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

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%

0

1

2

3

4

5

6

7

1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06

Year

Per

cen

t w

ith

Dia

bet

es

0

2

4

6

8

10

12

14

16

18

20

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

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

There is HopeThere is Hope

Patient Centered Medical Home

► Structured principles

Personal physician

Whole-person

orientation

Enhanced access

Group Visit model for

chronically ill

patients

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

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

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

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

Literature Literature

The StudyThe Study

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

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

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

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

ResultsResults

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)

Medications at Baseline

After 6 After 6 months…months…

HbA1c Pre- and Post-Intervention

p = 0.026

Individual HbA1c Change from Pre- to Post-Intervention

Intervention

Hb

A1

c (

%)

Diabetes Knowledge Test Score Pre- and Post-Intervention

p = 0.001

23 Questions

Weight Pre- and Post-Intervention

p = 0.044

Systolic Blood Pressure Pre- and Post-Intervention

p = 0.005

Patient Satisfaction Survey

►Organization: 5

►Content: 5

►Presenters: 5

►Helpfulness: 5

►Overall satisfaction: 5

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.”

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

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

Acknowledgements

Peter Farago, MD – Family Medicine

Patricia West, PhD, RN – Family Medicine

Ruth Moore, PhD – Medical Education

Karen Hagglund, MS – Medical Education

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.