Download - Aach group visit
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Efficacy of Group Visits
in
Outpatient Management
of Diabetes
Nicholas Urbanczyk, DO
Peter Farago, MD, Patricia West, PhDDepartment of Family Medicine
St. John HospitalDetroit, MI
October 17, 2011
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1999
Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2009
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2009
1990
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
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0
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1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06
Year
Per
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t w
ith
Dia
bet
es
0
2
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12
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Nu
mb
er w
ith
Dia
bet
es (
Mil
lio
ns)Percent with Diabetes
Number with Diabetes
Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2008
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
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Diabetes: The Epidemic
►Prevalence
20 million Americans diagnosed with DM
$174 billion each year
Number of DM to double by year 2030
►Relevance
Health care costs increasing
New models of care
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There is HopeThere is Hope
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Patient Centered Medical Home
► Structured principles
Personal physician
Whole-person
orientation
Enhanced access
Group Visit model for
chronically ill
patients
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Group Visits
►Seeing patients in small groups
►Weekly, monthly, quarterly for 1-2 hours
►Effectiveness supported by literature
►DM focused but can be extended to any chronic illness
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Group Visits
►Distinguish from more narrowly defined group education classes which address self-mgmt skills, exercise, and nutrition, but…
►Education classes do not provide – Medical evaluation Medication administration Coordination/delivery of preventive health
services
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DM Group Visit
►Include an educational session, plus most components of individual clinic visit Including one-on-one time with physician
►Not a lecture Lectures provide knowledge, but do not
change behavior
►Curriculum for visit is driven by patient questions and concerns
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Literature► AIM-HI Bulletin AAFP 2008
Group medical visits reportedly improved critical health parameters
► Wheelock et al. Fam Med 2009 Patients were making life style changes
HbgA1c and LDL levels did not differ
► Sadur et al. Diabetes Care 1999 Group visits for 6 months
Improved patient satisfaction, self-efficacy and blood-glucose control
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Literature Literature
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The StudyThe Study
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Purpose
In this pilot study, we evaluate whether
Diabetic patients who regularly attend
Group Visits for 6 months at a Patient
Centered Medical Home will show
improvement in their metabolic parameters
and knowledge of their Diabetes
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Methods► All adult Type II diabetics established at
FMC were eligible► Protocol approved by St. John Hospital IRB► Recruitment letters ► Randomly assigned to 2 small groups
10 patients per group► HIPPA disclosure and confidentiality forms► Study length 12 months
January – June 2010 and July – December 2010 Two 6-month block sessions
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Methods►Monthly meetings
75min group visit
Vitals
Labs, HbA1C,
lipids
Med review
Immunizations
►Monthly diabetic topic
DM Basics
Common medications
Hyper and hypoglycemic states
Diabetic lab goals
Nutritionist
Foot care
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Methods►Main Outcomes
HbA1c
DM Knowledge
►Secondary Outcomes Weight
Systolic Blood Pressure (SBP)
Patient Satisfaction
►Completion of knowledge test
23 multiple-choice questions
Michigan Diabetes Research and Training Center
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ResultsResults
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Baseline Characteristics n = 19
Mean + SD or n (%) n (%)
Weight (lbs) 224.6 + 53.8 HbA1c<7% 5 (26)
Hypertension stage >7% 14 (74)Normal 3 (16)Pre-HTN 7 (37) LDL (mg/dl)Stage I 6 (31) <100 6 (38)Stage II 3 (16) >100 10 (62)
Random fingerstick glucose 217.1 + 62.4 UrinalysisKetones 0 (0)Glucose 3 (33)Albumin 8 (89)
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Medications at Baseline
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After 6 After 6 months…months…
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HbA1c Pre- and Post-Intervention
p = 0.026
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Individual HbA1c Change from Pre- to Post-Intervention
Intervention
Hb
A1
c (
%)
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Diabetes Knowledge Test Score Pre- and Post-Intervention
p = 0.001
23 Questions
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Weight Pre- and Post-Intervention
p = 0.044
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Systolic Blood Pressure Pre- and Post-Intervention
p = 0.005
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Patient Satisfaction Survey
►Organization: 5
►Content: 5
►Presenters: 5
►Helpfulness: 5
►Overall satisfaction: 5
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Patient Satisfaction Comments
►“I have had diabetes for over 10 years and until these meetings I never knew what it meant. Something about sugar.”
►“I didn’t realize so many people like me had diabetes.”
►“Great class. Nutrition talk was very helpful. Now, I know what to eat and what to avoid.”
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Summary► Statistically significant improvements in Primary
and Secondary outcomes
HbA1c and Knowledge of Diabetes
Weight, SBP, and Patient Satisfaction
► Gains were realized in a well established diabetic patient population
► Gains were realized without the addition or modification of any medications
► Increased patient satisfaction compared to traditional office visit
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Conclusions► In a PCMH, Diabetics not under good glycemic
control with typical office visits, can be empowered to make beneficial lifestyle changes and to self manage their diabetes when participating in a group visit model facilitated by Family Medicine Residents
► Future study
Investigate whether positive changes persist in larger study
Utility of Group Visits for other medical conditions
Community Medicine Rotation for residents
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Acknowledgements
Peter Farago, MD – Family Medicine
Patricia West, PhD, RN – Family Medicine
Ruth Moore, PhD – Medical Education
Karen Hagglund, MS – Medical Education
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References► Clancy DE, Huang P, Okonofua E, Yeager D, Magruder KM.
Group Visits: Promoting Adherence to Diabetes Guidelines. J Gen Intern Med 2007; 22: 620-624.
► Sadur CN, Moline N, Costa M, Michalik D, Mendlowitz D, Roller S, Watson R, Swain BE, Selby JV, Javorski WC. Diabetes Management in a Health Maintenance Organization: Efficacy of care management using cluster visits. Diabetes Care 1999; 22: 2011-2017.
► Theobald M, Masley S. A Guide to Group Visits for Chronic Conditions Affected by Overweight and Obesity. Americans In Motion – Healthy Interventions. AAFP. June 17, 2008
► Wheelock C, Savageau J, Silk H, Lee S. Improving the Health of Diabetic Patients Through Resident-initiated Group Visits. Fam Med 2009; 41: 116-9.