title: A 5-year randomized controlled study of learning, problem solving ability, and quality of life modifications in people with type 2 diabetes managed by group care. Pharmacist-Led Group Medical Appointment Model in Type 2 Diabetes Culturally Tailored Intervention for Rural African Americans With Type 2 Diabetes Lifestyle intervention for type 2 diabetes patients – trial protocol of The Copenhagen Type 2 Diabetes Rehabilitation Project A randomised controlled clinical trial of nurse-, dietitian- and pedagogistled Group Care for the management of Type 2 diabetes A model educational program for people with type 2 diabetes: a cooperative Latin American implementation study (PEDNID-LA). Can a Chronic Care Model Collaborative Reduce Heart Disease Risk in Patients with Diabetes? Evaluation of the effectiveness of an ambulatory teaching/treatment programme for non-insulin dependent (type 2) diabetic patients Evaluating concordance to American Diabetes Association standards of care for type 2 diabetes through group visits in an uninsured or inadequately insured patient population. Chronic care clinics for diabetes in primary care: a system-wide randomized trial. Culturally competent diabetes self-management education for Mexican Americans: the Starr County border health initiative. Group Visits: Promoting Adherence to Diabetes Guidelines Assessment of group versus individual diabetes education: a randomized study. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Group Education for Obese Patients with Type 2 Diabetes: Greater Success at Less Cost EVALUATION OF A STRUCTURED TREATMENT AND TEACHING PROGRAMME ON NON-INSULIN-DEPENDENT DIABETES Physician–nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients' perception of care The North Dublin randomized controlled trial of structured diabetes shared care. Evaluation of a structured teaching and treatment programme for type 2 diabetes in general practice in a rural area of Austria. Medical Clinics Versus Usual Care for Patients With Both Diabetes and Hypertension Do diabetes group visits lead to lower medical care charges? Group visits in medically and economically disadvantaged patients with type 2 diabetes and their relationships to clinical outcomes. Effect of the diabetes outpatient intensive management programme on glycaemic control for type 2 diabetic patients. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk A multifaceted intervention in support of diabetes treatment guidelines: a cont trial. ROMEO: rethink organization to improve education and outcomes. Lifestyle intervention by group care prevents deterioration of Type II diabetes: a 4-year randomized controlled clinical trial A study of central serotoninergic activity in healthy subjects and patients with Type 2 diabetes treated by traditional one-to-one care or Group Care. Group Visits for Hmong Adults with Type 2 Diabetes Mellitus: A Pre-Post Analysis Problems in the medical interpretation of overviews. Rethink Organization to iMprove Education and Outcomes (ROMEO) Improving Chronic Care of Type 2 Diabetes Using Teams of Interprofessional Learners The cost-effectiveness of improving diabetes care in U.S. federally qualified community health centers.
abstract: OBJECTIVE To study time course changes in knowledge , problem solving ability , and quality of life in patients with type 2 diabetes managed by group compared with individual care and education . RESEARCH DESIGN AND METHODS We conducted a 5-year r and omized controlled clinical trial of continuing systemic education delivered by group versus individual diabetes care in a hospital-based secondary care diabetes unit . There were 120 patients with non-insulin-treated type 2 diabetes enrolled and r and omly allocated to group or individual care . Eight did not start and 28 did not complete the study . The main outcome measures were knowledge of diabetes , problem solving ability , quality of life , HbA1c , BMI , and HDL cholesterol . RESULTS Knowledge of diabetes and problem solving ability improved from year 1 with group care and worsened among control subjects ( P<0.001 for both ) . Quality of life improved from year 2 with group care but worsened with individual care ( P<0.001 ) . HbA1c level progressively increased over 5 years among control subjects ( + 1.7 % , 95 % CI 1.1 - 2.2 ) but not group care patients ( + 0.1 % , -0.5 to 0.4 ) , in whom BMI decreased ( -1.4 , -2.0 to -0.7 ) and HDL cholesterol increased ( + 0.14 mmol/l , 0.07 - 0.22 ) . CONCLUSIONS Adults with type 2 diabetes can acquire specific knowledge and conscious behaviors if exposed to educational procedures and setting s tailored to their needs . Traditional one-to-one care , although delivered according to optimized criteria , is associated with progressive deterioration of knowledge , problem solving ability , and quality of life . Better cognitive and psychosocial results are associated with more favorable clinical outcomes Purpose The purpose of this study was to assess whether the VA-MEDIC ( Veterans Affairs Multi-disciplinary Education and Diabetes Intervention for Cardiac risk reduction ) , a pharmacist-led group medical visit program , could improve achievement of target goals in hypertension , hyperglycemia , hyperlipidemia , and tobacco use in patients with type 2 diabetes compared to usual care . Methods This was a r and omized controlled trial of VA-MEDIC intervention in addition to usual care versus usual care alone in diabetic patients to reduce cardiac risk factors . VA-MEDIC consisted of a 40- to 60-minute educational component by nurse , nutritionist , physical therapist , or pharmacist followed by pharmacist-led behavioral and pharmacological interventions over 4 weekly sessions . Measures The attainment of target goals in hemoglobin A1C ( A1C ) , blood pressure , fasting lipids , and tobacco use recommended by the American Diabetes Association . Results Of 118 participants , 109 completed the study . VA-MEDIC ( n = 58 ) participants were younger and had greater tobacco use at baseline than usual care but were similar in other cardiovascular risk factors . After 4 months , a greater proportion of VA-MEDIC participants versus controls achieved an A1C of less than 7 % and a systolic blood pressure less than 130 mm Hg . No significant change was found in lipid control or tobacco use between the 2 study arms . Conclusion Pharmacist-led group medical visits are feasible and efficacious for improving cardiac risk factors Purpose The purpose of this pilot study was to evaluate a culturally tailored intervention for rural African Americans . Social Cognitive Theory provided the framework for the study . Methods Twenty-two participants were recruited and r and omly assigned to either Group or Individual diabetes self-management ( DSME ) . Group DSME included story-telling , h and s-on activities , and problem-solving exercises . Individual DSME sessions focused on goal - setting and problem-solving strategies . Sessions were offered in an accessible community center over a 10-week period . Results Outcomes included