# Presentation: 433866

## Inter-Professional Diabetes Care: Research and Operational Issues of Group Appointments 

- Susan Kirsh, MD
- David Edelman, MD, MPH
- Hank Wu, M.D.

## Overview of Group Medical Appointments in Diabetes 

- Hank Wu, M.D.
- Providence VA Medical Center
- Assistant Professor of Medicine
- Alpert Medical School, Brown University

## Impact of Diabetes Mellitus

- 23.6 Million with diabetes (7.8%) in the US
- Health care costs surpassed $92 billion
- 65% die from cardiovascular disease
- Prevalence of DM among veterans is 12%
- Performance measures are not being met nationwide

| VA Diabetes Performance Measures | VA | VISN-1 | Goal |
| --- | --- | --- | --- |
| HgbA1c > 9% or not done (Lower is Better) | 16% | 16% | 15% |
| LDL-Cholesterol < 100 | 68% | 68% | 67% |
| Blood Pressure  < 140/90 | 78% | 81% | 79% |

**Notes:**
Diabetes is a progressive illness that requires continuous modification of medication by the provider, and patients will require multi-factorial interventions such as education and counseling, in addition to pharmacotherapy 
65% of DM pts will die of CV disease, so other cardiovascular risk factors such as hypertension, hyperlipidemia and tobacco use also had to be addressed to diminish micro and macro vascular events
However, multi-factorial, multi-targeted interventions is difficult to accomplish in traditional care settings and costly

## CV Risk Factor Control in Diabetes

- *LDL-C and TG not evaluated.
- Saydah SH, et al. *JAMA.* 2004;291:335-342.

**Fewer than half of adults with diabetes achieve**** treatment goals for CV risk factors**

**  ****A1C**** ****Level****<7%**

**Blood Pressure **
**<130/80 mm Hg**

**  ****Total Cholesterol***
** ****<200 mg/dL**

**  ****Achieved all 3 treatment goals**

- 0

- 10

- 20

- 30

- 40

- 50

- 60

**Adults (%)**

**NHANES III (n = 1204)**

**NHANES 1999-2000 (n = 370)**

## Chronic Care Model

- System Redesign

- Electronic Medical Record
- Organization Commitment to Quality
- Provider Decision Support

- VA Standard

**Notes:**
Diabetes is a chronic progressive illness that requires continuous modification of medication by the provider, and patients will require multi-factorial interventions such as education and counseling, in addition to pharmacotherapy 
Concomitant cardiovascular risk factors such as hypertension, hyperlipidemia and tobacco use also had to be addressed to diminish micro and macro vascular events
However, multi-factorial, multi-targeted interventions is difficult to accomplish in traditional care settings and costly
Application of the chronic care model for system redesign is necessary. There are some elements of the CCM that are VA standards.

## Chronic Care Model

- Care Delivery Redesign

**Group visits**
**Alternative providers: Clinical Pharmacists, Nurses**

- Shared Medical Appointments

- Self Management

**Group education**
**Equipment**

- Link to Resources

**Case Management**

**Notes:**
Group Medical Visits completed the remaining components of the CCM for multifactorial management of DM

## Group Medical Appointments (GMA)

- “Group visits through which several patients meet with the same provider(s) at the same time” (Weinger)
- Other terms:
- 	“Group medical visits”
-   “Shared medical appointments”
- Targeted to a common problem for efficiency and peer support:
- HTN, DM, Lipids
- Smoking Cessation
- Mental illness, e.g. bipolar disorder, PTSD
- Heart failure
- Frail elderly

**Notes:**
Group medical visits have been proposed to be an efficient method to achieve cardiovascular risk reduction and guideline implementation in diabetes mellitus, through efficient resource use, improvement of access to care, and promotion of behavioral change through group support.(7, 8) However, these treatment models require intensive physician involvement to show clinical efficacy, which may reduce the potential cost savings expected from this intervention.(9-11)

## Types of Group Visits

|  | Education | Behavioral modification | Pharmaco-therapy | Case Management |
| --- | --- | --- | --- | --- |
| Education-Behavioral |  |  |  |  |
| Shared Medical Appt |  |  |  |  |
| Dropped-in Medical Appt |  |  |  |  |
| Education / Pharmaco-therapy |  |  |  |  |

- Group / Indiv.

- Indiv.

- Indiv.

**Notes:**
There are many ways to classify GMA. The current classification is based on whether a pharmacotherapy component is present or not and whether this occurred in an individual or group setting.

