Harris AC, Weinberger M. Effectiveness of Group Medical Clinics in Diabetes and Hypertension: A Two-Site Randomized Controlled Trial. Paper presented at: VA HSR&D National Meeting; 2009 Feb 14; Baltimore, MD.
  9. Jackson, Fredrickson, Weinberger, Jeffreys, Coffman, Melnyk, Harris, Stewart, Hamilton, Edelman. Relationship between Distance to VA Hospitals and Patient Body Mass Index. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 10; Washington, DC.
  10. Jackson GL, Weinberger M, Hamilton N, Edelman D. Racial and socioeconomic differences in diabetes care experiences. Paper presented at: AcademyHealth Annual Research Meeting; 2007 Jun 7; Orlando, FL.
  11. Jackson GL, Edelman D, Weinberger M. Prevalence of refractory hypertension among primary care patients with diabetes. Paper presented at: Society of General Internal Medicine Annual Meeting; 2007 Apr 7; Toronto, Canada.
  12. Jackson GL, Weinberger M, Yano EM, Murawsky J, Velez R, Grambow S, Hamilton N, Edelman D. Association between structure of primary care and diabetes outcomes. Paper presented at: VA Career Development Award Program Annual Conference; 2007 Feb 14; Arlington, VA.
  13. Jackson GL, Weinberger M, Grambow S, Edelman D. Evaluation of the Chronic Illness Care System for patients with diabetes. Paper presented at: VA HSR&D National Meeting; 2006 Oct 10; Durham, NC.
  14. Bosworth HB, Allen KD, Edelman D, Oddone EZ. Self-Management Interventions for Patients with Chronic Illness. Paper presented at: VA HSR&D National Meeting; 2006 Feb 15; Arlington, VA.


DRA: Health Systems
DRE: Prevention
Keywords: Diabetes, Outpatient, Primary care
MeSH Terms: none

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