glycosylated hemoglobin ( A1C ) , self-care actions , self-efficacy level , goal attainment , and satisfaction with DSME . Participants in both Group and Individual DSME improved slightly over the 3-month period in self-care activities , A1C level , and goal attainment . Although differences were not statistically significant , trends indicate improved scores on dietary actions , foot care , goal attainment , and empowerment for those experiencing Group DSME . Conclusions The culturally tailored approach was well received by all participants . Improvements among those receiving Individual DSME may indicate that brief sessions using a culturally tailored approach could enhance self-care and glycemic control . Additional testing among more participants over a longer time period is recommended Background Current guidelines recommend education , physical activity and changes in diet for type 2 diabetes patients , yet the composition and organization of non-pharmacological care are still controversial . Therefore , it is very important that programmes aim ing to improve non-pharmacological treatment of type 2 diabetes are developed and evaluated . The Copenhagen Type 2 Diabetes Rehabilitation Project aims to evaluate the effectiveness of a new group-based lifestyle rehabilitation programme in a Health Care Centre in primary care . Methods / Design The group-based diabetes rehabilitation programme consists of empowerment-based education , supervised exercise and dietary intervention . The effectiveness of this multi-disciplinary intervention is compared with conventional individual counselling in a Diabetes Outpatient Clinic and evaluated in a prospect i ve and r and omized controlled trial . During the recruitment period of 18 months 180 type 2 diabetes patients will be r and omized to the intervention group and the  control group . Effects on glycaemic control , quality of life , self-rated diabetes symptoms , body composition , blood pressure , lipids , insulin resistance , beta-cell function and physical fitness will be examined after 6 , 12 and 24 months . Discussion The Copenhagen Type 2 Diabetes Rehabilitation Project evaluates a multi-disciplinary non-pharmacological intervention programme in a primary care setting and provides important information about how to organize non-pharmacological care for type 2 diabetes patients .Trail Registration Clinical Trials.gov registration number : NCT00284609 Aim : To verify if Group Care , a model to manage Type 2 diabetes ( T2DM ) by systemic continuing group education , can be administered by nurses and dieticians under pedagogic guidance , and improve metabolic control , quality of life , Locus of Control , and insulin resistance . Material and subjects : Twenty-five patients with non-insulin-treated T2DM were r and omized to Group Care and 24 to continued habitual individual care and education delivered by a diabetes specialist and pedagogist , respectively . Six nurses and 1 dietician received training by an accredited programme , a detailed operating manual and pedagogical supervision throughout the study . Follow-up was for 2 yr and included measurements of fasting blood glucose , glycated hemoglobin ( HbA1c ) , body mass index , waist circumference , lipids , creatinine , blood pressure , serum insulin , homeostasis model assessment ( HOMA ) index of insulin resistance , health behaviors , quality of life , state and trait anxiety , and Locus of Control . Results : One patient on Group Care and 3 controls dropped out . At the end of study , the patients on Group Care had lower HbA1c ( 7.6± 0.8 vs 8.4± 1.3 , p<0.05 ) , insulin ( 18.0± 9.6 vs 24.3± 13.7 , p<0.001 ) , HOMA index ( 6.9± 5.4 vs 9.2± 6.6 , p<0.05 ) , and fatalistic attitude ( 17.2± 5.9 vs 24.9± 4.2 , p<0.001 ) and better quality of life ( 65.0± 11.0 vs 78.4± 19.6 , p<0.001 ) than controls . Conclusions : Group Care delivered by trained nurses and dietitan is associated with better outcomes than those obtained by a medically and pedagogically qualified team . It may offer a model for health operators to re-organize clinical practice and for patients to improve lifestyle and strengthen the therapeutic alliance with their carers OBJECTIVE To implement an educational program in 10 Latin American countries and to evaluate its effect on the clinical , biochemical , and therapeutic aspects as well as the economic cost of diabetes . RESEARCH DESIGN AND METHODS Educators from each participating country were previously trained to implement the educational model .  The patient population included 446 individuals with type 2 diabetes ; all patients were < 65 years of age , did not require insulin for metabolic control , did not have severe complications of diabetes or life-limiting illnesses , and had not previously participated in diabetes education courses .  Clinical and therapeutic data and the cost of their pharmacological treatment were collected 6 months before participation in the educational program ( -6 months ) , on entry into the program ( time 0 ) , and at 4 , 8 , and 12 months after initiation of the program . RESULTS All parameters measured had improved significantly ( P < 0.001 ) by 1 year : fasting blood glucose ( mean + /- SD ) 10.6 + /- 3.5 vs. 8.7 + /- 3.0 mmol/l ; HbA(1c ) 9.0 + /- 2.0 vs. 7.8 + /- 1.6 % ; body weight 84.6 + /- 14.7 vs. 81.2 + /- 15.2 kg ; systolic blood pressure 149.6 + /- 33.6 vs. 142.9 + /- 18.8 mmHg ; total cholesterol 6.1 + /- 1.1 vs. 5.4 + /- 1.0 mmol/l ; and triglycerides 2.7 + /- 1.8 vs. 2.1 + /- 1.2 mmol/l . At 12 months , the decrease in pharmacotherapy required for control of diabetes , hypertension , and hyperlipidemia represented a 62 % decrease in the annual cost of treatment ( $ 107,939.99 vs. $ 41,106.30 [ U.S. ] ) . After deducting the additional cost of glucosuria monitoring ( $ 30,604 ) , there was still a 34 % annual savings . CONCLUSIONS The beneficial results of this educational model , implemented in 10 Latin American countries , reinforce the value of patient education as an essential part of diabetes care . They also suggest that an educational approach promoting healthy lifestyle habits and patient empowerment is an effective strategy with the potential to decrease the development of complications related to diabetes as well as the socioeconomic costs of the disease Background There is a need to identify effective practical interventions to decrease cardiovascular disease risk in patients with diabetes . Objective We examine the impact of participation in a collaborative implementing the chronic care model ( CCM ) on the reduction of cardiovascular disease risk in patients with diabetes . Design Controlled pre- and postintervention study . Patients / Participants Persons with diabetes receiving care at 13 health care organizations exposed to the CCM collaborative and controls receiving care in nonexposed sites . Measurements and Main Results Ten-year risk of cardiovascular disease ; determined using a modified United Kingdom Prospect i ve Diabetes Study risk engine score . A total number of 613 