**Transcript of Cyberseminar**

**Evidence-based Synthesis Program Series**

**Group Visits Focusing on Education for the Management of Chronic Conditions in Adults**

**Presenter: Ana Quiñones, Ph.D.;  Jeannette Richardson**

**April 1, 2013**

**Group Visits Focusing on Education for the Management of Chronic Conditions in Adults**

**April 1, 2013**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at**http://www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm**or contact**mailto:quinones@ohsu.edu*

Moderator:Our presenter, our first presenter is Ana Quiñones. She is the health research specialist at the Portland VA Medical Center and an assistant professor in public health and preventative medicine at the Oregon Health Sciences University. Our second presenter is Jeannette Richardson. She is a clinical nurse specialist in the primary care division at the Portland VA Medical Center. She has a leadership role in the implantation of many pact and evidence based initiatives at the local level. We also have a couple discussants on today’s call. The first is Sharon Watts. Sharon has a doctorate in nursing practice, a masters of science in public health nursing and is certified as a family nurse practitioner and a certified diabetes education. She has worked with group visits for the past eleven years and shared medical appointments for the past nine years. 

And our second discussant for today will be Susan Kirsh. She is a staff physician, division of general internal medicine of the Cleveland VA Medical Center and attending staff position for resident community clinic. She is a diabetes QUERI – on the diabetes query executive committee and co-director of the VA patient care service as redesigned for diabetes. Ana, can I turn things over to you? 

Ana Quiñones:Yes you may. Great, good morning everybody. Thank you for joining us for the ESP HSRD seminar this morning on educational group visits for the management of chronic health conditions, the systematic review that we conducted here at the Portland VA Medical Center. We would like to acknowledge firstly our report authors myself and Jeannette Richardson along with Michele Freeman, Maya O’Neil and Devan Kansagara. Our presenters today, as Heidi told us, is myself and Jeannette as well as Sharon Watts and Susan Kirsh. And we would like to also acknowledge our report nominators as well as our reviewers for the report. The nominators were Beverly Priefer, Storm Morgan, and Christine Engstrom along with the many reviewers that we had. 

So full disclosure: this report is based on research that we conducted here at Portland VA Medical Center. It was funded by the Department of Veteran Affairs. However, the findings and conclusions of this document are solely the responsibility of the authors. So I would like to start by giving a brief overview of the VA evidence based synthesis program. The program is sponsored by VA QUERI, quality enhancement research initiative. It was established to provide timely and accurate syntheses and reviews of healthcare topics that are identified by VA clinicians, managers, and policymakers, our stakeholders, as they work to improve the health and healthcare of veterans. 

The ESP builds on staff expertise that is already in place at evidence based practice centers that are designated by AHRQ. And four of the EPCs are also VA ESP centers. And these four are located at the Durham VA Medical Center, the VA Greater Los Angeles Healthcare System, the Portland VA Medical Center, and the Minneapolis VA Medical Center. So the evidence based synthesis program provides syntheses on important clinical practice topics that are relevant to veterans. And these reports help us to develop clinical policies that are informed by evidence. They also help with the implementation of effective services to improve patient outcomes and to support VA clinical practice guidelines and performance measures. And finally, they help guide the direction of future research to address gap in clinical knowledge. 

There is a broad nomination process. So for example, VA central office, individual VISNs, as well as practitioners out in the field facilitated by the ESP coordinating center can nominate online and we were providing also the links for you to go and investigate that option. The steering committee representing research and operations provides oversight and helps the guide the program direction. We are also guided individually with our technical advisory panel which we assembled for each topic. These are individuals that are recruited for each topic and provide concept expertise. They help guide our topic development and help us refine our key questions and they review the data that we present as well as the draft report. 

The external peer reviewers and policy partners also review and provide comments on draft reports. These were invited and usually nominated by members of the technical advisory panel. Finally, the reports are posted on the VA HSRD website and they are disseminated widely through the VA. And again we provide the links for those publications that are listed there. So today’s report on group visits focusing on education for the management of chronic conditions in adults, a systematic review was published in December of 2012. And we also provide the link for the full length report available on the ESP website. Now please note that this report is for internal use for the Department of Veteran Affairs and should not be distributed outside the agency. 

Now firstly I would like to make a key distinction between group visits as we define them distinctly from shared medical appointments. For the purposes of this report we focused on group visits that were not led by a prescribing provider and whose purpose it was to educate patients on managing their chronic illness. So the VA evidence based synthesis program also conditioned a systematic review last year on shared medical appointments. And that report does focus on multi-patient visits where individualized medication management and treatment plans are incorporated into the shared visit. It is a key distinction for this report from that one. So I would like to turn it over to Heidi to poll the audience. We have a few questions for you. Question number one that we have is what is your reason for joining us on the cyber seminar today? Possible responses are general interest in group visits, number two: I am involved with a group visit at my clinic, number three: I conduct research on group visits, or number four: none of the above. You could please provide and answer to that question. 

Moderator:And responses are coming in. I will give it just another second or two and then close it out and show the results here. 

Ana Quiñones:Great. 

Moderator:There we go. 

Ana Quiñones:Great, I think I can see it. And of course it is hidden by all the other – there we go. [laughter] So the answer to the question what is your reason for joining us today on the cyber seminar, fifty-six percent of you responded that general interest in group visits. Thirty percent of you which is great are involved in group visits at their clinic. Seven percent of you conduct research on group visits, and seven percent of you none of the above. The majority of the audience today are either interested in group visits generally or are involved in conducting group visits at their clinic, great. So we would like to ask the second question polling the audience. Does your clinic currently conduct group visits for chronic disease management? To the best of your knowledge do you know whether your clinic currently conducts group visits? The response categories are yes, no, or not sure. 

Moderator:And Ana while we have a little break here is there any way that you can get a little closer to the phone? We are getting some comments of people cannot quite hear. 

Ana Quiñones:And I am trying to turn the volume up as well. 

Moderator:Thank you. 

Ana Quiñones:So hopefully that is better. 

Moderator:Here are your results. 

Ana Quiñones:Great so the response here for the quick poll of whether your clinic currently conducts group visits for chronic disease management: fifty-seven percent of you said yes and twenty-seven percent said no, and sixteen percent of you are not really quite sure. So about sixty percent of you has work in clinics – work in VAs where they do currently conduct group visits. That is great. So now for polling question three. So if you responded yes to question two could you please respond to question three where we ask if so in what area? The response categories are obesity, congestive heart failure or hypertension, diabetes, arthritis or falls prevention, or other. 

