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Holtrop JS, Gurfinkel D, Nederveld A, Reedy J, Rubinson C, Kwan BM. What works in implementing shared medical appointments for patients with diabetes in primary care to enhance reach: a qualitative comparative analysis from the Invested in Diabetes study. Implement Sci Commun 2024; 5:82. [PMID: 39049078 PMCID: PMC11267890 DOI: 10.1186/s43058-024-00608-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 06/24/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Diabetes is a serious public health problem affecting 37.3 million Americans. Diabetes shared medical appointments (SMAs) are an effective strategy for providing diabetes self-management support and education in primary care. However, practices delivering SMAs experience implementation challenges. This analysis examined conditions associated with successful practice implementation of diabetes SMAs in the context of participation in a pragmatic trial. METHODS Mixed methods study using qualitative and quantitative data collected from interviews, observations, surveys, and practice-reported data, guided by the practical, robust implementation and sustainability model (PRISM). Data were analyzed using qualitative comparative analysis (QCA). Successful implementation was defined as meeting patient recruitment targets (Reach) during the study period. Participants were clinicians and staff members from 22 primary care practices in Colorado and Missouri, USA. RESULTS The first necessary condition identified from the QCA was the presence of additional resources for patients with diabetes in the practice. Within practices that had these additional resources, we found that a sufficiency condition was the presence of an effective key person to make things happen with the SMAs. A second QCA was conducted to determine conditions underlying the presence of the effective key person (often performing functions of an implementation champion), which revealed factors including low or managed employee turnover, a strong baseline practice culture, and previous experience delivering SMAs. CONCLUSIONS Identification of key factors necessary and sufficient for implementation of new care processes is important to enhance patient access to evidence-based interventions. This study suggests that practice features and resources have important implications for implementation of diabetes SMAs. There may be opportunities to support practices with SMA implementation by enabling the presence of skilled implementation champions. TRIAL REGISTRATION Registered at clinicaltrials.gov under trial ID NCT03590041, registered on July 18, 2018.
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Affiliation(s)
- Jodi Summers Holtrop
- Department of Family Medicine, University of Colorado Denver School of Medicine, 12631 E. 17th Avenue, Aurora, CO, 80045, USA.
- University of Colorado Denver School of Medicine, ACCORDS, 1890 N Revere Ct, Aurora, CO, 80045, USA.
| | - Dennis Gurfinkel
- University of Colorado Denver School of Medicine, ACCORDS, 1890 N Revere Ct, Aurora, CO, 80045, USA
| | - Andrea Nederveld
- Department of Family Medicine, University of Colorado Denver School of Medicine, 12631 E. 17th Avenue, Aurora, CO, 80045, USA
| | - Julia Reedy
- University of Colorado Denver School of Medicine, ACCORDS, 1890 N Revere Ct, Aurora, CO, 80045, USA
| | - Claude Rubinson
- Department of Social Sciences, University of Houston-Downtown, 1 Main Street, Houston, TX, 77009, USA
| | - Bethany Matthews Kwan
- University of Colorado Denver School of Medicine, ACCORDS, 1890 N Revere Ct, Aurora, CO, 80045, USA
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, 12631 E. 17th Avenue, Aurora, CO, 80045, USA
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Reddick AL, Gray DC. Impact of culturally tailored shared medical appointments on diabetes self-care ability and knowledge in African Americans. Prim Health Care Res Dev 2023; 24:e30. [PMID: 37185043 PMCID: PMC10156467 DOI: 10.1017/s1463423623000166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (T2DM) continues to disproportionately affect African Americans, significantly impacting morbidity and mortality. Research suggests that addressing barriers that stem from socioeconomic circumstances, systemic inequalities, biological factors, and cultural factors may positively influence biometric indicators of health and diabetes control. OBJECTIVE The aim of this study was to evaluate a diabetes shared medical appointment (SMA) model program that has been culturally tailored to address the unique social determinants of health barriers faced by an inner city African American population in Norfolk, Virginia. METHODS A pilot study using a within-group pretest-posttest design was conducted. Information was collected from self-report surveys that included the Modified Michigan Diabetes Knowledge Test, the Diabetes Self-Efficacy Scale, and researcher generated surveys before and after a single-session three-hour SMA program. KEY RESULTS The program increased perceived diabetes self-care confidence and perceived overall diabetes knowledge levels. Increases in knowledge scores were seen but not statistically significant. Participants reported high levels of satisfaction with the program model. DISCUSSION Findings indicate that this model is an effective and engaging method of improving self-care ability and diabetes disease management knowledge among African Americans. Addressing unique circumstances and barriers experienced by this population may be more effective than usual traditional care approaches.