patients from CCM intervention sites and 557 patients from usual care control sites met the inclusion criteria . The baseline mean 10-year risk of cardiovascular disease was 31 % for both the intervention group and the control group . Participants in both groups had improved blood pressure , lipid levels , and HbA1c levels during the observation period . R and om intercept hierarchical regression models showed that the intervention group had a 2.1 % ( 95 % CI −3.7 % , −0.5 % ) greater reduction in predicted risk for future cardiovascular events when compared to the control group . This would result in a reduced risk of one cardiovascular disease event for every 48 patients exposed to the intervention . Conclusions Over a 1-year interval , this collaborative intervention using the CCM lowered the cardiovascular disease risk factors of patients with diabetes who were cared for in the participating organization ’s setting s. Further work could enhance the impact of this promising multifactorial intervention on cardiovascular disease risk reduction The aim of this study was to evaluate the effect of a structured teaching/treatment programme on the clinical and metabolic control of non-insulin-dependent ( type 2 ) diabetic patients . The programme was aim ed at improving the overall treatment quality in these patients through measures involving self-care , diet , exercise and weight reduction . Four theoretical-practical teaching units were given once a week to group of 5–8 ambulatory patients by previously trained general practitioners .  Clinical and biochemical parameters were recorded at the beginning of the course and 1 year after its completion in 40 patients attending the programme and in 39 patients of similar clinical characteristics under conventional diabetes treatment , but receiving no structured teaching before or during the survey period ( control group ) . The drop-out percentage in the intervention group ( 25 % ) was significantly lower than in the control group (45%),P<0.05 , suggesting an incentive toward greater compliance in the former . At the end of the 1-year follow-up , the mean differences observed in the control and in the intervention groups were : body weight loss −2.4±0.5 kg vs −0.4±0.5 ( P<0.001 ) ; haemoglobin HbA1 −0.2%±0.4 % vs + 0.8±0.4 % ( NS ) ; number of daily oral hypoglycaemic agent intake −1.4±0.2 vs + 0.9±0.2 tablets ( P<0.001 ) . Our results strongly suggest that this programme , applied through family doctors , may constitute an efficient tool to improve the compliance and clinico-metabolic control of type 2 patients at the primary health care level OBJECTIVE To evaluate the effectiveness of a managed care approach to health care delivery , group visits , in the management of uninsured or inadequately insured patients with type 2 diabetes . RESEARCH DESIGN AND METHODS A total of 120 patients with uncontrolled type 2 diabetes were r and omly assigned to receive their care in group visits or usual care for 6 months . After 6 months , concordance with 10 process-of-care indicators recommended by the American Diabetes Association ( ADA ) st and ards of care was evaluated through chart abstract ion . The 10 items evaluated were up-to- date HbA(1c ) levels and lipid profiles , urine for microalbumin , appropriate use of ACE inhibitor or angiotensin receptor blockers , use of lipid-lowering agents where indicated , daily aspirin use , annual foot examinations , annual referrals for retinal examinations , and immunizations against streptococcal pneumonia and influenza . RESULTS Patients who received care in group visits showed statistically significant improvement in concordance with these 10 process-of-care indicators ( P < 0.001 ) . Of the patients , 76 % who received care in group visits had at least 9 of these 10 items up to date , as compared with 23 % of control patients ; 86 % of patients in group visits had at least 8 of the 10 indicators compared with 47 % of control patients . CONCLUSIONS Group visits proved more effective in promoting concordance with ADA st and ards of care than usual care in the treatment of uninsured or inadequately insured patients with type 2 diabetes OBJECTIVE To evaluate the impact of primary care group visits ( chronic care clinics ) on the process and outcome of care for diabetic patients . RESEARCH DESIGN AND METHODS We evaluated the intervention in primary care practice s r and omized to intervention and control groups in a large-staff model health maintenance organization ( HMO ) . Patients included diabetic patients > or = 30 years of age in each participating primary care practice , selected at r and om from an automated diabetes registry . Primary care practice s were r and omized within clinics to either a chronic care clinic ( intervention ) group or a  usual care ( control ) group . The intervention group conducted periodic one-half day chronic care clinics for groups of approximately 8 diabetic patients in their respective doctor 's practice .  Chronic care clinics consisted of st and ardized assessment s ; visits with the primary care physician , nurse , and clinical pharmacist ; and a group education/peer support meeting . We collected  self-report question  naires from patients and data from administrative systems . The question naires were mailed , and telephoned interviews were conducted for nonrespondents , at baseline and at 12 and 24 months ; we queried the process of care received , the satisfaction with care , and the health status of each patient . Serum cholesterol and HbA1c levels and health care use and cost data was collected from HMO administrative systems . RESULTS In an intention-to-treat analysis at 24 months , the intervention group had received significantly more recommended preventive procedures  and helpful patient education .  Of five primary health status indicators examined , two ( SF-36 general health and bed disability days ) were significantly better in the intervention group . Compared with control patients , intervention patients had slightly more primary care visits , but significantly fewer specialty and emergency room visits . Among intervention participants , we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes , including patient satisfaction and HbA1c levels . CONCLUSIONS Periodic primary care sessions organized to meet the complex needs of diabetic patients imrproved the process of diabetes care and were associated with better outcomes OBJECTIVE To determine the effects of a culturally competent diabetes self-management intervention in Mexican Americans with type 2 diabetes . RESEARCH DESIGN AND METHODS A prospect i ve , r and omized , repeated measures study was conducted on the Texas-Mexico border in Starr County . A total of 256 r and omly selected individuals with type 2 diabetes between 35 and 70 years of age , diagnosed with type 2 diabetes after 35 years of age , and accompanied by a family member or friend were included . The intervention consisted of 52 contact hours over 12 months and was provided by bilingual Mexican American nurses , dietitians , and community workers . The intervention involved 3 months of weekly instructional sessions on nutrition , self-monitoring of blood glucose , exercise , and other self-care topics and 6 months of biweekly support group sessions to promote behavior changes . The approach was culturally competent in terms of language , diet , social emphasis , family participation , and incorporation of cultural health beliefs . Outcomes included indicators of metabolic control ( HbA(1c ) and fasting blood glucose ) , diabetes knowledge , and diabetes-related health beliefs . RESULTS Experimental groups showed significantly lower levels of HbA(1c ) and fasting blood glucose at 6 and 12 months and higher diabetes knowledge scores . At 6 months , the mean HbA(1c ) of the experimental subjects was 1.4 % below the mean of the control group ; however , the mean level of the experimental subjects was still high ( > 10 % ) . CONCLUSIONS This study confirms the effectiveness of culturally competent diabetes self-management education on improving health outcomes of Mexican Americans , particularly for those individuals with HbA(1c ) levels > 10 % BACKGROUND Current diabetes management guidelines offer blueprints for providers , yet type 2 diabetes control is often poor in disadvantaged population s. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems .  Group visits offer promise for delivering care to diabetic patients , as visits are lengthier and can be more frequent , more organized , and more educational . OBJECTIVE To evaluate the effect of group visits on clinical outcomes , concordance with 10 American Diabetes Association ( ADA ) guidelines [ American Diabetes Association , Diabetes Care , 28:S4–36 , 2004 ] and 3 United States Preventive Services Task Force ( USPSTF ) cancer screens [ U.S. Preventive Services Task Force , http://www.ahrq.gov/clinic/uspstf/re source .htm , 2003 ] . RESEARCH DESIGN AND METHODS A 12-month r and omized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient – physician dyad . Clinical outcomes ( HbA1c , blood pressure [ BP ] , lipid profiles ) were assessed at 6 and 12 months and quality of care measures ( adherence to 10 ADA guidelines and 3 USPSTF cancer screens ) at 12 months . RESULTS At both measurement points , HbA1c , BP , and lipid levels did not differ significantly for patients attending group visits versus those in usual care . At 12 months , however , patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators ( p < .0001 ) and higher screening rates for cancers of the breast ( 80 vs. 68 % , p = .006 ) and cervix ( 80 vs 68 % , p = .019 ) . CONCLUSIONS Group visits can improve the quality of care for diabetic patients , but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes OBJECTIVES The current study was conducted to compare the effectiveness of delivering diabetes education in either a group or individual setting using a consistent , evidence -based curriculum . RESEARCH DESIGN AND METHODS A total of 170 subjects with type 2 diabetes were r and omly assigned to either group ( n = 87 ) or individual ( n = 83 ) educational setting s. Subjects received education in four sequential sessions delivered at consistent time intervals over a 6-month period . Outcomes included changes in knowledge , self-management behaviors , weight , BMI , HbA(1c ) , health-related quality of life , patient attitudes , and medication regimen . Changes were assessed at baseline and after the 2-week , 3-month , and 6-month education sessions . RESULTS Both educational setting s had similar improvements in knowledge , BMI , health-related quality of life , attitudes , and all other measured indicators . HbA(1c ) decreased from 8.5 + /- 1.8 % at baseline to 6.5 + /- 0.8 % at 6 months ( P < 0.01 ) in the study population as a whole . Subjects assigned to the individual setting had a 1.7 + /- 1.9 % reduction in HbA(1c ) ( P < 0.01 ) , whereas subjects assigned to the group setting had a 2.5 + /- 1.8 % reduction in HbA(1c ) ( P < 0.01 ) . The difference in HbA(1c ) improvement was marginally greater in subjects assigned to group education versus individualized education ( P = 0.05 ) . CONCLUSIONS This study demonstrates that diabetes education delivered in a group setting , when compared with an individual setting , was equally effective at providing equivalent or slightly greater improvements in glycemic control . Group diabetes education was similarly effective in delivering key educational components and may allow for more efficient and cost-effective methods in the delivery of diabetes education programs OBJECTIVE To evaluate the effectiveness of a cluster visit model led by a diabetes nurse educator for delivering outpatient care management to adult patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS This study involved a r and omized controlled trial among patients of Kaiser Permanente 's Pleasanton , CA , center who were aged 16 - 75 years and had either poor glycemic control ( HbA1c > 8.5 % ) or no HbA1c test performed during the previous year . Intervention subjects received multidisciplinary outpatient diabetes care management delivered by a diabetes nurse educator , a psychologist , a nutritionist , and a pharmacist in cluster visit setting s of 10 - 18 patients /month for 6 months . Outcomes included change ( from baseline ) in HbA1c levels ; self-reported changes in self-care practice s , self-efficacy , and satisfaction ; and utilization of inpatient and outpatient health care . RESULTS After the intervention , HbA1c levels declined by 1.3 % in the intervention subjects versus 0.2 % in the control subjects ( P < 0.0001 ) . Several self-care practice s and several measures of self-efficacy improved significantly in the intervention group . Satisfaction with the program was high . Both hospital ( P = 0.04 ) and outpatient ( P < 0.01 ) utilization were significantly lower for intervention subjects after the program . CONCLUSIONS A 6-month cluster visit group model of care for adults with diabetes improved glycemic control , self-efficacy , and patient satisfaction and result ed in a reduction in health care utilization after the program It has been suggested that much effort expended in teaching diabetic diets is ineffective and wasteful . We have tested a different system by r and omly allocating 75 newly diagnosed obese Type 2 diabetic patients to usual ‘ unstructured ’ clinic care or to group education by diabetes specialist nurses and a dietitian . Patients allocated to group education attended five 90‐min group sessions during the first 6 months . Six months after diagnosis they had lost more weight ( median ( 95 % CI ) , 7 ( 5.5–9 ) vs 2 ( 1–5 ) kg , p<0.002 ) and were better controlled ( HbA1 : 7.5 ( 7.0–8.1 ) vs 9.5 ( 8.7–10.4 ) % , p<0.001 ) than those r and omized to the usual clinic system . At 1 year ( after no further visits ) the difference in weight loss was less ( 5.5 ( 4–6.5 ) vs 3 ( 2–4 ) kg , p<0.05 ) and diabetic control was similar ( HbA1:9.0 ( 8.2–9.8 ) vs 9.9 ( 8.9–10.9 ) % . At 1 year only 14 ( 39 % ) of the education group and 9 ( 23 % ) of those attending the clinic had a fasting blood glucose less than 7.0 mmol l−1 A structured treatment and teaching programme for non-insulin-treated non-insulin-dependent ( type 2 ) diabetes was evaluated prospect ively in general practice . The four group sessions were mainly conducted by paramedical personnel . 