Examining Adaptations to Implementation of Diabetes Shared Medical Appointments in Primary Care

Context: Self-management, including diet, exercise, use of medications, and stress management, is essential for good outcomes in Type 2 Diabetes Mellitus (T2DM). Shared medical appointments (SMAs) are an avenue for primary care practices to support development of self-management, but implementation of SMAs is context dependent and often requires adaptations for each practice.

Objective: To describe adaptations made by practices participating in the Invested in Diabetes (IID) project during implementation of SMAs.

Study Design and Analysis: IID is a pragmatic cluster-randomized, comparative effectiveness trial designed to compare two different approaches to delivery of diabetes shared medical appointments (SMAs). Key informant interviews with traditional qualitative thematic analysis, thematic analysis of coach notes and session observations; multi-step process to categorize adaptations using FRAME.

Population studied: primary care team members involved in delivering SMAs including medical and behavioral health providers, health educators, coordinators.

Intervention/Measurement: Semi-structured interview guide, session observation guide.

Outcome measures: Emergent themes pertaining to adaptations made by participating practices

Results: Four dominant themes emerged: 1) Adaptations are common in implementation of SMAs. 2) Implementation challenges can be improved or overcome through actively identifying those challenges and making changes in response. Specific challenges identified include recruitment and retention, physical space, staff involvement and turnover, and scheduling 3) Content changes in the classes were often planned and enacted to better address the contextual circumstances such as patient needs and culture. 4) Adaptation components tend to cluster together in certain types that may reveal ways to improve on desired implementation outcomes.

Conclusions: SMA implementation in real-world primary care settings requires adaptations related to practice-specific contexts. Practices benefit from support to identify and address areas that need adaptation for successful implementation.