Objective: The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20) are seen by a multi-disciplinary team in a 1-2 h appointment. Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this quality improvement project was to improve intermediate outcome measures for diabetes (A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk. Setting: Primary care clinic at a tertiary care academic medical center. Subjects: Patients with diabetes with one or more of the following: A1c .9%, SBP blood pressure .160 mm Hg and LDL-c .130 mg/dl were targeted for potential participation; other patients were referred by their primary care providers. Patients participated in at least one SMA from 4/05 to 9/05. Study design: Quasi-experimental with concurrent, but non-randomised controls (patients who participated in SMAs from 5/06 through 8/06; a retrospective period of observation prior to their SMA participation was used). Intervention: SMA system redesign Analytical methods: Paired and independent t tests, x 2 tests and Fisher Exact tests. Results: Each group had up to 8 patients. Patients participated in 1-7 visits. At the initial visit, 83.3% had A1c levels .9%, 30.6% had LDL-cholesterol levels .130 mg/dl, and 34.1% had SBP >160 mm Hg. Levels of A1c, LDL-c and SBP all fell significantly postintervention with a mean (95% CI) decrease of A1c 1.4 (0.8, 2.1) (p,0.001), LDL-c 14.8 (2.3, 27.4) (p = 0.022) and SBP 16.0 (9.7, 22.3) (p,0.001). There were no significant differences at baseline between control and intervention groups in terms of age, baseline intermediate outcomes, or medication use. The reductions in A1c in % and SBP were greater in the intervention group relative to the control group: 1.44 vs -0.30 (p = 0.002) for A1c and 14.83 vs 2.54 mm Hg (p = 0.04) for SBP. LDL-c reduction was also greater in the intervention group, 16.0 vs 5.37 mg/dl, but the difference was not statistically significant (p = 0.29). Conclusions: We were able to initiate a programme of group visits in which participants achieved benefits in terms of cardiovascular risk reduction. Some barriers needed to be addressed, and the operations of SMAs evolved over time. Shared medical appointments for diabetes constitute a practical system redesign that may help to improve quality of care.

With the increasing numbers of patients with chronic illnesses, healthcare systems are increasingly challenged to provide necessary care and empower patients to participate in that care. NPs can play a key role in helping to meet these challenges.

Most patients and providers were satisfied with the services provided by the pharmacist-managed lipid clinic. The clinic helped improve patients' LDL cholesterol, total cholesterol, and triglyceride levels.

Purpose To assess the impact on glycemic control (A1c, %) in a primary care urban Veterans Affairs (VA) shared medical appointments (SMAs). Data sources A retrospective pretest/posttest study included all patients who had attended ≥1 SMA from 4/06 to 12/10. A1cs 810 days pre‐ and postinitial SMA were obtained from 90‐day time periods. A1c levels were averaged within patient in these 90‐day intervals and data were aggregated based upon corresponding time intervals. Conclusions Of 1290 individuals seen in SMAs, 1288 (99.8%) had ≥1 A1c levels and 1170 (90.7%) individuals had ≥1 level collected both before and after attendance. The sample was predominantly (96%) male and middle aged or older (mean [±1 SD] age of 62.6 + 9.09 years) with a mean Diabetes Severity Index 3.01 (2.34). There were significant A1c reductions (∼1%) in A1c overall (n = 1170) and for patients with ≥1 measurement in the 180‐day periods preceding and following their first SMA appointment (n = 815). Linear regression analysis showed a significant (p < .001) pre‐SMA positive trend (r2 = 0.90). Implications for practice Limitations notwithstanding (single site and design lacking a control group), the large number of patients demonstrates SMA clinical effectiveness in improving A1c for high‐risk patients with diabetes.

F r o m r e s e a r c h t o P r a c t i c e / s h a r e d m e d i c a l a P P o i n t m e n t s i n d i a b e t e s c a r e In BriefDiabetes educators have valued and unique skills in the art and science of diabetes management that are beneficial in the delivery of shared medical appointments (SMAs). These contributions augment and expand the medical model of intervention in chronic disease because psychosocial concerns and behavior change are integral to successful outcomes. This article reflects on lessons learned from a multidisciplinary team of diabetes health care professionals with a strong diabetes education background who have been delivering comprehensive diabetes care for more than 6 years in an SMA model.