By Annette M. Boyle
WASHINGTON — For the more than one million VHA patients who have diabetes, peer support and shared medical appointments offer an efficient, surprisingly effective, way to deliver care and improve disease management.
The shared medical appointment (SMA) is a multidisciplinary team approach that, at the VA, typically includes a physician, diabetes nurse, health psychologist, dietician and clinical pharmacist. In addition, the team draws on the expertise of patients, who must deal with practical management of the disease and often have solutions clinicians have not considered.
“By having patients in the same room, they can support each other, especially when they share experiences,” said David Aron, MD, MS, associate director of the VA’s Quality Enhancement Research Initiative (QUERI) Center for Implementation Practice and Research Support.
“I remember one particular incident when a veteran with diabetes was listening to another veteran and saying he couldn’t do ‘x or y.’ She pulls up her sleeve, and there is an AV fistula which is going to enable her to have hemodialysis. She says ‘Listen, I didn’t take care of myself, and this is what I have because of that. You better get started.’ Veterans talking to veterans can be very, very effective,” Aron said.
Several randomized clinical trials have proven the technique’s effectiveness. A study published in Quality and Safety in Health Care found that patients who participated in one to seven shared medical appointments with as many as 19 other patients over a three-month period achieved a 1.4 point reduction in glycated hemoglobin measures (HbA1c). Other research has demonstrated that diabetic patients who participate in shared medical appointments have significantly fewer specialty and emergency room visits.
The benefit of peer support, though, extends beyond the shared medical appointment. Researchers at the Ann Arbor, MI, VA and University of Michigan Medical School found peer-to-peer support significantly more effective than traditional nurse support in controlling blood sugar levels in diabetic male veterans. The randomized controlled trial, published in the Annals of Internal Medicine, looked at the six-month change in blood glucose levels in 244 men with HbA1c levels in excess of 7.5%.
Patients in the peer-support group were trained in communication skills and instructed to call each other at least once a week to discuss their efforts to improve diabetes control. All patients were offered periodic nurse-facilitated group sessions.
Equal to New Medication
Peer-support participants achieved average HbA1c levels 0.58 points lower than those in the nurse care group. Patients in the peer-support group who started the study with HbA1c levels above 8% saw a drop of 0.88 points — about the change expected from adding a new medication — compared with a decline of only 0.07 percentage points for those only receiving nursing care.
Eight of the peer-supported patients in the Ann Arbor study started insulin, compared with only one in the nursing-care group. Overcoming the fear of injecting insulin often is a stumbling block for patients who need the greater control insulin provides.
At a Media Roundtable, Aron recounted the story of an older veteran who responded to a question about the biggest challenge he faced as a diabetic: “I was in Vietnam. I’ve been shot. I’ve been stabbed. I’ve been beaten; but the idea of injecting myself with insulin every day scared the crap out of me.”
“We’ve found that patients in peer-support programs are significantly more willing to start insulin, and that’s not so surprising. Talking to someone who’s on insulin who says it’s not that bad is a lot different than talking to your doctor who tells you it’s not that bad,” said Michele Heisler, MD, staff physician at the VA Ann Arbor Health Care System and director of the Community Outreach and Engagement Core at the Michigan Center of Diabetes Translation Research.
Another recent study conducted at the Philadelphia VA Medical Center assigned 118 African-American veterans with uncontrolled diabetes to one of three groups for six months. The first group received telephone counseling from other African-American veterans who had gained control of their own diabetes. Mentors earned $20 per month if they contacted their mentee at least once a week. The other group received treatment as usual. The third group earned $200 at the end of the study, if they significantly reduced their blood glucose levels.
The peer-supported group achieved about a 1-point drop in HbA1c, from about 9.8% to 8.7%. Neither the usual care nor the group with a financial incentive had statistically significant reductions in blood glucose measures. Results were published in the Annals of Internal Medicine.
In addition to being effective, peer support has minimal costs. “Nurse-led care management programs definitely improve diabetes self-care and risk-factor control. The problem is these programs are very labor and resource intensive and may not provide as much support as many patients need. Telephone-based peer support among patients is a very promising approach to improve both the quality and the quantity of support,” Heisler said.
In partnership with four different facilities, Heisler and her colleagues are studying whether the superior results in the peer-support program in the Ann Arbor study can be more broadly replicated.
Peer support might work better than other approaches such as nurse-managed or pharmacist-led interventions, because it taps into veterans’ shared identity and the universal need to be needed, Heisler said.
“One veteran said a lot of old people with diabetes like us sit at home and stare out the window. We feel sick and pretty useless. I learn things about taking care of my diabetes from my peer partner, but I also felt like I helped him. It made me feel inspired to do more.”
Others note that peer pressure continues to be a powerful motivator at any age. “Ever since I’ve been in this program, I’ve done much better,” a participant told Heisler. “It’s peer pressure. I don’t want to have to admit to this guy that my blood sugar is up.”
“Among other reasons for the intervention’s success,” said Judith Long, MD, lead researcher for the Philadelphia study and core investigator with the VA Health Services Research & Development Service Center for Health Equity and Promotion, “we believe there was a strong culture of camaraderie among the veterans who took part in the study.”
As with other chronic illnesses, social support is a critical factor in managing diabetes — and one often difficult for family and friends to fill. That social support might help VA patients improve their health beyond managing their diabetes — and possibly improve the health of those around them.
“When you help patients control their blood sugar, you might have spillover into other risk factors, like blood pressure or cholesterol,” said William Yancy, MD, MHSc, senior physician in the Ambulatory Care Service and senior investigator for the Center for Health Services Research in Primary Care at the Durham, NC, VA Medical Center. “There can also be spillover to patients’ family members and their friends. We have multiple anecdotes of spouse, children, church members who have learned dietary control from our patients and themselves lost large amounts of weight,” reducing their risk of developing diabetes.