Examining Group Office Visits for Diabetes Management

In this randomized trial, "Medical Clinics Versus Usual Care for Patients With Both Diabetes and Hypertension," conducted in two Veterans Administration clinics, 239 patients with poorly controlled hyperglycemia (A1c > 7.5%) and blood pressure (systolic > 140 mm Hg or diastolic > 90 mm Hg) were assigned to attend either a group medical clinic or receive usual care (n = 133). The group medical clinic conducted a structured group interaction, with 7 or 8 patients, a general internist, a pharmacist, and a nurse or certified diabetes educator. The pharmacist and physician adjusted medications to manage A1c and blood pressure. Sessions lasted 90-120 minutes, and the groups met every 2 months for a total of 7 visits over 12 months. The primary analyses compared mean A1c and systolic blood pressure at the end of the study. The researchers also compared the proportion of patients who achieved A1c ≤ 7% and blood pressure < 130/80 mm Hg, as well as emergency care visits, primary care visits, and hospitalizations during the study. Costs of the intervention were also calculated.

Mean patient age of the study groups was 62 years; 96% of participants were men. Mean baseline values were 9.2% for A1c and 153 mm Hg for systolic blood pressure. At the end of the study, systolic blood pressure had improved by 13.7 mm Hg in the group medical care patients and by 6.4 mm Hg in the usual care patients (P = .011). Mean A1c improved by 0.8% and 0.5%, respectively (P = .159). Similarly, 22% of patients receiving group medical care and 12% of those receiving usual care achieved blood pressure control (odds ratio, 2.0; 95% confidence interval [CI], 1.0-4.2), but the proportion who achieved glycemic control did not differ. Group medical care patients had fewer emergency visits (0.9 vs 1.3 per patient-year; P < .001) and fewer primary care visits (5.3 vs 6.2; P = .010), and were less likely to be hospitalized (odds ratio, 0.8; 95% CI, 0.4-1.4). The cost of the intervention was approximately $500 per patient.

The equivocal results, coupled with the sex bias of participants (96% men) and their relatively poor blood pressure and glycemic control even after the intervention, make it difficult to be enthusiastic about this study. With the growing burden of diabetes, the hope is that group visits can achieve better outcomes at a reasonable cost or equal outcomes at a lower cost than the typical one-on-one visit, but neither seems to be the case here. A favorable effect on blood pressure was noted, but the additional reduction of 7.3 mm Hg was not sufficient to bring most patients into control; 78% remained above the goal of < 130/80 mm Hg. Whether the difference is sustainable or sufficient to affect cardiovascular risk cannot be determined without long-term follow-up. Although the present study was unable to influence glycemic control, previous studies conducted in more general populations have found that group visits improved A1c. Thus, it may well be that the current study was conducted in a particularly difficult population segment Furthermore, the relatively low cost of the intervention is encouraging, although it was not clear that all costs were fully accounted for. The reduction in healthcare utilization seen in this and other studies^.suggests that group visits still hold promise, at least in integrated delivery systems that can implement them.

From the results it was concluded that group medical clinics are a potent strategy for improving blood pressure but not A1c levels in diabetic patients.

Ann Intern Med. 2010 Jun 1;152(11):745-6.

Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care.1999;22:2011-2017. Abstract

Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Diabetes Care. 2001;25:695-700.