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Shared Medical Appointments for Patients with Diabetes Mellitus: A Systematic Review

A Capsule Commentary to this article was published on 07 October 2014

ABSTRACT

OBJECTIVES

Shared medical appointments (SMAs) are an increasingly used system-redesign strategy for improving access to and quality of chronic illness care. We conducted a systematic review of the existing literature on SMA interventions for patients with diabetes in order to understand their impact on outcomes.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from January 1996 through April 2012. PubMed search updated June 2013.

STUDY SELECTION

English-language peer-reviewed publications of randomized controlled trials (RCTs), nonrandomized cluster controlled trials, controlled before-and-after studies, or interrupted time-series designs conducted among adult patients with diabetes. Two independent reviewers used prespecified criteria to screen titles and abstracts for full text review.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two different reviewers abstracted data and rated study quality and strength of evidence. When possible, we used random-effects models to synthesize the effects quantitatively, reporting by a weighted difference of the means when the same scale was used across studies, and a standardized mean difference when the scales differed. We measured heterogeneity in study effects using Forest Plots, Cochran’s Q, and I2, and explored heterogeneity by using subgroup analyses for categorical variables and meta-regression analyses for continuous or discrete variables. Outcomes not suitable to meta-analysis were summarized qualitatively.

RESULTS

Twenty-five articles representing 17 unique studies compared SMA interventions with usual care. Among patients with diabetes, SMAs improved hemoglobin A1c (∆ = −0.55 percentage points [95 % CI, −0.11 to −0.99]); improved systolic blood pressure (∆ = −5.2 mmHg [95 % CI, −3.0 to −7.4]); and did not improve LDL cholesterol (∆ = −6.6 mg/dl [95 % CI, 2.8 to −16.1]). Nonbiophysical outcomes, including economic outcomes, were reported too infrequently to meta-analyze, or to draw conclusions from. The A1c result had significant heterogeneity among studies, likely secondary to the heterogeneity among included SMA interventions.

LIMITATION

Heterogeneity among the components of diabetes SMAs leads to uncertainty about what makes a particular SMA successful.

CONCLUSION

SMA interventions improve biophysical outcomes among patients with diabetes. There was inadequate literature to determine SMA effects on patient experience, utilization, and costs.

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Acknowledgements

The authors thank Connie Schardt, MLS, for help with the literature search and retrieval, Avishek Nagi, MS, for organizational support, and Liz Wing, MA, for editorial assistance.

Conflict of Interest

No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report.

Financial Support

U.S. Veterans Affairs Office of Research and Development, Quality Enhancement Research Initiative (VA-ESP Project 09-010;2012). The sponsor chose the topic and guided the key questions for the review, and provided access to peer review and edits for the original VA Evidence Report, but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of this manuscript; and decision to submit the manuscript for publication.

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Correspondence to David Edelman MD.

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Edelman, D., Gierisch, J.M., McDuffie, J.R. et al. Shared Medical Appointments for Patients with Diabetes Mellitus: A Systematic Review. J GEN INTERN MED 30, 99–106 (2015). https://doi.org/10.1007/s11606-014-2978-7

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KEY WORDS

  • shared medical appointments
  • diabetes
  • chronic illness care