Therapeutics
Review: In type 1 or type 2 diabetes, group medical visits improve HbA1c levels compared with usual care
Housden L, Wong ST, Dawes M. Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis. CMAJ. 2013;185:E635-44.
Clinical impact ratings: F ★★★★★★✩ e ★★★★★★✩ Question
Conclusions
In patients with type 1 or type 2 diabetes, do group medical visits improve biophysical and patient-reported outcomes compared with usual care?
In patients with type 1 or 2 diabetes, group medical visits reduce hemoglobin A1c levels compared with usual care. Group visits do not improve other cardiovascular risk factors.
Review scope
*Information provided by author.
Included studies evaluated group medical visits in patients 16 to 80 years of age with type 1 or type 2 diabetes. Exclusion criteria were educational interventions or lack of a health care provider who could order tests, diagnose, make referrals, and prescribe medication. Reported outcomes included hemoglobin (Hb) A1c level, blood pressure, body mass index, weight, cholesterol levels, triglyceride level, and quality of life.
Review methods MEDLINE, EMBASE/Excerpta Medica, CINAHL, Biosis, Web of Science, PsycINFO, ProQuest Dissertations and Theses, and Cochrane Database of Systematic Reviews to Feb 2012; gray literature; and reference lists were searched for randomized controlled trials (RCTs) or observational studies published in English or with an English-language translation. 26 studies ({n = 5817}*; 56% men and mean age 59 y where reported) met the selection criteria: 13 RCTs ({n = 2319}*, median study duration 12 mo) and 13 observational studies {n = 3498}*. Only the RCTs were included in the meta-analyses and are reported in this abstract. 4 RCTs had low risk for bias in allocation concealment, 4 in blinding of patients and clinicians, 1 in blinding of outcome assessors, and 6 in completeness of outcome data.
Main results Meta-analysis showed that group medical visits improved HbA1c levels compared with usual care; group medical visits and usual care did not differ for other cardiovascular risk factors or quality of life (Table). Group medical visits vs usual care in patients with type 1 or type 2 diabetes† Outcomes
Number of trials (n)
HbA1c, %
Weighted mean difference (95% CI)‡
10 (1854)
−0.46 (−0.80 to −0.12)
Systolic blood pressure, mm Hg
5 (797)
−2.81 (−6.84 to 1.21)
Diastolic blood pressure, mm Hg
4 (709)
−1.02 (−2.71 to 0.67)
Body mass index
4 (497)
0.05 (−0.90 to 1.00)
Weight, kg
3 (288)
−0.50 (−3.87 to 2.88)
Total cholesterol, mmol/L
3 (288)
0.04 (−0.21 to 0.30)
HDL cholesterol, mmol/L
3 (288)
0.01 (−0.07 to 0.10)
Triglycerides, mmol/L
3 (288)
−0.01 (−0.41 to 0.38)
Diabetes Quality of Life Questionnaire
2 (142§)
−29 (−61 to 2.05)
†Hb = hemoglobin; HDL = high-density lipoprotein; CI defined in Glossary. ‡Differences < 0 indicate benefit with group medical visits. §Data provided by author.
JC6
© 2014 American College of Physicians
Source of funding: No external funding. For correspondence: L. Housden, University of British Columbia, Vancouver, BC, Canada. E-mail [email protected]. ■
Commentary 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 (1). 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. Marianne Sumego, MD David L. Bronson, MD, MACP Cleveland Clinic Cleveland, Ohio. USA Reference 1. Noffsinger EB. Group visits for efficient, high-quality chronic disease management. Group Practice Journal 2008;Feb:23-40. www.ma-ri-hfma.org/ edudocs/June%2026,%202009%20Meeting%20Handouts/Noffsigner%20%20Shared%20Medical%20Appointments%20-%202.pdf (accessed 11 Dec 2013). 18 February 2014 | ACP Journal Club | Volume 160 • Number 4
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/929769/ by a Uppsala Universitetsbibliotek User on 07/09/2017
Review: In type 1 or type 2 diabetes, group medical visits improve HbA1c levels compared with usual care
Housden L, Wong ST, Dawes M. Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis. CMAJ. 2013;185:E635-44.