Moderator:And we will give about just a couple more seconds, some – show the results here. There we go. 

Ana Quiñones:Great so the quick poll response here, if so in what area? About sixteen percent have clinics that provide group clinics in obesity, six percent in CHF/hypertension, fifty-six percent in diabetes. So that is the overwhelming majority. None in arthritis falls prevention and about twenty-two percent which is the next largest category in other or unsure. Great so it looks like we are mostly represented by the diabetes group visits at least for our audience today. Fantastic. So the overview for today’s presentation, we will go over the background, the scope of the review. I will turn it over to Jennie to discuss the results for which we found eighty-seven publications of eighty-one studies. We will go through and describe those included studies and provide summary results by clinical area. And then we will turn it to implications for the VA and future research. 

So the goal of group based visits led by non-prescribing facilitators is to reinforce chronic disease education and provide training in order to improve self-management skills for the large numbers of patients coping with chronic illness. The Veterans Administration has prioritized group visits as part of a new primary care model that focuses on patient centeredness which we call the Patient Aligned Care Team or PACT. So though the group visit intervention delivery model has been widely used there are vast differences in program structure and the content, the length of the intervention, and follow up time points. And there is little consensus whether group visits are an effective tool and for whom they are effective. So given the variety of different interventions, the broad array of chronic conditions for which group visits have been studied, and the lack of an overall understanding of its effectiveness we felt along with our technical panel that it was useful to clarify what is known and not known about group visit interventions and patients with chronic illness. 

So the current report was commissioned to address four key areas. Number one: to summarize the characteristics of group visit interventions that have been tested in randomized control trials of patients with chronic illness. Number two: to assess the effects of these interventions on quality of life, self-efficacy, healthcare utilization and other health outcomes. Number three: to understand whether there are certain patient characteristics that associated with intervention effectiveness. And lastly, we looked to examine which components of group visit intervention structure and delivery might be associated with intervention effects. 

So we had three key questions scoped for this review. In the first key question we asked in adults with chronic medical conditions how do group visits compare to usual care affect the following: medication adherence, biophysical or physiological markers such as HbA1C and blood pressure, symptom status, functional status, mortality, patient satisfaction, utilization of medical resources, healthcare costs, and finally we also look at adverse outcomes for which we examine patient confidentiality, participation, and missed appointments as examples of outcomes that we looked at. For key question two we asked for adults with chronic medical conditions do the effects of group visits vary by patient characteristics? And again the characteristics of interest that we explored included medical diagnosis, severity of disease, and comorbidities. For key question three we asked which components of group visits are associated with greater intervention effects? The ability to address this particular question depended on the comparability of elements of group visits reported in the literature. 

So the P Codes criteria that we used which defines the patients, the intervention, the comparator, the outcome, the timing, and the settings that were included in the review were the following: so for patients we examined patients that were diagnosed with diabetes melitis, hypertension, congestive heart failure, COPD, asthma, arthritis, pain management, and history of falls. We excluded comorbid serious mental illness such as schizophrenia and studies with patients who had comorbid depression may be included but they could not be the focus of the intervention. For the intervention this is kind of a key scoping area. The group visits focus on education and they were led by individuals who were non-prescribing health professionals as well as lay facilitators. 

So for example, we looked at dieticians, nurses, social workers, peer educators, psychologists, pulmonary technicians, physical therapists, occupational therapists. We stipulated that the group visits may include prescribing providers if they function only in an advisory capacity meaning they do not provide individual care plans or medication management in the group visit intervention. Kind of a mouthful but it is an important distinction. For the comparator we examined both usual care as well as non-group visit care. For the outcomes we looked at biophysical physiological indicators such as hemoglobin, A1C, and blood pressure as we mentioned control of these markers, functional status, healthcare utilization such as hospitalizations and emergency department visits, patient satisfaction, patient participation, and nutrition. We did not limit on timing or setting so we included any.

So for the methods we conducted the original search in February of 2012 and the updated search in January of 2013. We included multiple databases such as MEDLINE via PubMed, Cochrane Register of Control Trials, CINAHL via EBSCO, and PsycINFO via Ovid. We used terms for non-prescribing practitioners and group visit interventions including but not limited to terms for group education, group program, and group session. We also obtained articles from reference lists of key studies by consulting experts. We had some exclusions. So we excluded studies that were not published in English or studies that included non-adult populations. We did not examine studies that focused exclusively on support groups or on group exercise classes, for example, yoga, aerobic, or resistance training. We felt that existing Cochrane reviews of group exercise summarize the effectiveness of these interventions and represent a systematic evaluation of that literature. 

We excluded group visit studies if any portion of the intervention focused on individual level prescription changes such as blood pressure medication management or insulin titration. We excluded diabetes studies published before 1998 because we felt the overall approach to adult diabetes likely changed substantially after publication of the United Kingdom perspective diabetes studies thereby rendering older studies less directly applicable today. So our data extraction: we focused on study design, objectives, setting, population, demographics, findings of the studies, structure of the intervention, information on the comparators, and participation and attrition rate. 

Based on the content delivered of these interventions we were able to categorize group visits based on the type of content delivered in the programs. So we noted three categories of educational content. Number one: self-management education. So in addition to providing disease specific information to patients these programs teach patients self-management skills to cope with their symptoms. So examples here include goal setting, contracting, and building skills to reinterpret symptoms. So these interventions use techniques such as motivational interviewing and cognitive behavioral therapy. So we identified these, the SME, self-management education, as distinct from didactic education so number two on the list. So here the content is informational and the format is usually lecture based. So for example, if an intervention provided information on the pathophysiology of disease symptoms or using and reading equipment, potential strategies for reducing pain and stress or understanding nutritional advice, we categorized these as delivering didactic education. 

And then three, experiential education was identified as instruction based on demonstrations. So for example, specific exercises: cooking, reading nutritional labels, and calculating nutritional information. But there was always some kind of structured demonstration that occurred during the visit and those were experiential. So in the review there was a breadth of outcomes examined across the various group visit trials as well as pretty substantial variation in outcome metric validity in a large number of outcomes measured and reported across studies. We found a lot of outcomes. We anticipated that such challenges would render a full accounting and synthesis of all outcomes both infeasible and uninformative so therefore we chose to focus on distal health outcomes measuring quality of life and functional status because these are likely to be important to patients and could conceivably be impacted by interventions examined in the studies under consideration. 

