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Nederveld A, Phimphasone-Brady P, Gurfinkel D, Waxmonsky JA, Kwan BM, Holtrop JS. Delivering diabetes shared medical appointments in primary care: early and mid-program adaptations and implications for successful implementation. BMC PRIMARY CARE 2023; 24:52. [PMID: 36803773 PMCID: PMC9936115 DOI: 10.1186/s12875-023-02006-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/09/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Self-management is essential for good outcomes in type 2 diabetes and patients often benefit from self-management education. Shared medical appointments (SMAs) can increase self-efficacy for self management but are difficult for some primary care practices to implement. Understanding how practices adapt processes and delivery of SMAs for patients with type 2 diabetes may provide helpful strategies for other practices interested in implementing SMAs. METHODS The Invested in Diabetes study was a pragmatic cluster-randomized, comparative effectiveness trial designed to compare two different models of diabetes SMAs delivered in primary care. We used a multi-method approach guided by the FRAME to assess practices' experience with implementation, including any planned and unplanned adaptations. Data sources included interviews, practice observations and field notes from practice facilitator check-ins. RESULTS Several findings were identified from the data: 1) Modifications and adaptations are common in implementation of SMAs, 2) while most adaptations were fidelity-consistent supporting the core components of the intervention conditions as designed, some were not, 3) Adaptations were perceived to be necessary to help SMAs meet patient and practice needs and overcome implementation challenges, and 4) Content changes in the sessions were often planned and enacted to better address the contextual circumstances such as patient needs and culture. DISCUSSION Implementing SMAs in primary care can be challenging and adaptations of both implementation processes and content and delivery of SMAS for patients with type 2 diabetes were common in the Invested in Diabetes study. Recognizing the need for adaptations based on practice context prior to implementation may help improve fit and success with SMAs, but care needs to be given to ensure that adaptations do not weaken the impact of the intervention. Practices may be able to assess what might need to adapted for them to be successful prior to implementation but likely will continue to adapt after implementation. CONCLUSION Adaptations were common in the Invested in Diabetes study. Practices may benefit from understanding common challenges in implementing SMAs and adapting processes and delivery based on their own context. TRIAL REGISTRATION This trial is registered on clinicaltrials.gov under Trial number NCT03590041, posted 18/07/2018.
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Affiliation(s)
- Andrea Nederveld
- Department of Family Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, 80045, USA.
| | - Phoutdavone Phimphasone-Brady
- grid.430503.10000 0001 0703 675XDepartment of Psychiatry, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Dennis Gurfinkel
- grid.430503.10000 0001 0703 675XAdult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Jeanette A. Waxmonsky
- grid.430503.10000 0001 0703 675XDepartment of Family Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045 USA ,grid.430503.10000 0001 0703 675XAdult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Bethany M. Kwan
- grid.430503.10000 0001 0703 675XAdult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045 USA ,grid.430503.10000 0001 0703 675XDeparment of Emergency Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045 USA
| | - Jodi Summers Holtrop
- grid.430503.10000 0001 0703 675XDepartment of Family Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045 USA ,grid.430503.10000 0001 0703 675XAdult and Child Center for Outcomes Research and Delivery Science, University of Colorado, Anschutz Medical Campus, Aurora, CO 80045 USA
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Bottino CJ, Puente GC, Burrage A, Tannis C, Cheng JK, Epee-Bounya A, Cox JE. Primary Care Group Visits for Childhood Obesity: Clinical Program Evaluation. Clin Pediatr (Phila) 2018; 57:442-450. [PMID: 28929794 DOI: 10.1177/0009922817728696] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
We conducted 29 group visits targeting children with elevated body mass index (BMI) and their families. Visit activities focused on social support, mind-body techniques, exercise, and nutrition. Measures included attendance, family satisfaction scores, and per-patient change in BMI percentile. Ninety-six patients attended ≥1 group visit, mean 2.0 (SD ±1.8; range 1-14). Mean patient age was 9.6 years (SD ±2.4; range 4-15 years); 53.1% were female; 44.8% had a BMI 95th to 99th percentile for age/sex; 35.4% had a BMI >99th percentile. Mean attendance per group visit was 6.8 patients (SD ±3.8; range 1-16 patients). Mean family satisfaction scores were 9.8 (SD ±0.8) with 10/10 "would recommend to family or friends." Of 42 patients who attended ≥2 group visits, 5 (11.9%) experienced a ≥5 BMI percentile reduction between first and last visits; 3 (7.1%) maintained this reduction 2 years later. Group visits were associated with high family satisfaction scores, though few patients experienced a reduction in BMI percentile.
