Type II Diabetes is a prevalent chronic disease with poor outcomes, and requires daily self-care, including blood glucose monitoring, following a diabetes-friendly diet, engaging in regular physical activity, and medication adherence. Patients with diabetes benefit from comprehensive diabetes self-management education (DSME) and self-management support (SMS) in primary care. Shared medical appointments (SMAs) are one way to efficiently and effectively provide DSME and SMS. SMAs can have a variety of different features, but it is not known which features are most effective for which types of patients. 

Invested in Diabetes is a pragmatic, cluster randomized comparative effectiveness trial of diabetes shared medical appointments (SMAs) using patient-driven educational content delivered by multidisciplinary care teams including peer mentors, compared to SMAs with standardized content delivered by health educators. The aims are to implement patient-driven and standardized SMAs in twenty practices using patient and provide partner engagement and evidence-based implementation strategies, and to evaluate differences in patient participation in care, patient-reported outcomes (diabetes distress, self-care behaviors, quality of life), clinical outcomes, and practice-level adoption, implementation, and maintenance. Invested in Diabetes was funded by the Patient Centered Outcomes Research Institute (PCORI), and more information about Invested in Diabetes can be found at this link. 

Patient and primary care clinic partners engaged in planning this study proposed a model with "diabetes' veterans" (i.e., diabetes peer mentors) who co-facilitating group visits with a variety of diabetes care professionals, and then working one-on-one with patients to help apply what they learned. The group visit curriculum should include topics on physical activity, healthy eating, taking medication, acceptance and coping, and social support, and each cohort of patients should get to select topics most relevant to them. 

Based on feedback from our patient partners, we designed a study that compared the effectiveness of patient-driven diabetes SMAs to standardized diabetes SMAs. The curriculum used was Targeted Training for Illness Management (TTIM), a 6-session modular group intervention for chronic illness self-management, and that has been tested in diabetes.

The standardized group visit model consisted of diabetes SMAs with the full TTIM 6-session curriculum, led by a health educator. For the patient-driven SMAs, patients chose the topics and the order of sessions from the TTIM curriculum, which was delivered collaboratively by the multidisciplinary care team consisting of several professional providers (health educator, medical provider, and behavioral health provider) and a lay worker (diabetes peer mentor).

The primary patient-centered outcome, selected by patient partners, was diabetes distress. Secondary outcomes included autonomy support and diabetes self-management behaviors, clinical outcomes (hemoglobin A1c, blood pressure, and body mass index), patient reach and engagement, and practice-level value and sustainability. Patient, caregiver, and primary care practice partners as well as research collaborators were engaged in all aspects of the research. Patients and primary care practice partners informed the process of implementation of patient-driven and standardized SMAs, helped finalize the research protocol (including data collection and recruitment), and contributed to interpretation of findings and dissemination of findings, including messages that help other patients make decisions about whether or not to participate in SMAs.

Invested in Diabetes Implementation Guide. 

Targeted Training in Illness Management Curriculum and Instructor Materials

The Invested in Diabetes team included experts, partners, and professionals from across the country.

Principal Investigators:

• Bethany M. Kwan (PI), CU Anschutz Medical Campus
• Jeanette A. Waxmonsky (Co-PI), CU Anschutz Medical Campus

Co-Investigators:

• Russel Glasgow, PhD (Co-I), CU Anschutz Medical Campus
• Martha Sajatovic, MD (Co-I), Case Western Reserve University
• R. Mark Gritz, PhD (Co-I), CU Anschutz Medical Campus
• L Miriam Dickinson, PhD (Co-I), CU Anschutz Medical Campus
• Jodi S Holtrop, PhD (Co-I), CU Anschutz Medical Campus
• Andrea Nederveld, PhD, MPH (Co-I), CU Anschutz Medical Campus
• Natalie D Ritchie, PhD (Co-I), Denver Health
• Don Nease Jr., MD (Co-I), CU Anschutz Medical Campus
• Christina Hester, PhD (Co-I), AAFP National Research Network
• Jennifer Dailey-Vail, APRN, DNP (Co-I), CU Anschutz Medical Campus

Patient Partners:

• Ramona Koren
• Sharon A Trujillo
• David Downey
• Thomas Carrigan
• Barbara Clay

Professional Support:

• Dennis Gurfinkel, MPH (Study manager), CU Anschutz Medical Campus
• Robyn Wearner, MA, RD (practice facilitator), CU Anschutz Medical Campus
• Anowara Begum, MPH (research assistant), CU Anschutz Medical Campus
• Jack Cronin, MS (research assistant), CU Anschutz Medical Campus
• Julia Reedy, MA (research assistant), CU Anschutz Medical Campus
• Patrick Hosokawa, MS (analyst), CU Anschutz Medical Campus
• Jayna DeRoeck, MS (diabetes educator), Denver Health
• Kristin Cassidy, MA (research assistant), Case Western Reserve University
• Angie Lanigan, MPA, RD (research assistant), AAFP National Research Network
• Carol Gorman, BA (research assistant), CU Anschutz Medical Campus
• Mika Hamer, PhD (research assistant), CU Anschutz Medical Campus
• Johnny Williams, MPH (research assistant), CU Anschutz Medical Campus
• Peter Ferrarone, MA (research assistant), CU Anschutz Medical Campus
• Jenny Rementer, MA (former practice facilitator), CU Anschutz Medical Campus