Aach group visit


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St. John Hospital Family Medicine Residency Initiative with Diabetic Group Visits

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  • I have been passionate about the notion of Group Visits, since my residency training. I always felt that a better educated patient, equaled a healthy patient. My resident research project focused on group visits for Pediatric obesity. I wanted to carry the group visit idea into my practice. And then as faculty physician at St. John I had some help from the residents I was teaching. So really this research project is a large collaboration with residents giving lectures during their community medicine rotation. Residents are so eager to get involved and we set up each resident with a topic to facilitate during the DM Group Visit. So I was able to harness that energy to move forward this research pilot study.
  • Behavioral Risk Factor Surveillance System performed by CDC, The data shown in these maps were collected through the CDC's Behavioral Risk Factor Surveillance System (BRFSS) , on the basis of self-reported weight and height. Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults. Prevalence estimates generated for the maps may vary slightly from those generated for the states by the BRFSS as slightly different analytic methods are used
  • Methodology Number and percent of the U.S. population with diagnosed diabetes were obtained from the National Health Interview Survey (NHIS, available at http://www.cdc.gov/nchs/nhis.htm ) of the National Center for Health Statistics (NCHS), Centers for Disease Control and Prevention (CDC) for years. Conducted continuously since 1957, the NHIS is a health survey of the civilian, noninstitutionalized population of the United States. The survey provides information on the health of the United States population, including information on the prevalence and incidence of disease, the extent of disability, and the utilization of health care services. The multistage probability design of the survey has been described elsewhere (1,2). Estimates for years 1958-1979 were obtained from published data (3) and estimates from 1980 forward were derived directly from the NHIS survey data. References 1. Massey JT, Moore TF, Parsons VL, Tadros W. Design and estimation for the National Health Interview Survey, 1985-1994. Hyattsville, MD: National Center for Health Statistics. Vital and Health Statistics 1989;2(110). 2. Botman SL, Moore TF, Moriarity CL, Parsons VL. Design and estimation for the National Health Interview Survey, 1995–2004. National Center for Health Statistics. Vital and Health Statistics 2000;2(130). 3. Harris MI: Prevalence of noninsulin-dependent diabetes and impaired glucose tolerance. Chapter VI in Diabetes in America , Harris MI, Hamman RF, eds. NIH publ. no. 85-1468, 1985.
  • Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011) Total prevalence of diabetes Total: 25.8 million children and adults in the United States—8.3% of the population—have diabetes. Diagnosed: 18.8 million people Undiagnosed: 7.0 million people Prediabetes: 79 million people Cost of Diabetes $174 billion: Total costs of diagnosed diabetes in the United States in 2007 $116 billion for direct medical costs $58 billion for indirect costs (disability, work loss, premature mortality)
  • This article states “The future of family Medicine”, but this article is from 2004, and so the future is already the past. But in this report, the committee supported the PCMH concept. And mentioned Group Visits as 1 tool to provide higher quality and better access at a lower cost to the health care system
  • Quality measures – patient disease registries, establish core performance measures, test result tracking Patient experience – increased access to care, same day appointments, email, support patient self management through motivational interviewing, group visits
  • Dr. Andrew Davis published a Review article in clinical diabetes 2008. There has been much research in Group Visits, starting from late 1990s
  • Group visit setting is a superb time to catch up on preventive health maintenance, immunizations, labs, etc.
  • We did have several patients who made dramatic positive change in HbA1c which may have affected our results
  • Aach group visit