We also examined intermediate health metrics focusing specifically on biophysical markers such as A1C and on self-efficacy. Self-efficacy refers to personal beliefs in one’s ability to succeed in managing and self-managing illness. In this report we used the term broadly and we used to refer to any measures examining self-efficacy, patient activation, coping skills, or illness belief. So we chose to examine this group of outcomes because there are validated tools to assess self-efficacy related concepts and these metrics were commonly reported in many studies. 

So two reviewers independently assessed the quality of each trial. Individual studies were rates as good, fair, or poor according to the following criteria. We examined whether they were randomized, the allocation concealment, the blinding and outcome reporting as well as considerations for similarity of compared groups at baseline, adequate reporting of participation, loss to follow up attrition, and the use of intent to treat analysis as well as the ascertainment of outcomes. So we describe the overall quality of evidence for outcomes in each clinical subsection using a method developed by the grade working group. And the grade method considers the consistency, coherence and applicability of a body of evidence as well as the internal validity of individual studies. And all of these methods are described in the full report as well as the full rendering of our results in tables in the full report. 

So the results, I will just go over kind of a quick sketch of what we found. The search yielded three thousand four hundred and fifty citations; five hundred and ninety-nine were selected for full text review. And from those we included eighty-seven publications that reported on eighty-one group visit intervention trials that focused on education for the management of arthritis, fall prevention, asthma, chronic obstructive pulmonary disease (COPD), hypertension, congestive heart failure, diabetes melitis, or chronic pain. And for diabetes interventions we found twenty-nine studies. For arthritis and falls interventions we found twenty-two. For asthma/COPD we found ten. For hypertension/CHF we found twelve. For chronic pain there were four included studies and multiple chronic conditions there were four included studies in the report. 

I will also go over before turning it over to Jennie, excuse me; I will go over the findings by key question. So again, take question one just to remind you: in adults with chronic medical conditions what is the effectiveness of group visits compared to usual care on intermediate and distal health outcomes as well as on utilization and adverse outcomes? So overall group visit interventions in most clinical areas were associated with short and medium term improvements in self-efficacy. We found little evidence that interventions improved qua6ity of life, functional status, or utilization. And group visit interventions were associated with modest short term improvements in A1C but the strength of this evidence was low because of inconsistent results across studies and methodological concerns with the studies finding the greatest benefits. 

For key question two, again for adults with chronic medical conditions do the effect of group visits vary by patient characteristics. Overall we found little evidence in studies of group visit effectiveness according to patient demographic and socioeconomic conditions such as gender, education, age, and race. So various authors noted that small sample sizes limited the power to detect differences in subgroup analyses. So we did not find very much for key question two. In key question three, which components of group visits are associated with greatest intervention effects. We found that studies that report on findings of effectiveness of [inaud.] visits do so from head to head comparisons of multiple active group visit treatment arms as well as studies that compare individual visits to group visits. So overall in five studies group visit interventions that focus on self-management education strategy, so those SME strategies were more effective than sessions that were limited to didactic education. 

However, in four of these five studies the intervention arms differed considerably from the comparators. So for example, at least one of them had non-equivalent number of sessions. I think a couple of those did, limiting the strength of those conclusions. Studies that compared group visits to individual education we found some mixed results here on a variety of outcomes. There were no appreciable differences in three studies. There were improvements for group visits in four studies and there were improvements for individual visits in one study so mixed bag there. And then finally in two studies that compared the effects of in-person group self-management education and a mailed self-management education program, so postal mailed, found no differences in self-efficacy, pain, and functional status outcomes so that the mailed program was as effective as the in-person program. Great, now I am going to turn it over to Jennie to discuss the results by clinical area. 

Jeannette Richardson:Thank you, Ana. So another perspective in consideration of the results breaking them down by clinical area. So under arthritis eighteen studies from the US, Europe, and Australia evaluated the effectiveness of educational group visit intervention. That included ten studies using self-management education, eight studies of didactic education, and six studies using experiential education approaches. The studies varied widely in intervention structure, content, and duration as well as comparison group. Overall there is a moderately strong body of evidence that group self-management education interventions can improve short and medium term self-efficacy in patients with arthritis but they have little effect on quality of life or utilization outcomes. 

Under the category of falls: four studies from the US, Canada, and Australia examined effectiveness of educational group visit interventions in patients with a history of falls or at risk for falling. Overall didactic falls prevention training along with exercise training may improve patient self-efficacy and reduce the risk of falls. Though the strength of this evidence is low because of inconsistencies among studies and the small number of studies. 

Under the category of asthma five studies conducted in the US or Australia examined the effects of group visit intervention compared with usual care in patients with asthma. Four of these involved didactic education approaches and one study involved self-management education. There is little methodologically sound evidence examining the impact of group visits on quality of life or utilization in patients with asthma. For the diagnosis of COPD five studies from northern Ireland, the UK, the Netherlands, France, and a VA medical center in the United States were included. Three studies compared didactic education combined with exercise training to didactic education alone or to usual care. Two other studies examined the effects of self-management education compared with didactic education, usual care, or individual support. Overall a small body of fair to good quality evidence suggests that group didactic in combination with experiential exercise training may be associated with small improvements or less decline over time in exercise capacity and COPD symptoms though the clinical significance of these findings is unclear. 

For hypertension, congestive heart failure, and coronary artery disease our literature search identified three fair quality studies of group visit interventions conducted in patients with CHF or CAD in four publications from the US and the Netherlands. Seven studies examined the effects of group visits on blood pressure in patients with hypertension from settings in the US, Iran, Argentina, Thailand, and Italy. Six of these studies used self-management education techniques and four relied on didactic education approaches. Overall there were very few studies of group visits in CHF patients and their findings on self-efficacy, quality of life, and biophysical measures were largely neutral. Group self-management education interventions in patients with hypertension reported improvements in blood pressure control in the short and long term but the overall strength of evidence is low. 

Our largest diagnostic group was diabetes. We included thirty publications of twenty-nine studies of group visit interventions in patients with diabetes. Five studies found improvements in self-efficacy. Four of these five focused on self-management education strategies rather than didactic education. There was little evidence that group visit interventions improved quality of life over the short or long term. Eleven of the studies compared a group visit intervention to one or more active intervention. Three of these studies found that interventions focused on self-management education were associated with greater improvements in glycemic control than didactic education approaches. So there were multiple other differences in the interventions being compared making it difficult to draw firm conclusions about the effects of educational approach alone. 

