Shared medical appointments for weight management among patients with type 2 diabetes: A service evaluation

Abstract

Background: Shared medical appointments (SMAs) have gained interest as a possible solution to the current limitations of the traditional healthcare model related to chronic disease management. In October 2019, the Auckland Diabetes Centre (ADC) piloted a new SMA program in the hope to meet increased demands and improve patient care and treatment outcomes. The program was designed specifically for patients with T2DM and obesity wanting to lose weight, using evidence-based elements from the DiRECT trial, indicating the efficacy of the low energy diet (LED) using meal replacements for weight loss and diabetes remission for people with T2DM. Service Evaluation Aims The service evaluation aims were to determine whether the program: (a) met its intended clinical outcomes (i.e. to achieve weight loss in accordance with patient’s personal weight loss goals over 8 weeks by following a LED, to decrease HbA1c and improve glycaemic control, and to achieve reduction in BP); (b) improved participant behavioural outcomes related to eating habits, diabetes self-efficacy (DSES) and problem areas in diabetes (PAID); (c) was viewed favourably and could be improved from the participant and HCP perspective. Methods: A mixed-methods approach was taken using data collected and analysed from cohort one (C1) and cohort two (C2) of this SMA program. The program was designed to include 8 in-person SMAs over a 6-month period to support implementation of the LED (8-weeks) followed by food reintroduction and weight loss maintenance. Due to COVID-19, the program was adapted into a virtual delivery format, with C1 and C2 combined to form one “merger” SMA group. Clinical and behavioural data was collected as part of standard clinical procedure. Quantitative data included clinical (weight, HbA1c, BP and patient medications) and questionnaire (DSES, PAID and visual analogue scale [VAS]) analysis. Changes in clinical data were analysed from baseline (week 1) to post-LED (week 8 in C1, week 14 in C2) and from baseline to follow-up (week 34 in C1, week 26 in C2), with questionnaires analysed from baseline to 3-months. Qualitative evaluation included patient and HCP feedback from an initial co-design meeting and retrospective semi-structured interviews. Semi-structured questionnaires were designed with the aim to analyse program benefits and limitations, practicalities of the SMA program (LED, Zoom SMAs, merger SMAs, rapport/confidentiality), recommendations for improvement, and overall satisfaction in comparison to one-to-one care. Results: Clinical Fourteen patients were recruited in total (seven patients in each cohort). Of these, six patients participated in the SMA program until at least 6-months. From baseline to post-LED, 5/6 patients lost weight, with a median weight loss of -5.3kg (range = -19.4 – 0.4). A median weight loss of -4.8kg (range = -23.2 – 3.4), was achieved at follow-up. However, weight loss was not statistically significant at either time point (p=0.063 at post-LED, p=0.188 at follow-up). Change in HbA1c was not statistically significant. However, an overall median reduction in HbA1c was achieved at both post-LED and follow-up (-8.5 [range = -28 – 8] mmol/mol and - 4 [range = -28 – 8] mmol/mol, respectively). C2 achieved greater reductions in HbA1 in comparison to C1. BG medications did not change significantly from either baseline to post- LED or from baseline to follow-up (p=1.00). Changes in SBP and DBP were not statistically significant. Behavioural/Questionnaires From baseline to 3-months, 5/6 patients reduced PAID scores with a median of -11.25 (range = -55 – 0), (p=0.063). Median DSES scores increased from baseline to 3-months by a median of 1.25 (range = -0.75 – 5.625), (p=0.188). No significant changes were found in patient eating habits over this period. Patient and provider perspectives Four patients (three completers and one drop-out) and all five HCPs involved in C1 and C2 took part in semi-structured interviews. The themes identified as key benefits of this pSMA program included the group environment, increased access to health care, behaviour change support, clinician growth and perceived outcomes of the program. Themes identified as limitations of the program included challenges of implementing a pilot program, teething issues, multidisciplinary team (MDT) investment, recruitment, drop-out, barriers to attendance and unmet expectations. Program limitations were suggested to lead to the high drop-out rate and non-adherence/non-implementation of the LED among patients. Regarding SMA “practicalities”, barriers (program factors, meal replacement products, interpersonal factors, individual factors, change of environment/COVID-19) and facilitators (supportive/group environment of SMA, individual factors and environmental factors) of LED implementation/adherence were identified as key themes. Patient outcomes in C2 were suggested to be more successful than those in C1 secondary to improvements made to the structure and recruitment of patients in C2, taken from the learnings of C1. Regarding virtual SMAs, two themes emerged including benefits of Zoom SMAs (increased accessibility, timeefficiency, lower cost) and difficulties experienced on Zoom (inability to communicate/build rapport/connect, technology, accountability, hard to facilitate). Ability to build rapport/confidentiality was not found to be negatively influenced by the SMA environment. Satisfaction of the SMA program was high among patients who completed, with the patient who dropped out suggesting nonsatisfaction. HCP satisfaction was mixed regarding use of time and patient attendance and outcomes. Conclusion: Participants in this SMA program had heterogeneous clinical and behavioural results with no overall statistically significant outcomes achieved. Limited adherence to the LED and the high dropout rate experienced in this program impacted the lack of overall clinical effectiveness of this SMA program. Implementation of SMA programs into routine healthcare clinics can come with several challenges and thus requires thorough preparation and planning. SMA structure and content should be tailored to meet patient, provider and practice needs. Additionally, the LED is not appropriate for all patients and requires screening to identify those who are likely to benefit most, the provision of long-term support, structured weight maintenance emphasising food reintroduction and psychosocial strategies for behavioural change, and a formalised rescue plan for those who regain weight. Patients and providers identified several benefits of this SMA program in comparison to usual care. Of importance, the group environment provided peer support for patients, reducing social isolation. Further research is needed to evaluate the long-term clinical and behavioural effectiveness of this program. However, with implementation of the recommendations made for this SMA service, greater clinical and behavioural outcomes may be achieved in the future.