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Affiliation(s)
- Clement J Bottino
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Gabriella C Puente
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA
| | - Amanda Burrage
- 3 Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Candace Tannis
- 3 Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jennifer K Cheng
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Alexandra Epee-Bounya
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
| | - Joanne E Cox
- 1 Division of General Pediatrics, Boston Children's Hospital, Boston, MA, USA.,2 Harvard Medical School, Boston, MA, USA
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Implementation and Evaluation of Shared Medical Appointments in Veterans With Diabetes: A Quality Improvement Study. J Nurs Adm 2018; 48:154-159. [PMID: 29461352 DOI: 10.1097/nna.0000000000000590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study is to implement and evaluate shared medical appointments (SMA) in veterans with diabetes. BACKGROUND Health systems are challenged to meet the complex care needs of veterans with diabetes. Use of SMA has resulted in significant improvements in A1c, blood pressure, and self-management skills in this population. METHODS Shared medical appointments were implemented in a Veterans Administration Health System. A1c, blood pressure, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, weight, and height were collected at baseline, 3 months, and 6 months; hospitalization anytime; and veteran satisfaction at baseline and 6 months. RESULTS From October 15, 2015, to March 15, 2016, 30 male veterans with diabetes participated in monthly SMA. Outcome measures except for high-density lipoprotein improved significantly (P < .02) from baseline to 6 months. No veterans were hospitalized. Veteran satisfaction increased significantly (P < .001). CONCLUSION Shared medical appointment can be a highly effective intervention for veterans with diabetes. Nursing leaders need to be at the forefront of implementing SMA for populations with chronic conditions.
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Fujita T, Iida Y, Tanaka C, Nakamura K, Yamanaka K, Ueno J, Iino Y, Chitose H, Sakamoto H, Daiko H. Development and evaluation of an "Interdisciplinary Postoperative Support Program" in outpatient clinics after thoracic esophagectomy. Int J Surg 2017; 43:58-66. [PMID: 28529190 DOI: 10.1016/j.ijsu.2017.05.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Revised: 05/13/2017] [Accepted: 05/15/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND To support patients discharged from the hospital after surgery, we launched an "Interdisciplinary Postoperative Support Program" in outpatient clinics for patients who were discharged within 1 month after thoracic esophagectomy and their families. We introduce our program and clarify the patient's physical and psychologic status by analyzing the questionnaire provided from this program. MATERIALS AND METHODS From August 2014 to January 2015, we conducted the Interdisciplinary Postoperative Support Program every month. Thus, questionnaires regarding physical and psychologic symptoms as well as the meaningfulness of the program were obtained from 59 patients and prospectively analyzed. RESULTS We obtained valid responses from 48 patients (81.4%). Frequent postoperative difficulties included dysphagia (50%) and decreased physical strength (39.5%). Oral intake decreased to half (55.3%) and one-fourth (25.5%) of that before esophagectomy. Frequent requests made by patients to medical staff included explanations of the postoperative symptoms (97.9%), further information on the treatments of esophageal cancer (93.8%), and the typical postoperative course experienced by other patients (76.6%). A higher percentage of positive comments were obtained regarding the management of symptoms (87.8%) and optimal access to the consultations (78.9%). The incidences of unscheduled outpatient visits were 4.1% and 14.0%, respectively, under conditions with and without this postoperative program (P = 0.03). CONCLUSION We found that our program could provide appropriate information with higher levels of satisfaction after thoracic esophagectomy. Further investigations regarding longer periods of physical and psychologic symptoms, as well as the needs of patients and their families should be conducted to augment our program.
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Affiliation(s)
- Takeo Fujita
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan.