Two of the studies compared group to individual education. One fair quality study found that in automated telephone based self-management intervention performed similarly to an in-person group self-management skills intervention. We conducted meta-analyses of the seventeen studies which compared the effects of a group visit intervention to usual care on HbA1C. This slide includes studies results at the less than or equal to six month follow up period. In fourteen studies group visit interventions reduced HbA1C slightly more over six months of follow up than usual care though there was significant heterogeneity which should temper confidence in these results. At least part of the heterogeneity seemed to be associated with study quality. The two good quality studies found no short term improvements in HbA1C. 

This next slide includes study results at the seven to twelve month follow up mark. We found similar effects on HbA1C at seven to twelve months in the ten studies with longer term follow up. Funnel cloud analyses showed no evidence of publication bias for six month outcomes but some evidence of publication bias for these twelve month outcomes. Multi-variant meta-regression models showed that none of the co-variants examined: duration of the group visit intervention, study quality, or year of publication were independently associated with changes in HbA1C. on this next slide we are moving on to the diagnosis of chronic pain. Four studies evaluated the effects of group based interventions compared to usual care, educational reading materials, or individual treatments in patient with chronic pain. Though many findings from the studies were not statistically significant and did not differ from the comparison, some results favored the group based interventions. Overall a very small body of literature suggests group based self-management education interventions may improve pain coping skills at least over the short term though the strength of this evidence is low because there were few studies and the methodological quality of one of the studies finding benefit was poor. 

Finally we had a category for multiple chronic conditions. Four studies evaluated the chronic disease self-management program in populations with various chronic conditions not limited to a particular disease group. Overall the peer-led, community-based program appears to be associated with medium term improvements in self-efficacy, health status, and healthcare utilization and these effects may persist long term. These findings are based on moderately strong evidence from two large US trials though findings were not replicated in other countries and the findings likely apply most to patients engaged enough in care to agree to attend a multi-week course. So for discussion we do have some conclusions. Group visit interventions can improve short term self-efficacy but appear to have little effect on quality of life and other health outcomes. 

Group visit interventions for diabetic patients may modestly reduce HbA1C in the short term. A peer-led community based self-management program appears to improve health and utilization outcomes in mixed groups of patients with various chronic illnesses. Chronic visits may be as effective as individual education visits and may represent a reasonable alternative of educating patients with chronic illness. However, there are a couple of caveats. The varied and sometimes low participation and retention rates suggest they should not be the sole alternative. And although we did not find evidence of direct harms associated with group visits there are theoretic concerns that might temper widespread implementation in group visit models for some patients especially given the lack of robust evidence that group visits improve long term health outcomes. 

For instance, travel and participation time associated with group visits may preclude participation for patients with limited work schedule flexibility and may be prohibitive for frail older participants. Limitations of the review: comparability of studies is limited given the vast heterogeneity and complexity of intervention content and outcomes examined. There may be important outcomes not captured in this report such as knowledge improvement outcomes. Participation rates when reported ranged from thirteen to one hundred percent though many studies provided little information about the recruitment process and there were relatively few comparative intervention studies. 

Some thoughts for future research: we did identify some evidence gaps that we have recommendations to consider. For patients and populations there were few good quality studies in patients with asthma, COPD, CHF, chronic pain, and multiple chronic conditions. We would recommend more trials in these populations. Under interventions there was a lack of clarity as to which intervention components are important in achieving improvement so we recommend head to head comparative trials. Under the comparator there were relatively few studies with active comparison groups so the recommendation is for comparative effectiveness trials. Under outcomes studies evaluated dozens of different outcomes many of which were non-standardized metrics of uncertain validities. We would recommend a standardized approach to outcome measurement and use of well-validated scales. 

Under timing there is a lack of studies examining long term outcomes so we are looking for trials with longer term follow up. There are also few trials assessing the effects of booster sessions so we would recommend trials evaluating the effects and timing of booster sessions. And in terms of the setting there were few trials in community and rural settings so to test telehealth trials of group visits and trials located in community settings such as churches and community centers. I will now turn you over to other presenters Dr. Watts and Dr. Kirsh. 

Dr. Watts will address the following questions: from a practitioner’s perspective are there any outstanding gaps that you think would be valuable to day-to-day practice? Are these findings surprising? And does the group visits report convey any information that would influence your teamlet’s practice? For Dr. Kirsh, if you could respond to the following questions: are there any implications for VA PACT level role out decisions? Any implications for funding research to better inform PACT roll out decisions? And any implications for collaboration between HSRD, QUERI, and the VA office of nursing services in future work on this topic? Thank you. 

Sharon Watts:Thank you, Jeannette. This is Sharon Watts responding first. I was asked to reiterate again some of the take-home points from this evidence in synthesis program. So I guess I would start with first saying group visits we found from this discussion that group visits increased self-efficacy in the short term especially those visits that incorporate self-management strategies versus didactic. Second, there was little effect on quality of life or functional status. We did find that there was no harm from the group visits and that the results were limited by small numbers of participants and low participation rates on the part of the patients. Specifically in diabetes because that has been my specialty we saw that there was significant heterogeneity of the two good quality studies comparing group visits to usual care and A1C reduction. 

Also they found that group visit interventions in patients with diabetes may have a modest effect on glycemic control. So we are talking zero point two five percent reduction in A1C That is over the short term. But the strength of the evidence supporting this conclusion is low and that self-efficacy is increased but not quality of life. So the second question, are these findings surprising? And I would have to say after looking at all this information over the past week or so I am not surprised because of the limited good studies we have to show outcomes. 

The third question was does the group visit report convey any information that would influence practice where I am at? So when I looked at this question I went over again the office of nursing services strategic goals. So we have several strategic goals within the VA now. And I am sure many of you are aware but I would just reiterate that we want our care to be patient driven. We want it to be team based, data driven and evidence based which is why we are on this call today many of us. We want to focus on prevention, population, health, providing value, and always continuously improving the care that we provide. So when I looked at those strategic goals and some of the gaps that might be missing in the information that was provided I thought of things like well, are group visits cost effective? Are they providing value this way? Are our group visits offloading PACT teamlet time? 

