A study in California highlights the importance of addressing cultural and structural barriers in implementing shared medical appointments.
While diabetes care has steadily improved over the years, room for further improvement still exists. An estimated 33%-49% of patients do not meet guideline-recommended goals for A1C, blood pressure (BP), and low-density lipoproteins (LDL). Research has shown that the uninsured and people of lower socioeconomic status suffer disproportionately from diabetes, leaving the question of how to serve this population best. In the development of a solution to address this disparity, clinicians must develop a model that addresses the structural barriers that prevent these patients from receiving optimal care. Structural barriers include lack of insurance, transportation, racism, and lack of language-concordant providers. Shared medical appointments (SMAs) are a method of providing diabetes education and self-management techniques to patients in a group setting that incorporates collaboration between patient and provider, group activities, and enhanced education beyond what an individual medical appointment would provide.
In a study conducted by researchers at the University of California San Francisco School of Nursing, SMAs were tailored to the Latino population prevalent in northern California rural communities. Before this study, research on SMAs has excluded monolingual Spanish-speaking populations, excluding a population disproportionately affected by diabetes. This study aimed to determine the effectiveness of ALDEA (Latinos con Diabetes en Accion), a Latino-specific, culturally-adaptive SMA, in lowering A1C in type 2 diabetes patients over six months in comparison to usual primary Care (UPC). To accomplish this, two Federally Qualified Health Centers (FQHCs) were selected to participate in the study. Patients were referred by their medical providers or recruited by advertisement to participate in the non-randomized prospective study. UPC included quarterly individual visits averaging 20 minutes with the patient’s primary care provider. In addition to A1C, BP and LDL were measured at three and six months. Instead of using continuous variables for BP and LDL, variables were dichotomized to whether or not patients met predefined goals of <140/90 mmHg for BP and <100 mg/dL for LDL. ALDEA included peer-support, formal diabetes self-management education and support (DSMES), and medical management. The ALDEA SMA model incorporates multiple measures to ensure patients can participate, including open enrollment, flexible late policy, and lack of a specific curriculum. The FQHCs were allowed to differ in their health team members, with site one having a nurse practitioner as the lead clinician and site two having a physician. Additionally, the FQHCs differed in the frequency of the SMAs, with site one being weekly and site two being bi-monthly with an education group on the off weeks.
Multiple regression analysis comparing SMA to UPC showed that the SMA group achieved a significant reduction of A1C at three months (F(3,82)=14.7, P=0.00) and also at six months (F(3,98)=11.5, P=0.00). The analysis also showed a -0.71% (P=0.03) change in A1C at three months and -0.80% (P=0.02) change at six months in the SMA group compared to the UPC group. No statistically significant change was observed in the outcome of either BP or LDL compared to the groups. No significant difference was seen in comparing the results of the two sites for A1C at three months, but a significant difference was seen at six months in favor of site one, which was the site with weekly SMA meetings.
While the results of the study may seem modest with only a 0.80% reduction in A1C at six months, the authors of the study assert the importance of the A1C reduction by citing the United Kingdom Prospective Diabetes Study (UKPDS). It was shown in the UKPDS that a 1% A1C decrease correlated to significant reductions in macrovascular disease, microvascular complications, and risk of deaths related to diabetes with decreases of 14%, 37%, and 21%, respectively. While not necessarily unexpected, it is essential to notice the difference in A1C reduction with regards to the sites. Site one, which had weekly visits as opposed to bi-monthly at site two, had shown a more significant decrease in A1C, which will be important when determining the frequency of SMAs should they be implemented in practice. The researchers made no strong claims about the exact mechanism by which SMA improves A1C compared to UPC. They did, however, postulate that it was “likely a combination of increased access to care and intensification of treatment in synergy with psychosocial and education support” and that the ALDEA model’s language concordance was a significant factor. Overall, the study demonstrated the efficacy of an SMA model that incorporates language concordance and allows for flexibility while taking note of and addressing structural and cultural barriers in the care of diabetes patients.
- Culture-specific shared medical appointments, such as the ALDEA program, show a significant decrease in A1C compared to usual primary care.
- Shared medical appointment programs that allow for flexibility in schedules, attendance, and lateness have better patient outcomes.
- When designing a shared medical appointment program, frequency matters. This study showed a significant difference in favor of weekly versus bi-monthly meetings.
Noya, Carolina et al. “Shared Medical Appointments: An Academic-Community Partnership to Improve Care Among Adults With Type 2 Diabetes in California Central Valley Region.” The Diabetes educator vol. 46,2 (2020): 197-205. doi:10.1177/0145721720906792
David Clarke, PharmD Candidate, University of Colorado, Skaggs School of Pharmacy and Pharmaceutical Sciences