65 patients from five general practice s were assessed at the start of the programme and 50 ( mean age 65 years , diabetes duration 7 years ) completed the 1 year follow-up ( intervention group ) . The control group consisted of 49 patients ( mean age 63 years , diabetes duration 7 years ) from three other general practice s without the programme . In the intervention group the percentage of patients receiving sulfonylureas  fell from 68 % at the start of the study to 38 % after 1 year ( mean difference 30 % , 95 % confidence interval [ CI ] 16 - 44 % ) ; the mean weight loss was 2.7 kg ( 95 % CI 1.6 - 3.8 kg ) , and non-fasting triglycerides were reduced by 0.77 mmol/1 ( 95 % CI 0.35 - 1.19 mmol/l ) ; and glycosylated haemoglobin remained unchanged ( 7.1 % of total haemoglobin ) . In the control group none of these indices was changed during the study year , and 10 % of patients started insulin treatment . The structured treatment and teaching programme improved the overall quality of patient care in elderly non-insulin-dependent diabetic patients treated by general practitioners Increasing dem and to deliver and document therapeutic and preventive care sharpens the need for disease management strategies that accomplish these goals efficiently while preserving quality of care . The purpose of this study was to compare selected outcomes for a new chronic disease management program involving a nurse practitioner - physician team with those of an existing model of care . One hundred fifty-seven patients with hypertension and diabetes mellitus were r and omly assigned to their primary care physician and a nurse practitioner or their primary care physician alone  . Costs for personnel directly involved in patient management , calculated from hourly rates and encounter time with patients , and pre- and post- study glycosylated hemoglobin ( HbA1c ) , high-density lipoprotein cholesterol ( HDL-c ) , satisfaction with care and health-related quality of life ( HRQoL ) were assessed . Although 1-year costs for personnel were higher in the team-treated group , participants experienced significant improvements in mean HbA1c ( − 0.7 % , p = 0.02 ) and HDL-c ( + 2.6 mg dL − 1 , p = 0.02 ) . Additionally , satisfaction with care improved significantly for team-treated subjects in several sub-scales whereas the mean change over time in HRQoL did not differ significantly between groups . This study demonstrates the value of a complementary team approach to chronic disease management in improving patient-derived and clinical outcomes at modest incremental costs BACKGROUND A new diabetes shared care service was introduced in North Dublin . It was design ed as a r and omized controlled trial with a complex intervention comprising education of participating practitioners , the introduction of a community-based diabetes nurse specialist , local agreement on clinical protocol s and structured communication across the primary - secondary care interface . OBJECTIVES Our aim was to assess the feasibility and effectiveness of a structured diabetes shared care service in a mixed health care system and to analyse the impact on total patient care . METHODS A Cluster r and omized controlled trial lasting 18 months was carried out in 183 patients with type 2 diabetes from 30 general practice s in North Dublin . Biophysical outcomes ( HbA1c , blood pressure , body mass index ) , psychosocial measures ( smoking status and Diabetes Clinic Treatment Satisfaction and Diabetes Well-being scores ) and process outcomes were collected . RESULTS There were significant improvements in diabetes care delivery and in psychosocial outcomes , but no significant improvements in biomedical outcomes . Process data collection revealed a significant increase in diabetes care-related activity for participating patients with an increase in structured annual review s and fewer patients defaulting from care . There were also significant improvements in information exchange between primary and secondary care . CONCLUSION Structured diabetes shared care , in a mixed health care system , can produce significant improvements in diabetes care delivery and in psychosocial outcomes for patients , with improved information exchange across the primary - secondary care interface The efficacy of a treatment and teaching programme for non-insulin-treated Type 2 diabetic patients in general practice was evaluated in a prospect i ve , controlled study . In a rural area in southern Austria , 53 patients from seven general practice s participated in a structured programme ( intervention group ) and 55 patients from seven general practice s without the programme served as the control group . After 6 months the weight reduction in the intervention group was 2.6 kg ( 1.6 - 3.7 kg , p < 0.001 ) and the difference in HbA1c between the groups was 0.92 % ( 0.23 - 1.61 % , p < 0.01 ) at follow-up . Systolic ( -16.6 mmHg ) and diastolic ( -11.1 mmHg ) blood pressure , serum triglycerides ( -0.63 mmol I-1 ) , and serum cholesterol ( -0.40 mmol I-1 ) were reduced significantly in the intervention group ( p < 0.006 ) . The number of patients with callus formation and poor nail care decreased significantly after participating in the teaching programme ( p < 0.001 ) . In the control group no reduction in body weight , metabolic control or in risk factors for diabetic foot complications were observed . Calculated health care costs per patient and year decreased in the intervention group ( -33 pounds ) and increased in the control group ( + 30 pounds ) mainly due to changes in prescription of oral hypoglycaemic agents in both groups . This programme may be an efficient and helpful model to increase overall quality of diabetes care according to the St Vincent Declaration BACKGROUND Group medical clinics ( GMCs ) are widely used in the management of diabetes and hypertension , but data on their effectiveness are limited . OBJECTIVE To test the effectiveness of GMCs in the management of comorbid diabetes and hypertension . DESIGN R and omized , controlled trial . ( Clinical Trials.gov registration number : NCT00286741 ) SETTING 2 Veterans Affairs Medical Centers in North Carolina and Virginia . PATIENTS 239 patients with poorly controlled diabetes ( hemoglobin A(1c ) [ HbA(1c ) ] level > or = 7.5 % ) and hypertension ( systolic blood pressure > 140 mm Hg or diastolic blood pressure > 90 mm Hg ) . INTERVENTION Patients were r and omly assigned within each center to either attend a GMC or receive usual care . Clinics comprised 7 to 8 patients and a care team that consisted of a primary care general internist , a pharmacist , and a nurse or other certified diabetes educator . Each session included