AIM: Group medical clinics improve blood pressure compared with conventional care

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Veterans with hypertension and diabetes who visited group medical clinics (GMCs) saw substantial improvements in blood pressure rates, but not glycemic control, according to a study published June 1 in the Annals of Internal Medicine.

David Edelman, MD, of the Durham Veterans Affairs Medical Center in Durham, N.C., and colleagues evaluated 239 diabetic patients between June 2006 and September 2007 who had poorly controlled HbA1c levels and hypertension to test the effectiveness of an intervention by GMCs compared to standard care methods.

"Although self-management skills may improve glycemic control, self-management training is often time and resource intensive,” the authors wrote. “Group visits have the potential not only to enhance self management but also to improve access, decrease costs and increase efficiency of care for patients with chronic diseases.”

During the randomized controlled trial, patients were randomly assigned at a 5:4 ratio to attend either a GMC or undergo standard care. Patients who attended a GMC were seen by a care team consisting of a primary care general internist, a pharmacist and a nurse/diabetes educator and each session included group interactions with 7-8 patients.

Sessions occurred every two months at two locations at the U.S. Department of Veterans Affairs (VAMC) in Richmond, Va., and the VAMC in Durham, N.C.

For those who attended GMCs, blood pressure and glucose levels where checked upon arrival and then patients attended an educational session delivered by the nurse or a diabetes educator. Sessions lasted between 90 and 120 minutes.

The researchers used HbA1c levels and blood pressure as the primary outcome measures.

During the study, overall, patients attended 78.4 percent of all GMC session, 44 percent attended all sessions and 22 percent only missed one session—three patients missed all seven sessions.

The results showed that mean systolic blood pressure was 7.3 mm Hg lower in the GMC group than those who underwent standard care. At the midpoint of the study, mean HbA1c levels differed between both groups by 0.2 percent.

At the end of the study the mean diastolic blood pressure was 3.8 mm Hg lower in the GMC group than the usual care group and 24 percent of patients in the GMC group obtained blood pressure control halfway through the study compared to 21 percent of the standard care group.

Additionally, the researchers found that at the end of the study 22 percent of patients in the GMC group achieved blood pressure control compared to 12 percent in the standard care group. “Glycemic control did not differ between the groups,” the authors wrote.

Researchers also looked at adverse event rates for the two groups. While few serious events occurred in either group, reported rates of falls and lightheadedness was less in the GMC group: 50 percent reported no falls or lightheadedness versus 37 percent in the standard care group.

"Group medical clinics also hold great promise because blood pressure control is more important than glycemic control for reducing cardiovascular morbidity and mortality among patients with diabetes,” the authors concluded.

“The reductions in emergency and primary care visits may offset the costs of the intervention. If found to be cost effective and efficient, GMCs could be implemented in a wide range of settings and become important in the remodeling of long-term care in the U.S.”