| | - Yoko Iida
- Supportive Care Center, National Cancer Center Hospital East, Kashiwa, Japan
| | - Chiharu Tanaka
- Supportive Care Center, National Cancer Center Hospital East, Kashiwa, Japan
| | - Kumi Nakamura
- Supportive Care Center, National Cancer Center Hospital East, Kashiwa, Japan
| | - Keiko Yamanaka
- Supportive Care Center, National Cancer Center Hospital East, Kashiwa, Japan
| | - Junya Ueno
- Division of Rehabilitation Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yoshie Iino
- Division of Rehabilitation Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Haruka Chitose
- Division of Nutrition, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hatoe Sakamoto
- Supportive Care Center, National Cancer Center Hospital East, Kashiwa, Japan
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Floyd BD, Block JM, Buckingham BB, Ly T, Foster N, Wright R, Mueller CL, Hood KK, Shah AC. Stabilization of glycemic control and improved quality of life using a shared medical appointment model in adolescents with type 1 diabetes in suboptimal control. Pediatr Diabetes 2017; 18:204-212. [PMID: 26919322 DOI: 10.1111/pedi.12373] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/19/2016] [Accepted: 01/28/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Declining glycemic control in type 1 diabetes (T1D) during adolescence persists despite treatment advances. Non-adherence, peer relations, diabetes burnout, risk taking, transition to autonomy, family conflict, and poor quality of life (QOL) are recognized barriers. Shared medical appointments (SMAs) in adolescent T1D may offer benefits, but data are limited. Our objective was to determine whether SMAs, with multi-component interventions utilizing multidisciplinary teams, improve glycemic control and psychosocial outcomes in poorly controlled adolescent T1D. METHODS SMAs focused on self-management, communication skills, goal setting, glucose pattern recognition, and peer/diabetes team support. SMAs included: individual history and physical, labs, surveys, multidisciplinary educational ice breakers, group session, and individual wrap up. Outcomes were QOL, adherence, and retrospective and prospective glycemic control. Three to six subjects and families came to 3 SMAs and 1 individual appointment every 3 months over 9 months. SUBJECTS A total of 37 English speaking subjects, ages 12-16 yrs, with T1D ≥ 1 year, and hemoglobin A1c (HbA1c) 7.5-11% enrolled. Thirty-two subjects attended 75% of visits, meeting inclusion criteria. RESULTS HbA1c worsened in the 9 months before study (ΔHbA1c= 0.7 ± 1.2; p < 0.01), but remained stable during study (ΔHbA1c = 0.01 ± 1.2; p > 0.05). There were significant improvements in overall QOL (p = 0.005), school function (p = 0.006), psychosocial function (p = 0.008), barriers (p = 0.02), adherence (p = 0.01), and communication (p = 0.02). Improvements in school function and communication reached clinical significance. CONCLUSION SMAs are feasible replacements to individual appointments in adolescent T1D, stabilizing glycemic control and improving QOL. Randomized controlled trials with optimizations are needed to further explore and refine this intervention.
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Affiliation(s)
- Baraka D Floyd
- Department of General Pediatrics, Stanford University School of Medicine, Stanford, CA, USA
| | - Jennifer M Block
- Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA
| | - Bruce B Buckingham
- Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA
| | - Trang Ly
- Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Robert Wright
- Department of Psychology, University of California Riverside, Riverside, CA, USA
| | - Claudia L Mueller
- Department of Pediatric Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Korey K Hood
- Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA
| | - Avni C Shah
- Department of Pediatric Endocrinology and Metabolism, Stanford University School of Medicine, Stanford, CA, USA
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Abstract
The number of people with diabetes is expected to rise to over 592 million by the year 2035. Past work provides evidence that the conventional method of primary care delivery may not meet many patients' needs. An alternative to the conventional one-on-one appointment is care offered to a group of patients through group medical visits (GMVs). Group medical visits for diabetes have a positive impact on physiologic and self-care outcomes including improved HbA1c, blood pressure control and self-management skills. Less work has examined the impacts of GMVs on systems of care; however, evidence suggests improved primary and secondary prevention strategies and the potential for GMVs to decrease emergency room visits and hospitalizations. Additional work is needed to examine the effect of GMVs on patient reported quality of life, functional health status and cost-savings. Further work is also needed on which patients GMVs work best for and patient barriers to attending GMVs.
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Affiliation(s)
- Laura M Housden
- University of British Columbia School of Nursing, T201 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada.
