• Effectiveness, Intervention Cost, and Health Care Utilization Associated with Group Medical 

Visits for Diabetes and Hypertension: A Randomized Controlled Trial 

Santanu Datta, Ph.D.; Cynthia Coffman, Ph.D.; Amy Jeffreys, M.S.; Morris Weinberger, Ph.D.; David 

Edelman, M.D. 

Presented by: Santanu Datta, Ph.D., Health Research Scientist / Assistant Research Professor, Center for Health 

Services Research in Primary Care / General Internal Medicine, Durham VA Medical Center / Duke University, 

HSR&D (152), 508 Fulton Street, Durham, NC 27705; Phone: (919) 286-6936; Email: santanu.datta@duke.edu

Research Objective: Group medical visits (GMVs) are being widely implemented for diabetes 

management. We evaluated the effectiveness of GMVs as well as its cost and impact on health services 

utilization. 

Study Design: Groups with the same 7-8 patients met with the same pharmacist and general internist 

each visit; there were different physicians and pharmacists across groups. Each session included group 

education and structured group interactions moderated by a registered nurse or certified diabetes 

educator. Additionally, individual medication adjustments were made by the pharmacist and physician to 

manage A1c and BP. Each group had an initial visit and then met every two months for a year. We 

estimated the cost of GMVs by summing labor costs (salary and fringe benefits) associated with the group 

sessions themselves, follow-up calls with patients, and 2 hours of nurse training. All patient-care related 

phone calls were logged throughout the study. We estimated base-case as well as minimum and 

maximum costs (provided in parentheses) using appropriate ranges of personnel salaries and call times. 

To assess intervention impact on health services utilization, we used VA-specific codes in administrative 

data to calculate primary care (exclusive of GMVs) and emergency department usage rates and 

hospitalizations that occurred between 1-13 months after enrollment. 

Population Studied: 239 patients receiving primary care at the Durham, NC or Richmond, VA Veterans 

Affairs Medical Center (VAMC) with poorly controlled diabetes (A1c > 7.5%) and blood pressure (BP) 

(systolic BP > 140 or diastolic BP > 90) were randomized within VAMC to receive either GMVs or usual 

care. 

Principal Findings: For patients in the GMV arm, BP improved from 153 mmHg at baseline to 139 

mmHg at 12 months; for patients in usual care, BP was 153 mmHg at baseline and 147 mmHg at 12 

months (p= 0.01). GMVs did not have a differential effect on A1c compared to usual care. GMVs 

averaged 1.5 hours of physician time and 2 hours each of pharmacist and nurse time. Clinicians also 

placed 175 follow-up calls to the 133 intervention patients. We estimated that the cost of each GMV was 

$504 ($445-$578); assuming 8 patients per group, the per-patient cost was $63 ($56-$72). If patients 

attended all 7 GMV sessions, the annual per-patient cost would be $441 ($389-$506); follow-up calls cost 

an additional $19 ($4-48), bringing the annual intervention cost per patient to $460 ($393-$554). Patients 

in the intervention group had 0.9 fewer primary care visits (5.3 vs. 6.2 per patient-year, 95% CI -1.5,-0.2, 

p=0.01) and 0.44 fewer emergency care visits (0.9 vs. 1.3 visits per patient-year, 95% CI -0.70,-0.20, 

p=0.0004). For inpatient stays, 23 GMV patients (17%) had a total of 32 hospitalizations; 23 usual care 

patients (22%) had a total of 39 hospitalizations (OR 0.8, 95% CI 0.4, 1.4). 

Conclusions: GMVs reduced primary care and emergency department visits and have the potential to 

reduce hospitalizations. These reductions at least partially offset the annual per patient cost of GMVs and 

could be cost-saving. 

Implications for Policy, Delivery or Practice: Given their beneficial effect on BP, GMVs may be a costeffective means for caring for patients with poorly controlled diabetes and hypertension. 

Funding Source(s): VA

Measuring Physician Cultural Competence: Results from a National Survey 

Somnath Saha, M.D., M.P.H.; Melissa Gatchell, M.P.H.; Martha Gerrity, M.D., Ph.D., M.P.H.; Nancy 

Perrin, Ph.D. 

Presented by: Somnath Saha, M.D., M.P.H., Associate Professor of Medicine, Section of General Internal Medicine, 

Portland VA Medical Center, 3710 SW U.S. Veterans Hospital Road (P3HSRD), Portland, OR 97239; Phone: (503) 

220-3474; Email: sahas@ohsu.edu
Research Objective: Cultural competence (CC) training for current and future physicians has been 

widely endorsed as a means to reduce racial disparities in health care. Evidence-based curriculum 

development and evaluation, however, has been limited by the paucity of well-designed, validated tools 

measuring physician CC. We sought to develop and test the construct validity of an instrument measuring 

physician CC. 