structured group interactions moderated by the educator . The pharmacist and physician adjusted medication to manage each patient 's HbA(1c ) level and blood pressure . MEASUREMENTS Hemoglobin A(1c ) level and systolic blood pressure , measured by blinded research personnel at baseline , study midpoint ( median , 6.8 months ) , and study completion ( median follow-up , 12.8 months ) . Linear mixed models , adjusted for clustering within GMCs , were used to compare HbA(1c ) levels and systolic blood pressure between the intervention and control groups . RESULTS Mean baseline systolic blood pressure and HbA(1c ) level were 152.9 mm Hg ( SD , 14.2 ) and 9.2 % ( SD , 1.4 ) , respectively . At the end of the study , mean systolic blood pressure improved by 13.7 mm Hg in the GMC group and 6.4 mm Hg in the usual care group ( P = 0.011 by linear mixed model ) , whereas mean HbA(1c ) level improved by 0.8 % in the GMC group and 0.5 % in the usual care group ( P = 0.159 ) . LIMITATION Measurements of effectiveness may have been limited by concomitant improvements in the usual care group that were due to co-intervention . CONCLUSION Group medical clinics are a potent strategy for improving blood pressure but not HbA(1c ) level in diabetic patients . PRIMARY FUNDING SOURCE U.S. Department of Veterans Affairs Health Services Research and Development Service OBJECTIVE To evaluate whether attending diabetes group visits ( GVs ) leads to lower medical care charges for inadequately insured patients with type 2 diabetes mellitus ( DM ) . STUDY DESIGN R and omized controlled clinical trial . METHODS Data were abstract ed from financial records for 186 patients with uncontrolled type 2 DM r and omized to receive care in GVs or usual care for 12 months . Mann-Whitney tests for differences of means for outpatient visits ( primary and specialty care ) , emergency department ( ED ) visits , and inpatient stays were performed . Separate charge models were developed for primary and specialty outpatient visits . Because GV adherence is potentially dependent on unobserved patient characteristics , treatment effect models of outpatient charges and specialty care visits were estimated using maximum likelihood methods . RESULTS Mann-Whitney test results indicated that GV patients had reduced ED and total charges but more outpatient charges than usual care patients . Ordinary least squares estimations confirmed that GVs increased outpatient visit charges ; however , controlling for endogeneity by estimating a treatment effect model of outpatient visit charges showed that GVs statistically significantly reduced outpatient charges ( P < .001 ) . Estimation of a separate treatment effect model of specialty care visits confirmed that GV effects on outpatient visit charges occurred via a reduction in specialty care visits . CONCLUSIONS After controlling for endogeneity via estimation of a treatment effect model , GVs statistically significantly reduced outpatient visit charges . Estimation of a separate treatment effect model of specialty care visits indicated that GVs likely substitute for more expensive specialty care visits To evaluate group visits in the management of underinsured patients with uncontrolled type 2 diabetes , 120 eligible patients enrolled were r and omly assigned to receive care in groups or continue usual care .  Feasibility , acceptability , and concordance with American Diabetes Association st and ards of care ( Diab Camre . 25[suppl 1]:533 - 549 ) were evaluated . Patients who received care in groups exhibited improvement in American Diabetes Association st and ards of care ( p < .001 ) , improved sense of trust in physician ( p = .02 ) , and tended to report better coordination of care ( p = .07 ) , better community orientation ( p = .09 ) , and more culturally competent care ( p = .09 ) . Group visits offer a promising model for delivering health care to these patients AIM The purpose of this study was to examine the effect of the diabetes outpatient intensive management programme ( DOIMP ) on glycaemic control over a 12 week follow-up period for type 2 diabetic patients in Korea . BACKGROUND Diabetic complications can be prevented if the glycaemic status of diabetes patients is maintained within a nearly normal range . Patient education is critical in controlling blood glucose levels of patients with diabetes within the optimal range . METHODS DOIMP was composed of multidisciplinary education , complication monitoring and telephone counselling .  Twenty-five patients in the intervention group participated in the DOIMP and 24 patients in the control group were briefed on the conventional description of diabetes mellitus by diabetes education nurses . RESULTS Patients in the intervention group had a mean decrease of 2.3 % , which those in the control group having a mean decrease 0.4 % in glycosylated haemoglobin ( HbA(1)c ) . There was no difference between the two groups in the change in fasting blood glucose ( FBG ) and two-hour postpr and ial blood glucose ( 2-h PBG ) . The proportion of the patients with HbA(1)c < 7 % was higher in the intervention group than in the control group at the post-test compare with the pretest . CONCLUSION DOIMP can reduce HbA(1)c in type 2 diabetes patients . RELEVANCE TO CLINICAL PRACTICE These findings indicated that DOIMP could be effective in glycaemic control in type 2 diabetes patients Objective : The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency . One method of system re design based on the chronic care model is the Shared Medical Appointment ( SMA ) in which groups of patients ( 8–20 ) 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-r and omised 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 re design Analytical methods : Paired and independent t tests , χ2 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 re design that may help to improve quality of care OBJECTIVE in an academic family practice clinic , we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes . Providers received didactic training and computerized compliance feedback to support staged diabetes management , an evidence d-based approach to diabetes care . RESEARCH DESIGN AND METHODS one firm of the clinic practice received the intervention , the other served as the control group  during a 14-month baseline period and a 14-month study period . HbA1(c ) was the principal outcome measure . RESULTS there was a significant 0.71 % difference in change in HbA1(c ) values between the intervention and control firms ( P=0.02 ) . The subgroup with the greatest improvement in HbA1(c ) was those subjects who started the intervention with a HbA1(c ) above 8 % . The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy . There were no changes in healthcare utilization or costs between the two firms . CONCLUSION in an academic family practice clinic , a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs . The improvement was mostly due to mitigation of the natural deterioration in control usually seen . Further efforts are required to involve all patients in co-managing their diabetes AIMS Scarcity of re sources , expertise and evidence -based models have so far limited delivery of patient-centred diabetes education . We have developed and vali date d a group care approach that is applicable to everyday clinical practice and cost-effective in improving metabolic control , knowledge of diabetes , health behaviours , and quality of life in Type 2 diabetes . A clinical trial ( ROMEO ) was planned to evaluate applicability and reproducibility of group care in other out patients facilities and assess its impact on a larger patient population . METHODS Multicentre , r and omized , controlled clinical trial of group vs. individual care in the routine management of Type 2 diabetes . Nine hundred patient aged < 80 , with diabetes of > or = 1 year known duration , treated by either diet alone or diet and oral agents , will be recruited in 15 centres and followed for 4 years .  