## Education-Behavioral Intervention

|  | Education | Behavioral modification |  | Pharmacotherapy | Case Management |
| --- | --- | --- | --- | --- | --- |
| Nutritionist |  |  |  |  |  |
| MD | sometimes |  |  |  |  |
| Pharm D | sometimes |  |  |  |  |
| RN /NP |  |  |  |  | sometimes |

- DSME groups
- In most VAMCs
- Modest improvement in glycemia
- HbA1C ↓ 0.32% to 0.43% at 12 months
- Best with face-to-face delivery, cognitive reframing, exercise intervention

**Notes:**
Education-based clustered visits, which usually consists of group visits with a multidisciplinary team led by a nurse educator and may include a dietitian, a pharmacist, and a behavioral therapist.  Education-based group visits showed only modest improvements in glycemia.
Multi-disciplinary providers: at least a nurse and a nutritionist
Focus on:
 Self-management education 
 Behavioral modification, at different intensities
No pharmacotherapy

## Shared Medical Appointment

|  | Education | Behavioral modification | Pharmaco therapy | Case Management |
| --- | --- | --- | --- | --- |
| Nutritionist |  | sometimes |  |  |
| MD | sometimes |  | Individual |  |
| Pharm D |  |  | Individual |  |
| RN /NP |  |  | Individual |  |

- Group Education with Individual Pharmacotherapy
- - Structured Appointments -

**Notes:**
Targeted pharmacotherapy may occur before, during or after the group education component
With pre-established appointment
Chronic Care Clinics
Group Medical Visits
Without pre-established appointment
Drop-in group medical appointments
Advantages:  avoids interruption of the group dynamics with individualized pharmacotherapy
                    some patients may prefer to discuss their medications in a more private setting

Problems: more provider time or need for more providers, which affects cost 

Dedicated multidisciplinary team (not patient’s regular PCP)
Group education with individual pharmacotherapy intervention during or after the group sessions 
Contains a education - behavioral component
Knowledge about the disease
Self-management skills
Behavioral Modification
Usually formed by a multi-disciplinary team
Nurse, pharmacists, psychologists, nutritionist, and/or physical therapist
Direct or indirect physician participation
VA and non-VA setting 
HbA1c levels improved 1.3 – 1.4% at approximately 6 months

Chronic-care clinics, which consist of individual (NOT group) appointments with the primary care physician, nurse, and clinical pharmacist, followed by group education and support by nurse. and a group education/ support meeting 
Non-VA HMO setting, west coast 
After 2 years, this model may improve quality of life, DM knowledge and reduce specialty and emergency room visits, but did not improve HbA1C levels compared to controls (worsened from 7.4% to 7.9% in both groups).  

WE think that the main reason for the difference in A1c results derived from intervention provided by their regular PCP’s (CHC model) vs. a dedicated team (GMV), since not every provider is suitable to run groups

## Cleveland VAMCShared Medical Appointment

**p < 0.05**
**1.4 vs. -0.3**

**p < 0.05**

**p = 0.29**

**Cleveland VAMC**Shared Medical Appointment

**Notes:**
Target : A1c>9%, SBP >160 mm Hg, or LDL cholesterol >130 mg /dL
Appointment of 1-2 h

## Durham and Richmond VAMC’s Shared Medical Appointment

**P = 0.03**

**P = 0.08**

**P = 0.38**

- Durham and Richmond VAMC’s Shared Medical Appointment

**Notes:**
While the MD is the theoretical leader, there is no true lead; the nurse (not an NP, RN only) runs the education session, and the MD and PharmD make the med changes 
Pharmacotherapy is on an individual basis.  All pateints get a 5-10'
breakout after group.
3.  MD and Pharm D jointly decide the pharmacotherapy; either then may represent that decision and negotiate it with the patient.

## Drop-in Group Medical Appointment-No Structured Appointment-

|  | Education | Behavioral modification | Pharmaco therapy | Case Management |
| --- | --- | --- | --- | --- |
| Nutritionist |  |  |  |  |
| MD |  |  |  |  |
| Pharm D |  |  |  |  |
| RN /NP |  |  |  |  |

**Notes:**
Providence VAMC – Pharmacist-led Insulin Initiation program
Target population: DM patients that needs insulin initiation 
Known time and place – without previous appointment
Group education and behavioral modification 
Individualized visits for pharmacotherapy during group sessions with another provider
Improves access for episodic medical needs

Concerns are often psychosocial
Can be led by physician or clinical pharmacist
Behaviorist in the team is helpful

Specific population is given access to the clinic
Patients were told when and where to show up
Not formally evaluated in RCT’s

Improves patient flow

May improve clinical outcomes

Present in VA and non-VA setting
Start patient on insulin
Smoking cessation counseling

## Providence VAMC  Pharmacist-led Insulin Initiation Program

**p < 0.01**

**10.6%**

**8.5%**

**Notes:**
Target : DM patients who need insulin initiation 
Set time and place – no appointment necessary
Pharm D led group education 
Individualized pharmacotherapy during group sessions w/ other provider