Study Design: We first conducted a systematic review of published articles describing physician CC and 

used qualitative analytic methods to develop a conceptual map of physician CC dimensions. For each 

dimension, we created a set of items that covered the breadth of its meaning as described in the 

literature. Eight national experts reviewed the items for content validity and suggested changes and 

additions. We revised our item pool and evaluated items for conceptual precision in cognitive interviews 

with 28 physicians from diverse racial/ethnic groups and specialties. After further revisions we included a 

final pool of 61 Likert-scale items in a questionnaire that also included items about demographics and 

prior formal training in CC and communication skills. 

Population Studied: We mailed the questionnaire to a random sample of 1800 internists and family 

physicians in zip codes with at least a 25% nonwhite population. We oversampled African American and 

Latino physicians. Respondents could complete the questionnaire online or on paper. Using responses to 

the 61-item pool, we conducted factor analysis to derive discrete scales and labeled the scales based on 

item content. We then used linear regression to test the hypotheses that minority physicians and those 

who had completed prior CC training would have higher CC scores as measured by these scales, after 

adjusting for physician age, sex, and prior communication skills training. 

Principal Findings: Among 1516 potentially eligible physicians, 795 (52%) responded. Respondents 

included mostly white (55%) or Asian (21%) physicians, with 12% being African American and 9% Latino. 

Most were male (65%), and most reported having had past training in CC (62%) and communication skills 

(78%). Our analysis generated 7 factors: cultural awareness (8 items, alpha 0.87), cultural self-efficacy (5 

items, alpha 0.79), awareness of racial disparities (5 items, alpha 0.81), valuing diverse perspectives (6 

items, alpha 0.77), support for “culturally and linguistically appropriate services” (CLAS) standards (6 

items, alpha 0.80), biomedical orientation (negative scale, 2 items, alpha 0.67), and relationship-centered 

orientation (13 items, alpha 0.88). In regression analyses, nonwhite physicians had higher scores than 

whites (p < .005) on all dimensions except biomedical orientation. Women had higher scores than men for 

awareness of racial disparities, valuing diverse perspectives, support for CLAS standards, and 

relationship centered orientation (p <= .001). Physicians reporting prior CC training had higher scores in 

all dimensions (p <= .002) except biomedical orientation and valuing diverse perspectives, whereas prior 

communication skills training was not associated with any CC dimension. 

Conclusions: We developed a theoretically based, novel instrument spanning multiple dimensions of 

physician CC that appears to have reasonable construct validity. 

Implications for Policy, Delivery or Practice: If further validated as a predictor of better and more 

equitable patient care, dimensions in this instrument could inform the content and objectives of future CC 

training, and validated scales could be used as evidence-based evaluation tools. 

Funding Source(s): NHLBI

• Cost-Related Medication Adherence and Patients’ Experience with the Chronic Care Model 

John Zeber, Ph.D.; Luci Leykum, M.D.; Krista Bowers, M.D.; Raquel Romero, M.D.; Michael Parchman, 

M.D. 

Presented by: John Zeber, Ph.D., Investigator / Assistant Professor, Psychiatry, Veterans Affairs HSRD 

/ UTHSCSA, 7400 Merton Minter Boulevard, San Antonio, TX 78229; Phone: (210) 617-5300; Email: 

zeber@uthscsa.edu

Research Objective: Medication adherence is a significant problem for patients with diabetes, one 

frequently exacerbated by financial considerations. Fortunately, provider and organizational factors (e.g., 

improved therapeutic alliance or clinical microsystem performance) can mitigate medication cost burdens. 

Research suggests that patients who are highly engaged in their care have better adherence, significantly 

improving clinical outcomes. Implementation of the Chronic Care Model in primary care should result in 

more activated patients who participate in their treatment. This study examines the relationship between 

patients’ experience of the CCM and its relationship with cost-related medication adherence burden. 
Study Design: Cross-sectional surveys from a large randomized trial in progress were administered as 

part of a study aim regarding how practice facilitation efforts influence better implementation of the 

chronic care model (CCM). Cost-related adherence burden (CRAB) was measured with a 5-item scale 

developed and validated by Piette and colleagues, where higher scores reflect more cost-related 

medication restrictions. The CCM was measured by the well-validated Patient Assessment of Chronic 

Illness Care (PACIC) survey, a 20-item instrument assessing perceptions of the primary care treatment 

environment. Each item was scored on a 1-5 Likert scale, with higher PACIC values indicating that 

patients experienced care delivery that was more consistent with the CCM. Random effects models 

controlling for nesting of patients within clinics analyzed the association between CRAB and perceived 

elements of the chronic care model. Population Studied: Patients with diabetes or other chronic medical 

illness presenting for care in 18 small, autonomous primary care offices in South Texas. 