    1. 1. Efficacy of Group Visits in Outpatient Management of Diabetes Nicholas Urbanczyk, DO Peter Farago, MD, Patricia West, PhD Department of Family Medicine St. John Hospital Detroit, MI October 17, 2011
    2. 2. 1999 Obesity Trends* Among U.S. Adults BRFSS, 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%
    3. 3. 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
    4. 4. Diabetes: The Epidemic <ul><li>Prevalence </li></ul><ul><ul><li>20 million Americans diagnosed with DM </li></ul></ul><ul><ul><li>$174 billion each year </li></ul></ul><ul><ul><li>Number of DM to double by year 2030 </li></ul></ul><ul><li>Relevance </li></ul><ul><ul><li>Health care costs increasing </li></ul></ul><ul><ul><li>New models of care </li></ul></ul>
    5. 5. There is Hope
    6. 6. Patient Centered Medical Home <ul><li>Structured principles </li></ul><ul><ul><li>Personal physician </li></ul></ul><ul><ul><li>Whole-person orientation </li></ul></ul><ul><ul><li>Enhanced access </li></ul></ul><ul><ul><li>Group Visit model for chronically ill patients </li></ul></ul>
    7. 7. Group Visits <ul><li>Seeing patients in small groups </li></ul><ul><li>Weekly, monthly, quarterly for 1-2 hours </li></ul><ul><li>Effectiveness supported by literature </li></ul><ul><li>DM focused but can be extended to any chronic illness </li></ul>
    8. 8. Group Visits <ul><li>Distinguish from more narrowly defined group education classes which address self-mgmt skills, exercise, and nutrition, but… </li></ul><ul><li>Education classes do not provide – </li></ul><ul><ul><li>Medical evaluation </li></ul></ul><ul><ul><li>Medication administration </li></ul></ul><ul><ul><li>Coordination/delivery of preventive health services </li></ul></ul>
    9. 9. DM Group Visit <ul><li>Include an educational session, plus most components of individual clinic visit </li></ul><ul><ul><li>Including one-on-one time with physician </li></ul></ul><ul><li>Not a lecture </li></ul><ul><ul><li>Lectures provide knowledge, but do not change behavior </li></ul></ul><ul><li>Curriculum for visit is driven by patient questions and concerns </li></ul>
    10. 10. Literature <ul><li>AIM-HI Bulletin AAFP 2008 </li></ul><ul><ul><li>Group medical visits reportedly improved critical health parameters </li></ul></ul><ul><li>Wheelock et al. Fam Med 2009 </li></ul><ul><ul><li>Patients were making life style changes </li></ul></ul><ul><ul><li>HbgA1c and LDL levels did not differ </li></ul></ul><ul><li>Sadur et al. Diabetes Care 1999 </li></ul><ul><ul><li>Group visits for 6 months </li></ul></ul><ul><ul><li>Improved patient satisfaction, self-efficacy and blood-glucose control </li></ul></ul>
    11. 11. Literature
    12. 12. The Study
    13. 13. Purpose <ul><li>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 </li></ul>
    14. 14. Methods <ul><li>All adult Type II diabetics established at FMC were eligible </li></ul><ul><li>Protocol approved by St. John Hospital IRB </li></ul><ul><li>Recruitment letters </li></ul><ul><li>Randomly assigned to 2 small groups </li></ul><ul><ul><li>10 patients per group </li></ul></ul><ul><li>HIPPA disclosure and confidentiality forms </li></ul><ul><li>Study length 12 months </li></ul><ul><ul><li>January – June 2010 and July – December 2010 </li></ul></ul><ul><ul><li>Two 6-month block sessions </li></ul></ul>
    15. 15. Methods <ul><li>Monthly meetings </li></ul><ul><ul><li>75min group visit </li></ul></ul><ul><ul><li>Vitals </li></ul></ul><ul><ul><li>Labs, HbA1C, lipids </li></ul></ul><ul><ul><li>Med review </li></ul></ul><ul><ul><li>Immunizations </li></ul></ul><ul><li>Monthly diabetic topic </li></ul><ul><ul><li>DM Basics </li></ul></ul><ul><ul><li>Common medications </li></ul></ul><ul><ul><li>Hyper and hypoglycemic states </li></ul></ul><ul><ul><li>Diabetic lab goals </li></ul></ul><ul><ul><li>Nutritionist </li></ul></ul><ul><ul><li>Foot care </li></ul></ul>
    16. 16. Methods <ul><li>Main Outcomes </li></ul><ul><ul><li>HbA1c </li></ul></ul><ul><ul><li>DM Knowledge </li></ul></ul><ul><li>Secondary Outcomes </li></ul><ul><ul><li>Weight </li></ul></ul><ul><ul><li>Systolic Blood Pressure (SBP) </li></ul></ul><ul><ul><li>Patient Satisfaction </li></ul></ul><ul><li>Completion of knowledge test </li></ul><ul><ul><li>23 multiple-choice questions </li></ul></ul><ul><ul><li>Michigan Diabetes Research and Training Center </li></ul></ul>
    17. 17. Results
    18. 19. Medications at Baseline
    19. 20. After 6 months…
    20. 21. HbA1c Pre- and Post-Intervention p = 0.026
    21. 22. Individual HbA1c Change from Pre- to Post-Intervention Intervention HbA1c (%)
    22. 23. Diabetes Knowledge Test Score Pre- and Post-Intervention p = 0.001 23 Questions
    23. 24. Weight Pre- and Post-Intervention p = 0.044
    24. 25. Systolic Blood Pressure Pre- and Post-Intervention p = 0.005
    25. 26. Patient Satisfaction Survey <ul><li>Organization: 5 </li></ul><ul><li>Content: 5 </li></ul><ul><li>Presenters: 5 </li></ul><ul><li>Helpfulness: 5 </li></ul><ul><li>Overall satisfaction: 5 </li></ul>
    26. 27. Patient Satisfaction Comments <ul><li>“ I have had diabetes for over 10 years and until these meetings I never knew what it meant. Something about sugar.” </li></ul><ul><li>“ I didn’t realize so many people like me had diabetes.” </li></ul><ul><li>“ Great class. Nutrition talk was very helpful. Now, I know what to eat and what to avoid.” </li></ul>
    27. 28. Summary <ul><li>Statistically significant improvements in Primary and Secondary outcomes </li></ul><ul><ul><li>HbA1c and Knowledge of Diabetes </li></ul></ul><ul><ul><li>Weight, SBP, and Patient Satisfaction </li></ul></ul><ul><li>Gains were realized in a well established diabetic patient population </li></ul><ul><li>Gains were realized without the addition or modification of any medications </li></ul><ul><li>Increased patient satisfaction compared to traditional office visit </li></ul>
    28. 29. Conclusions <ul><li>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 </li></ul><ul><li>Future study </li></ul><ul><ul><li>Investigate whether positive changes persist in larger study </li></ul></ul><ul><ul><li>Utility of Group Visits for other medical conditions </li></ul></ul><ul><ul><li>Community Medicine Rotation for residents </li></ul></ul>
    29. 31. Acknowledgements <ul><li>Peter Farago, MD – Family Medicine </li></ul><ul><li>Patricia West, PhD, RN – Family Medicine </li></ul><ul><li>Ruth Moore, PhD – Medical Education </li></ul><ul><li>Karen Hagglund, MS – Medical Education </li></ul>
    30. 32. References <ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>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 </li></ul><ul><li>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. </li></ul>