## Group Education and Pharmacotherapy

|  | Education | Behavioral modification | Pharmaco therapy | Case Management |
| --- | --- | --- | --- | --- |
| Nutritionist |  |  |  |  |
| MD |  |  |  |  |
| Pharm D |  |  |  |  |
| RN /NP |  |  |  |  |

**Notes:**
Education, pharmacotherapy and case management ALL in the group setting
Multidisciplinary team that provides education 
Case managers or group leaders that provides pharmacotherapy: physician or clinical pharmacists or nurses

Efficacy shown in short-duration RCT’s
Several ongoing RCT’s to assess cost-effectiveness

## Multidisciplinary Education in Diabetes & Intervention for Cardiac Risk Reduction (MEDIC) Providence VAMC

**p < 0.05**
**0.7 vs. 0.0**

**p < 0.05**

**p =NS**

- 3 month follow up

**Notes:**
6-8 participants per class 
2-hr sessions weekly x 4 wks
2 Components
Multidisciplinary education
Pharmacist-led behavioral & pharmacological intervention
Pilot RCT to plan larger trial
n = 58, MEDIC 
n = 51, control
3 month follow-up

## Are the Results Sustainable?MEDIC-Extended (MEDIC-E)

**P = NS**

**p < 0.05**

- 6 month follow up

**P = NS between groups, **
**P < 0.05, for MEDIC-E compared to baseline**

**Notes:**
MEDIC plus monthly 90 min. booster sessions for 5 mos.
Pilot RCT
MEDIC-E = 47
Control = 47
6 mo. follow-up

## Targeting in Diabetes with Depression (MEDIC-D) 

**P = NS between groups, **
**P < 0.05, for MEDIC-D compared to baseline**

**P = NS**

**P = NS**

- 6 month follow up

**Notes:**
6-8 participants per class 
Modified MEDIC-E:
2-hour sessions weekly x 4 weeks, then monthly booster x 5 months
2 Components
Multidisciplinary education
Pharmacist-led behavioral & pharmacological intervention
Pilot RCT
n = 28, MEDIC-D
n = 22, control

## Group Leader / Case Manager

- Need for a consistent group leader / case manager to provide continuity of care
- Content expert
- Medication case management
- Effectively control group dynamics
- Examples: Physician, Clinical Pharmacist, Nurse

**Notes:**
A content expert is needed, so someone who knows how to manage and educate pts on diabetes, this could be a physician, pharmacist or a nurse
You need a team member who can prescribe medications, physician, clinical pharmacist, nurse practitioner
And integral to program is have a facilitator who can effectively manage group dynamic b/c having one over talkative patient can kill any program

## Potential Benefits vs. Usual Care

- Better access to care
- Peer support
- Multi-faceted intervention
- Stronger education – behavioral component
- Fits well in Integrated Health Care Systems
- Cost-benefit

## Potential Obstacles

- Great variability in care delivery models, with consequences in:
- Efficacy
- Cost
- Access to care
- Institutional infrastructure and commitment a “must”
- Turf issues versus teamwork
- Billing, in the private sector

**Notes:**
Multidisciplinary team is costly. It may be more efficient to have less personnel that is capable of several functions, e.g. a clinical pharmacist who is a diabetes educator and can prescribe medications

## Continuum of Quality Improvement and Research:Rigor vs. Relevance

_**Operations**_
- “Relevant”
- Context-Dependent
- Problem Solving
- Quantitative >, <, or =
- Qualitative
- Pre-test post-test or
- quasiexperimental designs
- Tends to be NON-LINEAR

_**Research**_
- “Rigorous”
- Identify generalizable
- knowledge, i.e.,
- Eliminate Context
- Publishable
- Quantitative>Qualitative
- RCTs
- Tends to be LINEAR

- Continuum not a dichotomy
- Goal is relevance moving as close to rigor as one can

**Potential Synergy**

## *** Danger ***

**Linear Fallacy of Research and QI**: Widely-held assumption that social and biological systems can be largely understood by dissecting out micro-components and analyzing them in isolation.