Clinical impact ratings: F ★★★★★★✩ e ★★★★★★✩ Question
Conclusions
In patients with type 1 or type 2 diabetes, do group medical visits improve biophysical and patient-reported outcomes compared with usual care?
In patients with type 1 or 2 diabetes, group medical visits reduce hemoglobin A1c levels compared with usual care. Group visits do not improve other cardiovascular risk factors.
Review scope
*Information provided by author.
Included studies evaluated group medical visits in patients 16 to 80 years of age with type 1 or type 2 diabetes. Exclusion criteria were educational interventions or lack of a health care provider who could order tests, diagnose, make referrals, and prescribe medication. Reported outcomes included hemoglobin (Hb) A1c level, blood pressure, body mass index, weight, cholesterol levels, triglyceride level, and quality of life.
Review methods MEDLINE, EMBASE/Excerpta Medica, CINAHL, Biosis, Web of Science, PsycINFO, ProQuest Dissertations and Theses, and Cochrane Database of Systematic Reviews to Feb 2012; gray literature; and reference lists were searched for randomized controlled trials (RCTs) or observational studies published in English or with an English-language translation. 26 studies ({n = 5817}*; 56% men and mean age 59 y where reported) met the selection criteria: 13 RCTs ({n = 2319}*, median study duration 12 mo) and 13 observational studies {n = 3498}*. Only the RCTs were included in the meta-analyses and are reported in this abstract. 4 RCTs had low risk for bias in allocation concealment, 4 in blinding of patients and clinicians, 1 in blinding of outcome assessors, and 6 in completeness of outcome data.
Main results Meta-analysis showed that group medical visits improved HbA1c levels compared with usual care; group medical visits and usual care did not differ for other cardiovascular risk factors or quality of life (Table). Group medical visits vs usual care in patients with type 1 or type 2 diabetes† Outcomes
Number of trials (n)
HbA1c, %
Weighted mean difference (95% CI)‡
10 (1854)
−0.46 (−0.80 to −0.12)
Systolic blood pressure, mm Hg
5 (797)
−2.81 (−6.84 to 1.21)
Diastolic blood pressure, mm Hg
4 (709)
−1.02 (−2.71 to 0.67)
Body mass index
4 (497)
0.05 (−0.90 to 1.00)
Weight, kg
3 (288)
−0.50 (−3.87 to 2.88)
Total cholesterol, mmol/L
3 (288)
0.04 (−0.21 to 0.30)
HDL cholesterol, mmol/L
3 (288)
0.01 (−0.07 to 0.10)
Triglycerides, mmol/L
3 (288)
−0.01 (−0.41 to 0.38)
Diabetes Quality of Life Questionnaire
2 (142§)
−29 (−61 to 2.05)
†Hb = hemoglobin; HDL = high-density lipoprotein; CI defined in Glossary. ‡Differences < 0 indicate benefit with group medical visits. §Data provided by author.
JC6
© 2014 American College of Physicians
Source of funding: No external funding. For correspondence: L. Housden, University of British Columbia, Vancouver, BC, Canada. E-mail [email protected]. ■
Commentary 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 (1). 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. Marianne Sumego, MD David L. Bronson, MD, MACP Cleveland Clinic Cleveland, Ohio. USA Reference 1. Noffsinger EB. Group visits for efficient, high-quality chronic disease management. Group Practice Journal 2008;Feb:23-40. www.ma-ri-hfma.org/ edudocs/June%2026,%202009%20Meeting%20Handouts/Noffsigner%20%20Shared%20Medical%20Appointments%20-%202.pdf (accessed 11 Dec 2013). 18 February 2014 | ACP Journal Club | Volume 160 • Number 4
Downloaded From: https://annals.org/pdfaccess.ashx?url=/data/journals/aim/929769/ by a Uppsala Universitetsbibliotek User on 07/09/2017