Training of physicians , nurses and dietitians included preparation of operating manual and videos , interactive sessions , and evaluation of local facilities and re sources . RESULTS PRIMARY MEASUREMENTS 3-monthly HbA1c , fasting blood glucose , body weight , waist-hip ratio , yearly blood lipids , and bi-yearly assessment of knowledge of diabetes , health behaviours and quality of life . SECONDARY OUTCOMES systolic and diastolic blood pressure , evaluation of ECG for ischaemia and QT interval , hypoglycaemic and anti-hypertensive medication and cardiovascular events . Analysis will be by intention-to-treat . DISCUSSION If ROMEO confirms that group care can be successfully implemented in different clinics , a novel clinico-pedagogic tool will have been acquired to support patient-centred education , improve lifestyle and outcomes , support team work , enhance providers ' attitudes and competencies and ameliorate diabetes care organization Abstract Aims /hypothesis . Metabolic control worsens progressively in Type II ( non-insulin-dependent ) diabetes mellitus despite intensified pharmacological treatment and lifestyle intervention , when these are implemented on a one-to-one basis . We compared traditional individual diabetes care with a model in which routine follow-up is managed by interactive group visits while individual consultations are reserved for emerging medical problems and yearly checks for complications . Methods . A r and omized controlled clinical trial of 56 patients with non-insulin-treated Type II diabetes managed by systemic group education and 56 control patients managed by individual consultations and education .  Results . Observation times were 51.2±2.1 months for group care and 51.2±1.8 for control subjects . Glycated haemoglobin increased in the control group but not in the group of patients ( p<0.001 ) , in whom BMI decreased ( p<0.001 ) and HDL-cholesterol increased ( p<0.001 ) . Quality of life , knowledge of diabetes and health behaviours improved with group care ( p<0.001 , all ) and worsened among the control patients ( p=0.004 to p<0.001 ) . Dosage of hypoglycaemic agents decreased ( p<0.001 ) and retinopathy progressed less ( p<0.009 ) among the group care patients than the control subjects . Diastolic blood pressure ( p<0.001 ) and relative cardiovascular risk ( p<0.05 ) decreased from baseline in group patients and control patients alike . Over the study period , group care required 196 min and 756.54 US $ per patient , compared with 150 min and 665.77 US $ for the control patients , result ing in an additional 2.12 US $ spent per point gained in the quality of life score . Conclusion /interpretation . Group care by systemic education is feasible in an ordinary diabetes clinic and cost-effective in preventing the deterioration of metabolic control and quality of life in Type II diabetes without increasing pharmacological treatment AIM Central serotoninergic activity may modulate glucose metabolism via neuroendocrine effectors . Group Care is a clinico-pedagogic intervention that improves metabolic control and quality of life in Type 2 diabetes through lifestyle modification and , possibly , central mechanisms . The hypothesis that central serotoninergic activity is modified in patients followed by Group Care  was tested by measuring their hypothalamic- pituitary-adrenal response to citalopram , a selective serotonin reuptake inhibitor . METHODS AND SUBJECTS Ten healthy controls and 17 non-obese , non-insulin-treated patients with Type 2 diabetes received , in r and om order , iv infusions of either 20 mg citalopram or saline .  Nine patients had been longterm on Group Care and 8 had always been on traditional one-to-one  care . Circulating glucose , insulin , ACTH , cortisol , DHEA , GH and PRL were measured every 15 min for 240 min . Differences between areas under the curves after citalopram and saline ( Δ-AUC ) were calculated . RESULTS Citalopram stimulated ACTH and cortisol secretion in healthy subjects ( p=0.026 and p=0.011 , respectively ) and patients on Group Care ( p=0.056 and p=0.038 ) but not in patients on traditional care . In healthy subjects , basal glucose correlated with growth hormone Δ- AUC ( r=0.820 ; p=0.004 ) and inversely with insulin Δ-AUC ( r=-0.822 ; p=0.003 ) . The former correlation was preserved in the patients ( r=0.637 ; p=0.026 ) . CONCLUSIONS Diabetes may blunt the response of the hypothalamic-pituitary-adrenal axis to citalopram , but this is preserved in patients followed by a long-term intervention model that improves clinical as well as cognitive and emotional variables Hmong refugees with type 2 diabetes mellitus ( DM2 ) have poor glycemic control . For Hmong adults with DM2 , group visits were instituted at a community health center and evaluated for their influence on diabetes management . Pre- and postintervention measures of physical health , mental health , and behavior were collected on 39 participants ( 64 % participation rate ) . Baseline characteristics and clinical outcomes of 39 group visit participants were compared with 22 Hmong DM2 adults who refused to participate and 216 nonparticipating Hmong DM2 adults from a local diabetes registry . Baseline characteristics were similar among the three groups . Although participants received good medical services and their mental health improved ( p < 0.05 ) , clinical outcomes did not significantly improve . Although group visits are feasible for providing medical services for Hmong adults with DM2 , clinical outcomes remain outside of recommended targets . Addressing mental health in this population may be necessary before people can institute behavioral changes that improve diabetes management Recently , investigators have combined formally the results of all available r and omized trials testing a particular therapy to get a better estimate of the effectiveness of that treatment than any single trial can provide in isolation . It seems intuitively clear , however , that formal overviews will yield medically meaningful results only under certain defined circumstances . First , the treatments that are pooled should