**DATA**

**The journey up the ramp of complexity is NOT linear.**

**Complexity**

**Time**

## P

- Complexity

- Time

**A**

**P**

**S**

**D**

**A**

**P**

**S**

**D**

*Challenges*

*Opportunities*

**P**

**D**

**P**

**D**

**Revised Conceptual Model of Rapid Cycle Change**
**Tomolo, Lawrence, and Aron, QSHC, in press.**

**Legend:**
- P=Plan      D= Do                            = Barrier                                                          =   Direct flow of impact
- S=Study    A=Act                             = Lingering background impact         Arrowhead =  Feedback or feedforward
- Different Sizes of letters and cycles and bolding of letters = denotes differences in importance/impact

## Research

**Research**

- Project is fixed

*Context must adapt*

- Context is fixed

*Project must adapt*

- Practice

**Target of the interventions – the ****context ****- cannot as easily be controlled, randomized or matched in the same way as can patients**
**Quality programs usually cannot be controlled or standardized**
**The ****context**** of the intervention is constantly changing**

**Why? In short, the issue is CONTEXT**

- T. Greenhalgh

## Cleveland VAMC

## Kirsh SR, Lawrence R, Aron DC. Tailoring an Intervention to the Context and System Redesign Related to the Intervention:Case Study of Implementing Shared Medical Appointments for Diabetes; Implementation Science  2008

## Characteristic of Innovation  ~ Degree of which innovation provides or is: 	

**Relative advantage or utility** over existing or other methods
**Trialability, reversibility**** **without risk if doesn’t work
**Compatibility** with existing norms and values
**Visibility, observability** of results by other people
**Complexity** of explaining, understanding
**Centrality**** **of impact on daily working routine
**Divisibility**

**Costs** relative to benefits and level of investment
**Pervasiveness, scope**
**Risks **
**Magnitude, disruptiveness**
**Flexibility, adaptability** to situation/needs of local context/target group
**Duration** for when innovation/change must take place
**Involvement** of target group in development
**Form, physical properties** of innovation

## Grol R, Bosch M, Hulscher M, Eccles M, Wensing M. Planning and studying improvement in patient care: the use of theoretical perspectives. Milbank Q. 2007;85:93-138.

## Characteristics continued

**Leadership of the Clinic Director and strong team support critical promoting factors**

## For Improvement and Sustainability

- _For Improvement and Sustainability_

**SMAs require complex changes that impact on multiple  levels of the organization**
**Reconfiguration involved the primary care clinic itself and other services from which the patients and the team were derived. **
**Relationships among different parts of the system were altered.**

## Conclusions/Lessons Learned

**Tailoring the intervention alone will not ensure sustainability; system adjustments are required. **
**Qualitative work adds another dimension that makes quantitative data more meaningful**

## SQUIRE guidelines

**For writing up quality improvement work to add rigor**
**Largely incorporates contextual factors**
**Use of SOME signposts of SQUIRE, but not all applicable**

## Why Do Shared Medical Appointments Work?

- Who do they work for?
- When you have a hammer, everything looks like a nail......
- Targeting patients to different
-    interventions

## Short Answer–

- We don’t know.

## Possible Mechanisms of Action

- Patient-to-provider interactions
- Patient-to-patient interaction
- Self-management groups, with an educator only, have a well-documented modest effect
- Not discussed further here
- Other?

## Patient-to-Provider Interactions

- Multidisciplinary Approach
- Having a doc, a pharmacist, and a nurse is better than usual, MD-based care
- Group leader may function as a “specialist”
- Having someone really interested in (eg) diabetes may be better than usual primary care
- Lack of distractions
- Care of only (eg) diabetes may be better diabetes care than the ADHD environment of primary care
- More is better
- Just having more care for a chronic illness may be better care for that chronic illness

## Multidisciplinary Approach

- Theory– each provider brings a special expertise, increasing chance that each patient’s best approach to improvement may be available
- At least one small RCT assessed this
- Intervention 1.5% better A1c compared to control
- Other studies involving subspecialty MDs are similar in results
- It’s plausible that this is part of the effect

## “Specialty Referral”

- Theory– a provider interested enough to run a group might be a better provider for that disease than the usual PCP
- Untested theory to my knowledge
- Many group interventions rotate providers or have patients see their own PCPs
- My guess is that this is not a big part of the effect

## Care Focus

- Theory– without the distractions of usual primary care (acute issues, meeting quality guidelines, etc.) it is easier to improve a single target
- Not much literature on this
- May come out in qualitative evaluations of group processes
- Plausible, but hard to really know

## “More is Better”

- Theory– what you really need to manage chronic illness is more patient-provider contact, ANY contact.
- A wide variety of diabetes structural interventions have worked in RCTs (eg case management, pharmacist clinics)
- More probably is better, to a point
- Point of diminishing returns unknown

## Summary

- Probably a number of factors add up to provide the effects of shared medical clinics
- Some of these are probably independent of patient interactions within groups
- From a cost perspective, would be nice to know what pieces are the most “bang for the buck”
- Future study should focus on this

## How do you answer this question?

- Quantitative measurement
- Measure patients’ perception of care and see what changes
- Or, develop predictive models in an effort to match patients with intervention (SMA, case-management, pharmacist)
- Qualitative measurement
- If you want to know what’s working for the patients, just ask them
- Don’t bother
- “Just Do It,” treat groups as a “black box” intervention