So when you have a chronic disease like diabetes, specifically diabetes but many of the other chronic diseases as well, there is a lot of education upfront when you are newly diagnosed. If the group visits are not teaching this then who is? The PACT teamlet? and they are already burdened. And the primary care is not set up for chronic disease clinic times. They are set up originally for acute disease, in and out kind of fashion of treatment. So learning how to use a meter for a seventy year old veteran is not an in and out visit and can this be done effectively providing value to the patients? Another gap might be patient satisfaction and patient centered care. A lot of our veterans are extremely pleased with meeting other veterans and the support in talking about their chronic disease. so when I talk about team based care our group visits for diabetes and prevention and obesity and diabetes prevention often involve a nurse and a dietician. We incorporate the psychologist, podiatrist, and our guest speakers. The other thing that was not perhaps studied and a point that I would say would be a gap in care is patient safety. 

So none of these studies addressed the fact that perhaps hypoglycemia education is – it is always provided in our diabetes groups. We know hypoglycemia is a serious concern nowadays with diabetes much more so than we thought of it in the past. We talk about using alcohol in our groups. We talk about the safety of using insulin when we know insulin is the fifth dangerous drug out there now. So if not provided education in the groups where is this being provided or not provided? One other gap that I would think of is what is the difference between a new onset chronic disease versus a patient with chronic – an older patient who has had this chronic disease for a while? So with new onset there is much more education up front and with a chronic disease longer standing there is much more need for management of medications and adherence to medications which might be the function of a shared medical appointment versus a group visit. 

And one more thing that we do here in Cleveland is target our high risk patients with chronic disease. So those with an A1C over nine percent. Is that something that needs to be – can group visits address that or is that more a traditional shared medical appointment model where we can do much more medication management? So those would be some of the gaps that I would say. And that what might lead to changes in altering patient and team practice is that we recognize the different types of patients and the different types of interventions that they need. So there might be a patient who wants to learn on his own. And one of the studies quoted by Ana, I believe, was that telehealth diabetes programs, one fair quality study found automated telephone based self-management interventions performed similarly to an in-person group self-management skills intervention. 

So if we look at cost and providing value that – and that patient that wants the individual or works, a telephone health diabetes program might be optimal for that patient. In fact, we do have a good telehealth program in the national VA program. So we have mimicked what patients learn in a self-management group program and incorporated that into a telehealth program. And also for cell phone apps as well. So we need to look at the individual patients, see what they need, where they are on this continuum of this chronic disease and be able to continuously improve the types of visits we provide through evidence based and the gaps that we have identified where can we best meet their needs and the needs of our strategic plans within VA. So with that I will turn it over to Dr. Kirsh if she is on. 

Susan Kirsh:I am on and I am hoping that everyone can hear me. Can you hear me? 

Sharon Watts:Yes we can yes. 

Susan Kirsh:So thank you, Sharon. I have had the privilege of working with Sharon Watts over the last more than ten years looking at and thinking about chronic disease at the Cleveland VA. And in the last few years I have – I have wanted to correct what it says as my title there, that I have been the last almost three years a chronic disease consultant for PACT nationally working with Dr. Sheckman and Dr. Stark and Storm Morgan in office of nursing service to think about how to improve chronic disease care within the PACT roll out for the also years. Also a correction in the spelling of my last name only in that – I correct that so – in case people want to email me it is K-I-R-S-H, no C in it. So with some of that in mind I want to touch on and reiterate some of the points that I think that Sharon has made which I think are really great points and Sharon did an excellent job looking at some implications from this current review and I would like to then take it a step further for future directions and next steps and then point out some areas for consideration. 

I think that one component to consider is in this ESP is really, and I think that the evaluators and the faculty with probably agree, is that there is some heterogeneity in the model that they use. So it wasn’t a standardized one type of provider, that it was a nurse with a certain degree giving a group visit model to the same chronic condition in the same – using the same technique. And that creates difficulty in trying, I think, to make decisions and conclusions regarding the data. So I think in this group visit ESP and I was involved a bit in the shared medical appointment ESP and also in a shared medical appointment realist evaluation ESP which I will explain in a few minutes, I think one challenge is really that it is not in one disease state with one type of clinical provider giving one type of instruction or education.

For example, the use of peer support, the use of motivational interviewing. And so I bring these up in that I think that they have implications for the findings and I think that they do indeed have implications for really further evaluation. And so the summary of what I am saying is that we need studies really that look at contextual factors and explain some of the contextual factors a bit more. And we looked at that a bit with the realist review which is a different type of review that in some ways for shared medical appointments brought in the allowable studies so expands the number of studies to include abstracts and to include some materials in the gray literature. And we still – but there are not as many RCTs or as strong of a study so the conclusions are a bit weaker. And we found that in that realist review that the contextual factors were all over the map in terms of how many providers were there, how many patients were there. And I think that that putting together the group visits, the shared medical appointments, and that we need to collect further information around contextual factors such that we can make conclusions regarding what the best way to do this kind of work. So I am interested in hearing some feedback about that point. 

Another point in general is really that point that Sharon pointed out in that we need to think perhaps about virtual ways to do group visits and shared medical appointments. And I know that outside of VA there has been phone level group visits and that there has also been within VA in a pilot format some rural areas that are doing and that is a QUERI funded study, some virtual group visits such that some patients are at one site and the providers at another site. And this is a modality used to try and include patient that may live several hundred miles away in rural areas of our country so that they also have access to group visits and to shared medical appointments. 

So those are – so moving on then to the next point. I think that in the literature regarding shared medical appointments and group visits there is something that is – and I would be interested which is probably my second question, what are implications for funding and research and areas for exploration is really in looking at a VA population and the impact of group visits and shared medical appointments in this population. I think that Sharon can attest that there is something really very powerful about veterans helping each other. Perhaps it is really in the culture of veterans. But we do see that there has been a lot of work and some positive effects in effectiveness in group visits and in shared medical appointments in VA – in veterans. So there is something really powerful about that. So getting to the specific questions one, two, and three I will touch on number one first. I think I touched on number two a bit and then conclude with number three. 

Number one, really, the VA PACT roll out, I think that there are specific stock codes for group visits and for shared medical appointments that are identifiable ways to promote the use of group visits and shared medical appointments. And they are part of the PACT compass. Which for those of you – many of you may be familiar. For those of you who are not it is a way of looking at how well PACT teams and patient centered medical home teams are performing in terms of their – I mean, how well they are performing basically. And this is a component that is considered in VA primary care nationally to be a part of higher performing teams. So I think that that is something that is promoted and has been looked at and considered to be a part of a higher performing team. And we will continue to see that looked at specifically and individually as a component of teams that are functioning and doing well. 