be similar enough that any inferences about the effect of treatment will refer to something more specific than an idealized ' average therapy ' . Second , patient selection in the pooled trials should be uniform enough that the inferences will be applicable to some defined patient population . Third , although the potential biases of excluding trials from pooling are substantial , so are the problems of including trials whose execution might be flawed in a biased manner ; it is not clear what can be done about this , since biased studies probably can not be identified in an unambiguous manner . Finally , it would seem prudent to consider the medical context during which trials were performed ; it is probably not reasonable to assume that quantitative measures of treatment effect obtained by pooling studies from different eras of treatment will be an accurate reflection of what current treatment can achieve , even if everything else is held constant . For these reasons the quantitative measures of treatment effect that derive from formal overviews may have little relevance to medical decision-making . Overviews might still be useful in indicating the general direction of a treatment effect , provided that no qualitative interactions are present . Although such interactions may seem improbable , some recent examples from the cancer literature suggest that their presence can not be ruled out a priori OBJECTIVE A trial was performed to establish whether our group care model for lifestyle intervention in type 2 diabetes can be exported to other clinics . RESEARCH DESIGN AND METHODS This study was a 4-year , two-armed , multicenter controlled trial in 13 hospital-based diabetes clinics in Italy ( current controlled trials no. IS RCT N19509463 ) . A total of 815 non – insulin-treated patients aged < 80 years with ≥1 year known diabetes duration were r and omized to either group or individual care . RESULTS After 4 years , patients in group care had lower A1C , total cholesterol , LDL cholesterol , triglycerides , systolic and diastolic blood pressure , BMI , and serum creatinine and higher HDL cholesterol ( P < 0.001 , for all ) than control subjects receiving individual care , despite similar pharmacological prescriptions . Health behaviors , quality of life , and knowledge of diabetes had become better in group care patients than in control subjects ( P < 0.001 , for all ) . CONCLUSIONS The favorable clinical , cognitive , and psychological outcomes of group care can be reproduced in different clinical setting Purpose To improve the care and outcomes of adult patients with type 2 diabetes by teaching interprofessional teams of learners the principles and practice s of the Improving Chronic Illness Care Model . Method The study population consisted of 384 adult patients with type 2 diabetes . The study design was a nonr and omized , parallel-group , clinical trial conducted during 18 months in the University of California , San Francisco internal medicine clinics .  Interprofessional team care provided by primary care internal medicine residents , nurse practitioner students , and pharmacy students was compared with usual care by internal medicine residents only .  Processes of care , clinical status , and health utilization were measured in both patient groups . Learner outcomes also were assessed and compared . Results At study completion , intervention patients more frequently received assessment s of glycosolated hemoglobin ( 79 % versus 67 % ; P = .01 ) , LDL-C ( 69 % versus 55 % ; P = .009 ) , blood pressure ( 86 % versus 79 % ; P = .08 ) , microalbuminuria ( 40 % versus 30 % ; P = .05 ) , smoking status assessment ( 43 % versus 31 % ; P = .02 ) , and foot exams ( 38 % versus 20 % ; P = .0005 ) . Intervention patients had more planned general medicine visits ( 7.9 ± 6.2 versus 6.2 ± 5.7 ; P = .006 ) than did control patients . Interprofessional learners rated themselves significantly higher on measures of accomplishment , preparation , and success for chronic care than did the usual care learners . Conclusions Interprofessional team care by learners was effective in improving quality of care for adult patients with diabetes treated in general medicine clinics . The chronic illness framework result ed in more appropriate health care utilization OBJECTIVE To estimate the incremental cost-effectiveness of improving diabetes care with the Health Disparities Collaborative ( HDC ) , a national collaborative quality improvement ( QI ) program conducted in community health centers ( HCs ) . DATA SOURCES / STUDY SETTING Data regarding the impact of the  Diabetes HDC program  came from a serial cross-sectional follow-up study ( 1998 , 2000 , 2002 ) of the program in 17 Midwestern HCs . Data inputs for the simulation model of diabetes came from the latest clinical trials and epidemiological studies . STUDY DESIGN We conducted a societal cost-effectiveness analysis , incorporating data from QI program evaluation into a Monte Carlo simulation model of diabetes . DATA COLLECTION / EXTRACTION METHODS Data on diabetes care processes and risk factor levels were extracted from medical charts of r and omly selected patients . PRINCIPAL FINDINGS From 1998 to 2002 , multiple processes of care ( e.g. , glycosylated hemoglobin testing [ HbA1C ] [ 71 - ->92 percent ] and ACE inhibitor prescribing [ 33 - ->55 percent ] ) and risk factor levels ( e.g. , 1998 mean HbA1C 8.53 percent , mean difference 0.45 percent [ 95 percent confidence intervals -0.72 , -0.17 ] ) improved significantly . With these improvements , the HDC was estimated to reduce the lifetime incidence of blindness ( 17 - ->15 percent ) , end-stage renal disease ( 18 - ->15 percent ) , and coronary artery disease ( 28 - ->24 percent ) . The average improvement in quality -adjusted life year ( QALY ) was 0.35 and the incremental cost-effectiveness ratio was $ 33,386/QALY . CONCLUSIONS During the first 4 years of the HDC , multiple improvements in diabetes care were observed . If these improvements are maintained or enhanced over the lifetime of patients , the HDC program will be cost-effective for society based on traditionally accepted thresholds
target: The most significant effect observed is with the change from baseline results .
  Some evidence suggests post-intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe .
  There is no evidence that group visits improve LDL cholesterol values of the group visit participants .
  IMPLICATION S FOR PRACTICE The evidence suggests that the most powerful model of Group medical visits ( GMV ) is when a clinician prescriber is present during or immediately after GMV sessions for medication reconciliation or individual patient needs .
background: BACKGROUND The prevalence of diabetes mellitus is ubiquitous .
  Complications and costs of diabetes are rising and are depleting limited re sources .
  It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions .
  An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit .
  Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting .