Research: Shared medical appointments for Hispanic diabetic patients in a residency clinic

By Natalia Gutierrez-Chefchis, M.D., Nora Gimpel, M.D., Barbara Foster, Ph.D., Jay Ohagi, M.P.H., and Florence J. Dallo, Ph.D., M.P.H.

In recent years, shared medical appointments have gained attention in their ability to help patients manage chronic conditions as opposed to one-on-one patient-physician interactions. According to national data from 1999-2002, a low proportion of U.S. adults achieve the goals set forth by the American Diabetes Association (Resnick, Foster, Bardsley and Ratner, 2006). Minorities are less likely than whites to achieve the recommended goals (Saydah, Cowie, Eberhardt, De Rekeneire and Narayan, 2007).

We embarked on this study to compare the clinical effectiveness of shared medical appointments (SMA) versus standard of care (regular office visits) for Hispanic patients with diabetes in the Parkland Family Medicine Clinic in Dallas. Our specific objectives are twofold. First, we will determine whether shared medical appointments will improve glycemic control, LDL, HDL, triglycerides, blood pressure and body mass index; adherence to standards of medical care by the ADA (“Standards of medical care in diabetes—2007,” 2007); diabetes knowledge; and quality of life and satisfaction. Second, we will evaluate whether or not acculturation level is associated with glycemic control and body mass index among patients with diabetes.

METHODS

Sample: Hispanic diabetic patients 18 years of age or older with HbA1c > 7 percent were invited to participate by mail. We also received referrals from all residents, faculty and clinic staff. After we determined eligibility status, patients were consented and randomized to either intervention (SMA) or control (regular office visits). We continued this process up to three months prior to the study ending.

Procedure: The group visits were conducted by the resident/fellow researcher, a faculty member, pharmacist, lead nurse, medical assistant, registration clerk and social worker. The SMA were conducted in Spanish every other week in the waiting room of one of the clinics. After each session all the patients completed a patient satisfaction survey.

The control patients continued attending their regular office visits with their primary care providers. Their medical records were reviewed after each visit to document their blood pressure, weight, height, smoking status, immunizations, physical exam, foot exam, eye exam by ophthalmologist, referrals, laboratory results, presence or absence of co-morbidities, use of aspirin, and use of ACE/ARB if patients had microalbuminuria. These data were collected for 17 months for both control and intervention patients.

Survey instruments: During the initial consent process, all of the patients completed the diabetes knowledge questionnaire (Garcia, Villagomez, Brown, Kouzekanani and Hanis, 2001), diabetes quality of life brief clinical inventory (DQL) (Burroughs, 2004), and short acculturation scale for Hispanics (Marin, 1987). The group visit patients completed a post intervention DQL and diabetes knowledge assessment. Data was analyzed using SAS 9.2.

Results: Between January 2008 and June 2009 we conducted 36 SMA with an average of nine patients seen in each group. Patients in the group and control groups were followed up for an average of 9.5 months. There was not a statistically significant difference between intervention and control patients at baseline.

The group visits demonstrated a 1.19 percent (SD = 1.66, p < 0.05) decrease in HbA1c, while it was 0.67 percent (SD = 2.00, p < 0.05) for the control patients. The patients in the shared medical appointments showed an average decrease of 5.60 mm Hg (SD = 15.30, p < 0.05) in systolic blood pressure. Mean body mass index increased by 0.64 (SD = 2.32, p < 0.05) for the control group.

Adherence to the American Diabetes Association standards of care guidelines showed important improvements, especially in the shared medical appointment group. The proportion of individuals in the shared medical appointments who obtained a complete lipid measurement (92 percent to 100 percent), annual physical exam (96 percent to 100 percent), foot exam (68 percent to 94 percent), eye exam (64 percent to 92 percent), used aspirin (58 percent to 96 percent), and had the pneumovax vaccine (80 percent to 98 percent) statistically significantly increased from pre- to post-intervention (p < 0.05). For the control group, we observed a statistically significant decrease in flu shots (94 percent to 90 percent) and foot exams (84 percent to 61 percent) from pre- to post-study.

In the intervention group the DQL increased five points (from 53 to 58, p < 0.0001) and the diabetes knowledge score rose by 1.5 points (from 14 to 15.5, p = 0.0011). Patient satisfaction was high among group visits, 3.5 over 4 in a likert scale.

Acculturation status had a positive correlation with body mass index both prior to and after the intervention (r = 0.31, p = 0.002), but a negative correlation with diabetes quality of life (r = -0.22, p = 0.02). Among shared medical appointment patients and post-intervention, body mass index showed a negative correlation with diabetes quality of life (r = -0.32, p = 0.02), but body mass index was positively correlated with acculturation (r = 0.39, p = 0.004).

The correlation between diabetes quality of life and HbA1c was statistically significant (p = 0.05) but was only r = -0.28.

DISCUSSION

The findings from our study suggest that group visits offer an effective and efficient opportunity to increase quality of diabetes care through education and support. More specifically, we demonstrated that shared medical appointments improved HbA1c and systolic blood pressure levels, maintained body mass index, increased knowledge and quality of life and enhanced adherence to the ADA’s standards of care. Furthermore, although we did not find a direct correlation between diabetes control and acculturation, patients who were more acculturated had higher body mass index and lower diabetes quality of life scores.

STRENGTHS

This is the first randomized controlled trial that evaluates shared medical appointments in an exclusive Hispanic diabetic population. Because our study was a randomized controlled trial, we were able to control for extraneous factors that may have influenced our results by randomizing our patients to intervention versus control group.

LIMITATIONS

Recruitment was complicated due to the schedule of the resident/fellow researcher. It was not possible to do all the recruitment at the beginning of the study and then follow the totality of the patients; instead we had to continue recruitment during the study period.

Half of the control patients attended regular office visits with the pharmacist. This could have had a greater impact on their diabetes control than seeing the resident physician alone. When patients come for clinic visits with the physicians they usually have multiple issues to be addressed, but when they see the pharmacist it is exclusively for diabetes management, giving the pharmacist more time to educate the patient, address barriers and improve diabetes control.

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Sources of support: Department of Family and Community Medicine, University of Texas Southwestern Medical School, Parkland Family Medicine Clinic, Texas Academy of Family Physicians Foundation, and Care Project supported by HRSA.

Acknowledgements: Drs. Madelyn Pollock, Amer Shakil and Alison Dobbie, Margaret Shin, Pharm-D, Tiffany Barr, R.N.