So let me think on number one if there is – I think that that is really my thought on number one, on roll out. On number two I would say that there has been a little bit of QUERI money to investigate how shared medical appointments only and not group visits have been put into VISN seven, trying to understand relationships between the high performing teams that I alluded to and the use of group visits and shared medical appointments. It has not been looked at for group visits but I think that – and then tying into number three, some areas for further investigation would be the association between group visits and high performing teams. Throwing out for some discussion for those who are interested and perhaps Sharon, if you are – is there a relationship, basically, between a high performing PACT team and the use of group visits so that we can understand in real world effectiveness how to use this type of visit optimally to educate our patients as well as then the shared medical appointments. I think about addressing high risk populations. 

So of course there is always room for collaboration and further evaluation specifically with office nursing service. I think that QUERI has been in looking at some of this within diabetes and I hope that that will be expanded further. So I think I will stop here and really open it up if people have questions for me specifically or for Sharon and me. 

Moderator:We do definitely have some pending questions here. Are you guys ready to – Ana, I just want to double check you guys are ready to get to the Q&A portion here? 

Ana Quiñones:Yes, absolutely. 

Moderator:Sounds great, we will start at the top here and work our way down. Give us an idea of a simple well validated tool for quality measures. 

Susan Kirsh:Sharon, you want me to answer that? 

Unidentified Female:Or Ana? [crosstalk]

Unidentified Female:If you want to take a crack at it, Susan. [crosstalk]

Unidentified Female:Well, I know that you guys have self-efficacy and I recommend for people who are interested in looking at self-efficacy or at group visits or shared medical appointments, I like the self-efficacy tool or patient activation would be another one. If you guys are familiar with the Judith Hibbard, there is a longer and a short form of a patient activation. I think what we want is to engage and activate patients with chronic conditions to increase their self-care and self-management and so I say self-efficacy or the patient activation measure. And there in the last few months have been a short version has come out by Judith Hibbard. 

Ana Quiñones:Yes and can I add to that? So also part of the function of the evidence based, the review that we conducted, was to be as inclusive as possible but also triaging the outcomes that we included based on input from our technical expert panel what would be useful, what makes the most sense. So we kind of approached it from a much more agnostic perspective but also recognizing that there are some better validated scales out there. As Susan mentioned, the PAM, the patient activation measure scale and we did not include those based on input that we got from our panel. I am hoping that answers the question. I am not really quite sure if that is exactly what the questioner was getting at. 

Moderator:Well, the questioner can send in a clarifying question if they need to so we will move on to the – 

Ana Quiñones:[crosstalk] Heidi, can I request – there was at the very bottom – there was a question asking the differentiation between group visits and shared medical appointment. I think maybe we should approach that one just to make sure that everything else that we talk about is clear to that asker. 

Moderator:That is fine, yes. The question there: what is the distinction between group visits versus shared medical appointments? Feel free to run with that, yes. 

Ana Quiñones:And I will take that, this is Ana. So that is an important distinction also because they were two separate reports commissioned to the ESP. The Durham VA took the shared medical appointments systematic review and we at the Portland VA took the group visit systematic review. And both are available. Both of the full reports are available on the link that was provided in the earlier version of the slide, one of the earlier slides, that I think are available to all of you. But for the purposes of this report group visit were defined as those that were led by a non-prescribing provider or a lay-facilitator. And the purpose of the group visit was to educate patients on managing their chronic illness. Now on the other hand, the shared medical appointments focused on multi-patient visits where individualized medication management and treatment plans were incorporated into the shared visit. Hopefully that clarifies things for people. 

Moderator:Hopefully, thank you. The next question we have here: we need bigger and better studies of what works in educational group visits. Who in VA could help in coordinating facilities to do these larger studies such as in chronic pain? 

Ana Quiñones:Sharon, do you want to take that?

Sharon Watts:Well, we do have an evidence based nursing program through the office of nursing services. And Beverly Priefer, she is one of the names at the beginning of this, is on the program. We have several PhD nurses who are in the office of nursing service that you can send your questions to them and discuss how you might get started. Anna Altwhite is also another person that you could send your request to. But you would want to hook up with researchers in your area, PhD research nurses, and then secure funding through places like QUERI. And QUERI does fund some smaller studies as well. Both Susan and I are on the QUERI for diabetes. And there are sometimes funding resources. And then you could also look – Ana could tell you other areas as a PhD research nurse in the VA. 

Susan Kirsh:This is Susan. I will make a comment about pain in the VA and I will tell you that it is going to bubble up very quickly as this is something that is a priority for the undersecretary. And so there are four networks that are currently – have agreed to really engage in improving pain care. They recognize that group visits, education, as well as shared medical appointments will be a component of the care that is delivered. And I think that you will see a lot of movement in pain care in the next six – three, six, twelve months depending on what network that you are in. Once I think that we have some of that movement also supported by a joint very large grant between the VA and the Department of Defense to move pain care education and competencies forward I think we will have the clinical components really, some of the clinical pieces in place that would allow us to then do some bigger studies and evaluation across multiple sites. So I would say stay tuned. I think we are going to see a lot of improvements I think and hope in education around pain care in the VA in the next year. 

Moderator:Great, thank you. The next question I have: what definition of chronic illness are you using?

Jeannette Richardson: This is Jennie, I will take that one. The ESP group here in Portland was guided by our technical expert panel in the conditions that we included in the report. So that is essentially how we decided upon the chronic illnesses that were included. Just in general terms we operationalize this to be illnesses that were non-acute in nature or longer in duration. 

Moderator:Great, thank you. The next question here: what is the difference between usual care and non GV care? 

Ana Quiñones:I will take that one. This is Ana. So again, I will refer you to the full report. But essentially we looked at the different comparators. We were able to compare studies with active group visit arms with the comparators of usual care, treatment as usual. And in addition we also included head to head trials, so those trials that had active treatment arms that compared each other. So for example, there were some studies that compared didactic versus self-management education and there were others that compared group visits versus individual visits. And those were all included in the report. 

Moderator:Great, thank you. Next question: could you give the key words used in the search again? 

Ana Quiñones:Yes, and this is Ana. I will take that one. So going to sound like a broken record, but again I am going to refer you to the full report and it is specifically in appendix A. we list the full search strategy. But I will give you just a little primer based on what we reported this morning. So for example, we looked at – some of the mesh terms that we used were health education, self-care, counseling, management, coaching. We also looked at diseases of interest and then the group aspect we looked at things like group, self-help groups, and we excluded things like food groups. So again, the full reporting of the research strategy is included in appendix A in the full report. 

Moderator:Great, thank you. The next question here: did any of the studies look at DIGMA?

Ana Quiñones:So I will take that one again. From what I understand the DIGMA is the drop-in group medical appointments. And these seem to be centered around physicians. So again the distinction between the shared medical appointment and the group visit systematic review. So our nominating stakeholders were interested in group visits that were led by non-prescribing providers and lay-facilitators. So we did not include DIGMA or DIGMA was not represented in our included studies. 

Moderator:Great, thank you. The next question: based on this it is a bit discouraging given the current condition of our population. What is your opinion of what will work to improve the overall health of not only veterans but US citizens overall? 

Ana Quiñones:So Susan or Sharon. I mean, I can take the systematic review kind of based on the evidence and then maybe you can add a few words in terms of kind future direction. So from the literature that we examine and from the evidence we did not really find harms, per se, just concerns for applicability, generalizability, so which populations these results are applicable because of the low participation rates and the recruitment question. However, I do have to say that we were somewhat encouraged by the low cost programs that were peer led. For example, the chronic disease self-management program which did find some moderately strong evidence in the more distal health outcomes that we did not seem to find across some of the other clinical conditions than the other studies that we examined. 

Sharon Watts:And this is Sharon. I would say that in dealing with diabetes for multiple decades I know it can be discouraging, the chronic disease, but that we need to consider the motivation of the patient and that we have to wait until they are ready. And that goes for all people with chronic disease. And that we need to continue to look at ways to intervene that would fit the patient’s needs. So the tele – the phone application programs or the one-on-one visits. Or we have a shared medical appointment here for high risk patients. And both Susan and I have been encouraged with what we have seen with some of those patients but not all of them. So not everybody is ready and we just continue to work at whatever ways we can that would meet the patient’s needs and to continue to research it. And Susan, if you had anything else. 

Susan Kirsh:Well, to circle back to the comment that I made, I think that while these results are not overwhelmingly inspiring to immediately go out and do that, I mean, the people that are doing this work have seen some good results. And I think that there is a bit of a gap in understanding, reporting, I should say, of some contextual factors that really we think may be important in that we have not really gotten to some of those factors yet. But we did our realistic evaluation which was the expanded version of an ESP and was also a cyber seminar and you can look for that as well. We did find that more than one discipline and using more than one discipline so using perhaps a nurse and a pharmacist or a nurse and a nutritionist to do the visits, that that was helpful as well as using techniques to get patients really engaged in supporting each other, the peer support to be important. I think that we just do not have all the information. This was an excellent review but we do not – we are still missing some information to help us fine tune some of what we need to know. That is it. I do not know if there are other questions. 

Moderator:We do have a few other pending questions out here. I have three questions that came in on codes and I am going to – they are similar but not exactly the same. I will ask all three and then let you respond here. How do you code for group visits without causing copays? This is a real problem in our VISN. The next one: are there separate stock codes for group visits and shared medical appointments or are they lumped under the same code? And the third one is what specific primary and secondary stock codes would you suggest to use with these group appointments? 

Unidentified Female:So Susan, why don’t you address that one? 

Susan Kirsh:Well, I do not – I should – I apologize but I do not know off the top of my head the group visit code. It is distinctly different from a shared medical appointment code in DSS which is the way the – a lot of the stock codes for clinic coding is done. So for shared medical appointments it is 348 is the stock code. And there is a lot of confusion around this but – and I will explain in a moment because it applies also to group visits. An additional, if someone wants to email me, or I can send it to you guys – a colleagues, the group visit stock code, they are usually done in primary care. So 348 is a stock code and the three digit code that is for group visits is a stock code that is recognized by primary care as a primary care – an addition or a subgroup of primary care doing these types of visits. And then if there is more than one provider that is associated with it, so it is going to give primary care workload credit for it. if there is a secondary only one provide that is leading that visit then you could put a nurse or a nutrition person in the secondary stock code although this is – nutrition has not been capture. So if a nutrition assigns the note then they can get that credit. 

If there is more than one provider the trick is the following: the CPP coding you need to put the highest clinical person on and then add additional people to the encounter so that everyone will get workload credit if there is more than one provider. So the DSS code is workload credits and the CPT coding is – encounters – is to bill outside the VA. We have very, very little outside billing. And so people do sometimes get hung up on that. But it is supposed to be the highest level person filling out the encounter code. But since we are not changing medications it should not be as challenging or if there is not more than one person. And did I answer all of the questions regarding that? Oh the copays. That is something that is – it depends on what the CPT code is. If there is not any medication changing or no provider that is involved in a group visit I am not sure that that really will trigger a copay. I actually think it will not. Sharon, do you agree with me? 

Sharon Watts:Yes, we do not have a copay for our visits here for group visits, for diabetes health management education. 

Susan Kirsh:Because there is not a physician or a pharmacist or a nurse practitioner, I think, involved. 

Sharon Watts:Right, yes. 

Susan Kish:So there should not be a copay that is triggered. That is because it is not a type of visit or encounter that should trigger a copay. Shared medical appointments do trigger a copay and when it is within primary care you – it is a lower rate than if they were seeing an endocrinologist or a pulmonologist or an asthma type of visit or a pain/anesthesiologist. So there are probably less than, I think, ten percent of our patients get copays. You might be in an area that does. And I have spoken to some of the billing office before, there is – you could probably divide it over three visits but you cannot completely get rid of copays when a provider is providing those services. That is all I got. 

Moderator:Great, thank you. The next question that I have here: what is the average attendance rate to group visits? Do patients show up? And do they continue in attending these programs? 

Ana Quiñones:Yes, this is Ana. So [crosstalk] oh sorry, Susan. Let me just – Sharon, sorry, let me just report what we drew out and we abstracted in our report. So we reported in the cyber seminar the participation rates ranged from thirteen to hundred percent, pretty wide variation there. We also report in the full report the loss to follow up. So we do not know – I mean, I guess that would include the attendance rate for folks that no longer attend or that begin and do not attend the full rendering of the sessions. And that is again reported in the full report. I do not have the range there handy with me. However, I do recall that both of these raised flags for u in terms, again, in terms of applicable and how generalizable these findings are because it seems that those very well motivated patients and patients who did not have potentially work flexibility issues or who were not elderly frail patients who had difficulty attending these sessions were the ones that were being represented in the results. 