Principal Findings: To date, 1377 patients with a chronic health condition completed both baseline 

surveys. The mean study population age was 50.1 years, with 65% women and approximately 50% of 

Hispanic ethnicity; while overall self-reported health status was good, 45% acknowledged poor 

medication adherence behavior, with nearly 30% claiming some cost-related problems. The CRAB scale 

mean was 1.50 (SD 0.82), with an overall PACIC mean of 3.02 (SD 1.25). In multivariable models also 

adjusting for age, sex, education and ethnicity, CRAB was inversely associated with the total PACIC 

score (OR=1.17). Higher subscales scores for patient activation (OR=1.26), problem solving (OR=1.16), 

and practice design (OR=1.26) were also associated with fewer cost-related problems pertaining to 

medication adherence. 

Conclusions: Patients experiencing care more consistent with elements of the chronic care model had a 

lower cost-related adherence burden, up to a 25% reduction per incremental increase in treatment 

delivered via the CCM. Specifically, this finding was true for individuals who reported that their treatment 

team actively involves them in clinical decision-making and provided information that enhances 

understanding of their care. 

Implications for Policy, Delivery or Practice: Although the prevalence of poor medication adherence in 

chronic illness patients is widely understood, the specific role of cost-related problems is less appreciated. 

Clinical efforts to develop highly activated and involved patients can successfully mitigate the 

ramifications of financial pressures. Community providers should better recognize and openly discuss the 

burden of medication cost problems while focusing treatment efforts in accordance with proven chronic 

care treatment delivery.

Physician Views on the Use of Comparative Effectiveness Research 

Salomeh Keyhani, M.D., M.P.H.; Alex Federman, M.D., M.P.H. 

Presented by: Salomeh Keyhani, M.D., M.P.H., Assistant Professor, Health Policy, Mount Sinai School 

of Medicine/James J. Peters Bronx VAMC, 1 Gustave L. Levy Place, New York, NY 10128; Email: 

salomeh.keyhani@mountsinai.org

Research Objective: Comparative effectiveness research has been promoted as a vehicle to improve 

health care quality and decrease costs. However, there is no provision in current health care reform 

legislation to use this information to establish guidelines that govern physician practice in part because of 

the concern that this research could be used to ration care and restrict physician practice. Physician 

support for comparative effectiveness research will play an important role in how this research is used 

and implemented; however, their views have never been elicited. We conducted a national physician 

survey and examined physician’s views on the use and importance of data generated from comparative 

effectiveness research. 

Study Design: We conducted a national, mailed survey of physicians between June and October, 2009 

to assess physicians’ views on healthcare reform. Survey content was developed through expert 

consensus and questions were refined through cognitive interviews with 16 physicians from multiple 

specialties and practice backgrounds. Four items were developed to address comparative effectiveness 

research: 1) “National guidelines should be developed to guide physician practice”; 2) “If national 

guidelines are established, comparative effectiveness data should be used in their development” 3) 

“Comparative effectiveness data will be used to restrict my freedom to choose treatments for my patients” 

and 4) “The availability of comparative effectiveness data would improve the quality of care provided to 

patients”. We calculated the response rate using standard methods. To assess potential non-response 
bias, we compared the characteristics of respondents and non-respondents using data available in the 

AMA Master file. Agreement with the four statements was measured on a 5-point Likert scale ranging 

from strongly agrees to strongly disagree. We report the percentage of physicians that agree with each 

statement. We also examine differences in agreement with the four items by specialty using chi square 

statistics. 

Population Studied: From the American Medical Association Physician Masterfile, we randomly selected 

equal numbers of physicians within four groups: generalists (585), medical specialists (620), surgeons 

(618), and other specialties (593). Physicians in training and from U.S. territories were excluded from the 

analysis. 

Principal Findings: The response rate was 50.8%. Survey respondents were slightly older than nonrespondents (52.0 vs. 50.4 years, p<.001). There were no significant differences by gender, geographic 

location, specialty category, or type of practice. More than half ( 57.2%) of physicians believed that 

national guidelines should be developed to guide physician practice and 77% of physicians believed that 

comparative effectiveness data should be used in the development of these guidelines. Almost two thirds 

(65.5%) of physicians agreed with the statement that comparative effectiveness data will be used to 

restrict physician practice. At the same time, over half of physicians (55.5%) believed that this data will 

improved the quality of care provided to patients and only 16% disagreed with this statement. There were 

no statistically significant differences across specialties across these four items. A majority of generalists 

(56.8%), medical subspecialists (56.9%), surgical subspecialists (52.3%) and other specialists (55.1%) 

(p=0.47) agreed that this data can be used to improve the quality of care. 

Conclusions: A majority of physicians support the establishment of national guidelines and support the 

use of comparative effectiveness research in the development of these guidelines. Furthermore, while 

physicians believe that this data can be used to limit their autonomy, they also recognize that comparative 

effectiveness data can improve the quality of care delivered to patients. 

Implications for Policy, Delivery or Practice: Even though current legislation does not include 

provisions for guideline establishment from comparative effectiveness research and restricts its use for 

Medicare coverage decisions, there appears to be majority support among physicians for the 

establishment of guidelines using this data. This support will play an important role in ensuring that 

comparative effectiveness research can live up to its promise of improving the quality of care and 

reducing costs. 

Funding Source(s): RWJF