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Affiliation(s)
- Adrienne L Reddick
- Adjunct Professor, Old Dominion University, School of Nursing, Norfolk, VA, USA
| | - Deborah C Gray
- Associate Graduate Program Director, Clinical Associate Professor, Old Dominion University, School of Nursing, Norfolk, VA, USA
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Drake C, Abadi MH, Batchelder HR, Richard BO, Balis LE, Rychener D. National Implementation of a Group-Based Program Promoting Patient Engagement and Peer Support in the Veterans Health Administration: A Multi-Methods Evaluation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8333. [PMID: 35886181 PMCID: PMC9321656 DOI: 10.3390/ijerph19148333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 12/10/2022]
Abstract
Evidence-based approaches promoting patient engagement and chronic illness self-management include peer support, shared decision-making, and education. Designed based on these components, Taking Charge of My Life and Health (TCMLH) is a group-based, 'Whole Person' care program promoting mental and physical self-care and patient empowerment. Despite evidence of effectiveness, little is known about implementation for TCMLH and similar programs. In this first-of-its-kind, multi-methods evaluation conducted between 2015-2020, we report on implementation strategies and intervention adaptations with a contextual analysis to describe TCMLH translational efforts in Veterans Health Administration (VHA) facilities across the United States. Quantitative and qualitative data were collected via listening sessions with TCMLH facilitators, open-ended survey responses from facilitators, and quarterly reports from clinical implementation sites. We used the Consolidated Framework for Implementation Research (CFIR) to analyze, interpret, and organize qualitative findings, and descriptive statistics to analyze quantitative data. Most TCMLH programs (58%) were adapted from the original format, including changes to the modality, duration, or frequency of sessions. Findings suggest these adaptations occurred in response to barriers including space, staffing constraints, and participant recruitment. Overall, findings highlight practical insights for improving the implementation of TCMLH, including recommendations for additional adaptations and tailored implementation strategies to promote its reach.
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Affiliation(s)
- Connor Drake
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care, Durham, NC 27705, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC 27701, USA
| | - Melissa H. Abadi
- Pacific Institute for Research and Evaluation, Louisville, KY 40202, USA; (M.H.A.); (B.O.R.); (L.E.B.)
| | - Heather R. Batchelder
- Department of Community Health and Family Medicine, Duke University School of Medicine, Durham, NC 27710, USA;
| | - Bonnie O. Richard
- Pacific Institute for Research and Evaluation, Louisville, KY 40202, USA; (M.H.A.); (B.O.R.); (L.E.B.)
| | - Laura E. Balis
- Pacific Institute for Research and Evaluation, Louisville, KY 40202, USA; (M.H.A.); (B.O.R.); (L.E.B.)
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Drake C, Snyderman R, Cannady M, Batchelder H, Lian T, Wedda B, Clipper C, Edelman D. Personalized Medical Group Visits: A Novel Approach for the Care of Prediabetes. Diabetes Spectr 2022; 35:504-511. [PMID: 36545257 PMCID: PMC9668724 DOI: 10.2337/ds21-0077] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Connor Drake
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
- Corresponding author: Connor Drake,
| | - Ralph Snyderman
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Meagan Cannady
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
| | - Heather Batchelder
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
| | - Tyler Lian
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | | | - Christie Clipper
- Center for Personalized Health Care, Duke University School of Medicine, Durham, NC
| | - David Edelman
- Department of Medicine, Duke University School of Medicine, Durham, NC
- Durham VA Healthcare System, Durham, NC
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Heisler M, Burgess J, Cass J, Chardos JF, Guirguis AB, Strohecker LA, Tremblay AS, Wu WC, Zulman DM. Evaluating the Effectiveness of Diabetes Shared Medical Appointments (SMAs) as Implemented in Five Veterans Affairs Health Systems: a Multi-site Cluster Randomized Pragmatic Trial. J Gen Intern Med 2021; 36:1648-1655. [PMID: 33532956 PMCID: PMC8175536 DOI: 10.1007/s11606-020-06570-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 12/29/2020] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To examine whether diabetes shared medical appointments (SMAs) implemented as part of usual clinical practice in diverse health systems are more effective than usual care in improving and sustaining A1c improvements. RESEARCH DESIGN AND METHODS A multi-site cluster randomized pragmatic trial examining implementation in clinical practice of diabetes SMAs in five Veterans Affairs (VA) health systems was conducted from 2016 to 2020 among 1537 adults with type 2 diabetes and elevated A1cs. Eligible patients were randomly assigned to either: (1) invitation to participate in a series of SMAs totaling 8-9 h; or (2) continuation of usual care. Relative change in A1c (primary outcome) and in systolic blood pressure, insulin starts, statin starts, and anti-hypertensive medication classes (secondary outcomes) were measured as part of usual clinical care at baseline, at 6 months and at 12 months (~7 months after conclusion of the final SMA in four of five sites). We examined outcomes in three samples of SMA participants: all those scheduled for a SMA, those attending at least one SMA, and those attending at least half of SMAs. RESULTS Baseline mean A1c was 9.0%. Participants scheduled for an SMA achieved A1c reductions 0.35% points greater than the control group between baseline and 6-months follow up (p = .001). Those who attended at least one SMA achieved reductions 0.42 % points greater (p < .001), and those who attended at least half of scheduled SMAs achieved reductions 0.53 % points greater (p < .001) than the control group. At 12-month follow-up, the three SMA analysis samples achieved reductions from baseline ranging from 0.16 % points (p = 0.12) to 0.29 % points (p = .06) greater than the control group. CONCLUSIONS Diabetes SMAs as implemented in real-life diverse clinical practices improve glycemic control more than usual care immediately after the SMAs, but relative gains are not maintained. Our findings suggest the need for further study of whether a longer term SMA model or other follow-up strategies would sustain relative clinical improvements associated with this intervention. TRIAL REGISTRATION ClinicalTrials.gov ID NCT02132676.
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Affiliation(s)
- Michele Heisler
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
- North Campus Research Complex, University of Michigan, Ann Arbor, MI, USA.
| | - Jennifer Burgess
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jeffrey Cass
- VA Northern California Health Care System, Mather, CA, USA
| | - John F Chardos
- Veterans Affairs Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | | | | | - Adam S Tremblay
- Veterans Affairs Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Wen-Chih Wu
- Providence VA Medical Center, Providence, RI, USA
| | - Donna M Zulman
- Veterans Affairs Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Division of General Medicine Disciplines, Stanford University, Stanford, CA, USA
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