Sharon Watts:And this is Sharon. I would have to say that that reflects the – what happens here in Cleveland. It is very difficult to get attendance at these group visits. It can vary in that things like telephone call reminders and letters are absolutely necessary for group visits. And that we continually try to improve our attendance rate. But work schedules and the lure, I would have to say, for a shared medical appointment is that they know that they can renew their medications when they come. And that they cannot have that happen when they come to a group visit. So it is an ongoing problem. 

Moderator:Great, thank you. And we [crosstalk]

Unidentified Female:Go ahead. 

Moderator:We actually got a comment in while you were responding there in that it would be more helpful to have the mean of the number that attend rather than a range. 

Ana Quiñones:Yes, I think that may be the case if the number of sessions were even and equal. So again because we had a large number of studies across a large number of clinical areas they were all very different. I think in terms of a summary of giving you an idea, giving the audience an idea, giving the audience an idea of what was in the report I felt that that was sufficient. 

Moderator:Thank you. And question just got on here, what method do you use to track patient progress or to determine the need for follow-ups? 

Sharon Watts:So I will answer that, Sharon. And for our diabetes self-management we are American Diabetes Association recognized. And to be under the American Association of Diabetes you have to have goals, self-management goals and you have to have evaluation of your program. Most programs look at A1C outcomes and then patient goals. So that is tracked through CPRS. So patients choose diet or – and that we do have an ongoing after our initial three, we do invite patients for ongoing support. Some of the data has recommended this. So – and of course it is generally a self-selective group who participate in that ongoing advanced group support monthly. But that would be based on their preference, where we ask them to come back. 

Moderator:Great, thank you. And we have reached the end of our scheduled time for the cyber seminar. I do have about four or five pending questions left out here. I am not sure if any of you are able to stay on the line to discuss any of these or if I can send them to you offline. I am not sure what your preference would be. 

Unidentified Female:I am happy to stay online. [crosstalk]

Unidentified Female:Yes, I can stay online. 

Moderator:I cannot stay too late because I do have another cyber seminar starting in forty-five minutes but we will get through what we can here. 

Unidentified Female:Hopefully those four questions will not take forty-five minutes. 

Moderator:[laughter] Well, I need a little bit of admin time in the middle but we will get through what we can here. Next question: suggestions on how to increase the number of the veteran group participants? 

Susan Kirsh:I agree with Sharon, phone calls. We have – can be very helpful. And once you get to know them, once you get them there and if you are a consistent provider participating I think that that is a higher likelihood. 

Sharon Watts:Yes and I would have to say making sure that the classes are interactive, that they are not didactic in nature. We have just added a cooking demonstration to our diabetes self-management classes .and it is one of our dieticians, a male who is a veteran himself who does not know how to cook but he tells the veterans all the time I can follow a recipe and so can you. So that gets a lot – and they get to sample those – the food, the fare, and tall about carbohydrates and they get a lot of interest in those classes. So the act of participation. 

Unidentified Female:I would echo that. that is a great point, Sharon. I know that the heart failure group in Cleveland is doing a group visit on patients’ medications and having them really bring their bottles and set them out in pill boxes and it is – they are learning quite a bit about patients and patients are learning quite a bit as well in trying to work together around that patients. 

Unidentified Female:And one thing we did many years ago, we did not wait for the patients to come to us. We used a registry and just actively recruit patients with a letter, come to this shared – or this group visit on diabetes if you would like to learn more. We just send out mass mailings. We get some people who take it, some that do not. Next question? 

Moderator:This is a follow-up to something that Susan was mentioning, somebody is wondering if this is qualitative research appropriate to examine the contextual factors that Susan was mentioning to get to what does work from the patient perspective? 

Unidentified Female:So I think that it can fall into both, a mixed methods approach. What I was thinking about was – the based on the consolidated framework for implementation research, if you want to email me, that is fine. Laura Gamshroder through the Ann Arbor group put together some categories that look at implementation and that consider a lot of contextual factors in implementation. And I think that that would be a great study to do as well as I have also thought about identifying group visit and shared medical appointments, some of the names of the authors and holding some interviews to identify and code for some things. So I think both would be appropriate and very interesting. 

Moderator:Great, thank you. The next question I have here: were clinical video telehealth groups or classes part of any of these studies? And if not, will these types of appointments be part of the studies for PACT in the future? 

Ana Quiñones:So this is Ana, just really quickly to respond to what was included I do not believe that video telehealth was included in any of our represented studies. 

Susan Kirsh:And this is Susan, I know that Hank Lou who is investigator in Providence, Rhode Island is doing a virtual telehealth group visits and shared medical appointments funded by the diabetes QUERI right now. 

Moderator:Great, thank you. The next question: are there any efforts ongoing to evaluate and/or increase use of CDT to promote participation in these visits? 

Unidentified Female:Which I think is similar to the previous question, the way in. And I think that given the virtual technology push and the performance measure for a lot of networks to get to I think thirty percent of visits being virtual either telephone or telehealth type of visits, I think that we are moving in that direction. And we need to figure out how to make that happen. We are in the best position to do something like that even across networks to have patients participate with each other if need be. And we are doing something without – with providers and multiple providers in education with scan echo. And so we need to think about how to expand that. It is not too far off and I think that we need to really get there and that is an area for further investigation as well. 

Moderator:Great, thank you. And the last question that we have here, I believe this was sent in as a follow-up question from the coding. If diabetes program is a nationally recognized program billing can occur as a specialty. Please elaborate. 

Unidentified Female:I am not sure about that question. Does that mean that you – yes, if it is done by an endocrinologist or insult pump patients and you can absolutely use specialty care endocrinology stock codes to get workload credits within specialty care. Or if it is pulmonary who is doing an asthma group visit or shared medical appointment then you can absolutely bill it in specialty. Most of what is happening across the country in pain, heart failure, diabetes, is within primary care. So that is why I mentioned that, that it absolutely can be coded for specialty care. [crosstalk]

Sharon Watts:Yes, this is Sharon. And I would say some sites do I think outside billing but we do not at Cleveland for that. 

Moderator:Great, thank you, and that wraps up all of our questions. I do want to thank all of our presenters for taking the time to put this together and present for today’s cyber seminar. We really appreciate the time that you all put into this. For our attendees thank you for joining us today. As you leave today’s session you will be prompted with a feedback survey. If you could take a few moments to fill that out we would really appreciate it. We really do read through all of the feedback that you leave and do take it into account for our current and upcoming sessions. Thank you everyone for joining us for today’s evidence based synthesis cyber seminar and we hope to see you at a future session. Thank you. 

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