Review: In type 1 or type 2 diabetes, group medical visits improve HbA1c levels compared with usual care

A meta-analysis of 13 randomized, controlled trials of adults with type 1 or type 2 diabetes found that group medical visits improved HbA1c levels but not the other factors studied, which included blood pressure, body mass index, weight, cholesterol, triglycerides, and quality of life.

The study was published in CMAJ on Sept. 17, 2013. The following commentary by Marianne Sumego, MD, and David L. Bronson, MD, MACP, was published in the ACP Journal Club section of the Feb. 18 Annals of Internal Medicine.

The growing burden of chronic disease management, insufficient numbers of clinicians, suboptimal outcomes, and the need to provide increased patient access are generating a second look at shared medical appointments (SMAs). Early adopters have cited improved access, increased productivity, and education as benefits of the SMA care model. SMAs are set apart from usual care by the addition of a facilitator to address factors influencing patient care, such as understanding the disease, compliance, and lifestyle changes. SMAs are medical visits and differ from group therapy visits where the focus is providing therapy.

The conclusion of Housden and colleagues that SMAs improve HbA1c levels is both intuitive and substantiated by the studies included in their review. However, the nonstandardized nature of SMAs between studies needs to be considered when outcome data are being evaluated. Variations in targeted patient populations, resources added to SMAs, and length of appointments can make evaluating the benefits challenging. In addition, predetermined visit goals would change the focus and potentially the outcomes affected by SMAs. Interestingly, the duration of treatment, but not the frequency of SMA visits, may be associated with greater reduction of HbA1c levels.

Larger studies over a longer duration are needed to detect important changes in long-term micro- and macrovascular outcomes. In addition, studies are needed to identify the best SMA structure and characteristics of patients most likely to benefit.

The complexity of managing such diseases as diabetes and multiple health care needs and the projected decrease in available physicians requires us to consider innovative, high-quality management approaches. Learning more about how SMAs affect patient care and which patients may benefit most will guide the future role of SMAs. The less tangible benefits of peer support, understanding, and patient engagement may be more difficult to quantify but are critical to patient care.