| | - Sabrina T Wong
- Centre for Health Services and Policy Research, University of British Columbia School of Nursing, T201 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
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Prescott LS, Dickens AS, Guerra SL, Tanha JM, Phillips DG, Patel KT, Umberson KM, Lozano MA, Lowe KB, Brown AJ, Taylor JS, Soliman PT, Garcia EA, Levenback CF, Bodurka DC. Fighting cancer together: Development and implementation of shared medical appointments to standardize and improve chemotherapy education. Gynecol Oncol 2016; 140:114-9. [PMID: 26549108 PMCID: PMC4698218 DOI: 10.1016/j.ygyno.2015.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Revised: 11/03/2015] [Accepted: 11/04/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Shared medical appointments offer a novel approach to improve efficiency and quality of care consistent with the goals of the Institute of Medicine. Our objective was to develop and implement a shared medical appointment for gynecologic cancer patients initiating chemotherapy. METHODS We first assessed the level of interest in shared medical appointments among our patients and providers through qualitative interviews. Both patients and providers identified pre-chemotherapy as an optimal area to pilot shared medical appointments. We subsequently created a multidisciplinary team comprised of physicians, advanced practice providers, nurses, pharmacists, administrators, health education specialists and members of the Quality Improvement Department to establish a Shared Medical Appointment and Readiness Teaching (SMART) program for all gynecologic oncology patients initiating chemotherapy with platinum- and/or taxane-based regimens. We developed a standardized chemotherapy education presentation and provided patients with a tool kit that consisted of chemotherapy drug education, a guide to managing side effects, advance directives, and center contact information. RESULTS From May 9, 2014 to June 26, 2015, 144 patients participated in 51 SMART visits. The majority of patients had ovarian cancer and were treated with carboplatin/paclitaxel. Surveyed patients reported being highly satisfied with the group visit and would recommend shared medical appointments to other patients. CONCLUSIONS This model of care provides patient education within a framework of social support that empowers patients. Shared medical appointments for oncology patients initiating chemotherapy are both feasible and well accepted.
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Affiliation(s)
- Lauren S Prescott
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Andrea S Dickens
- Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Sandra L Guerra
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jila M Tanha
- The Learning Center, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Desiree G Phillips
- Patient Education, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Katherine T Patel
- Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Katie M Umberson
- Clinical Operations, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Miguel A Lozano
- Performance Improvement, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Kathryn B Lowe
- Department of Supportive Medicine, Memorial Hermann Healthcare System, Houston, TX, United States
| | - Alaina J Brown
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jolyn S Taylor
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Pamela T Soliman
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Elizabeth A Garcia
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Charles F Levenback
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Diane C Bodurka
- Departments of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Delichatsios HK, Hauser ME, Burgess JD, Eisenberg DM. Shared Medical Appointments: A Portal for Nutrition and Culinary Education in Primary Care-A Pilot Feasibility Project. Glob Adv Health Med 2015; 4:22-6. [PMID: 26665019 PMCID: PMC4653594 DOI: 10.7453/gahmj.2015.060] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Diseases linked to obesity such as cardiovascular disease, diabetes, degenerative joint disease, gastroesophageal reflux, and sleep apnea constitute a large portion of primary care visits. Patients with these conditions often lack knowledge, skills, and support needed to maintain health. Shared medical appointments (SMAs) that include culinary skills and nutrition education offer a novel, cost-effective way to address these diseases in primary care. METHODS Adult patients in a primary care practice at a large academic hospital in Boston, Massachusetts, who had at least 1 cardiovascular risk factor were invited to participate in SMAs that included cooking demonstrations and teaching about nutrition in addition to medical management of their conditions. Sessions were conducted by a physician and an assistant in a conference room of a traditional primary care practice as part of a pilot feasibility project. RESULTS Seventy patients, contributing a total of 156 patient visits, attended 17 nutrition-focused SMAs over a 4-year period. Patients were surveyed after each visit and indicated that they enjoyed the SMAs, would consider alternating SMAs with traditional one-on-one visits, and would recommend SMAs to others. Half would pay out of pocket or a higher copay to attend SMAs. Financially, the practice broke even compared with traditional one-onone office visits. CONCLUSION In this feasibility study, chronic disease SMAs conducted with a culinary/nutrition focus were feasible, cost-effective, and well received by patients. Follow-up studies are needed to evaluate short- and long-term outcomes of this SMA model on obesity-related diseases.
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Affiliation(s)
- Helen K Delichatsios
- Massachusetts General Hospital and Harvard Medical School, Boston (Dr Delichatsios), United States
| | - Michelle E Hauser
- Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California, and San Mateo Medical Center, Fair Oaks Health Center, Redwood City, California (Dr Hauser), United States
| | - Jonathan D Burgess
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire (Mr Burgess), United States
| | - David M Eisenberg
- Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts (Dr Eisenberg), United States
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Watts SA, Strauss GJ, Pascuzzi K, O'Day ME, Young K, Aron DC, Kirsh SR. Shared medical appointments for patients with diabetes: Glycemic reduction in high-risk patients. J Am Assoc Nurse Pract 2015; 27:450-6. [DOI: 10.1002/2327-6924.12200] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 03/04/2014] [Indexed: 11/06/2022]
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