inter-professional diabetes care: research and operational issues of group appointments susan kirsh,...
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Inter-Professional Inter-Professional Diabetes Care: Diabetes Care: Research and Research and
Operational Issues of Operational Issues of
Group AppointmentsGroup Appointments Susan Kirsh, MDSusan Kirsh, MD
David Edelman, MD, MPHDavid Edelman, MD, MPH
Hank Wu, M.D.Hank Wu, M.D.
Overview of Group Overview of Group Medical Medical
Appointments in Appointments in
DiabetesDiabetes Hank Wu, M.D.Hank Wu, M.D.
Providence VA Medical CenterProvidence VA Medical CenterAssistant Professor of MedicineAssistant Professor of MedicineAlpert Medical School, Brown Alpert Medical School, Brown
UniversityUniversity
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%
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
44.3
37.0
29.0
35.8 33.9
48.2
5.2 7.3
0
10
20
30
40
50
60
Adu
lts (%
)
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
Chronic Care Model
Care Delivery Redesign
Group visits
Alternative providers: Clinical Pharmacists, Nurses
Shared Medical Appointments
Self Management
Group educationEquipment
Link to Resources
Case Management
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
Types of Group VisitsTypes 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.
Education-Behavioral InterventionEducation
Behavioral modification
Pharmacotherapy
Case Management
Nutritionist
MD sometimsometimeses
Pharm D sometimsometimeses
RN /NP sometimesometimess
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
Shared Medical Appointment
Education
Behavioral modification
Pharmaco therapy
Case Management
Nutritionist
sometimesometimess
MD sometimsometimeses
IndividuIndividualal
Pharm D IndividuIndividualal
RN /NP IndividuIndividualal
Group Education with Individual Pharmacotherapy
- Structured Appointments -
-2.000.002.004.006.008.00
10.0012.0014.0016.0018.00
A1C (%) LDL cholesterol(mg/dL)
SBP (mm Hg)
Risk Factor
5 M
onth
s A
fter I
nter
vent
ion
SMA
Historical Controlsp < 0.05
1.4 vs. -0.3
p < 0.05
p = 0.29
Cleveland VAMCShared Medical Appointment
0.002.004.006.008.00
10.0012.0014.0016.00
A1C (%) LDL cholesterol(mg/dL)
SBP (mm Hg)
12 M
onth
s A
fter
Inte
rven
tion
SMA
Controls
P = 0.03P = 0.08
P = 0.38
Durham and Richmond VAMC’s Shared Medical Appointment
Drop-in Group Medical Appointment-No Structured Appointment-
Education
Behavioral modification
Pharmaco therapy
Case Management
Nutritionist
MD
Pharm D
RN /NP
Providence VAMC Pharmacist-led Insulin Initiation Program
0
2
4
6
8
10
12
A1c (%)
Baseline 1 month
Time
Change in A1c After Intervention
p < 0.01
10.6%8.5%
Group Education and Pharmacotherapy
Education Behavioral modification
Pharmaco therapy
Case Management
Nutritionist
MD
Pharm D
RN /NP
Multidisciplinary Education in Diabetes & Multidisciplinary Education in Diabetes & Intervention for Cardiac Risk Reduction Intervention for Cardiac Risk Reduction
(MEDIC)(MEDIC) Providence VAMC
0.00
2.00
4.00
6.00
8.00
10.00
12.00
SBP (mm Hg) A1C (%) LDL cholesterol(mg/dL)
MEDIC
Controls
p < 0.05
0.7 vs. 0.0
p < 0.05
p =NS3 month follow up
Are the Results Sustainable?MEDIC-Extended (MEDIC-E)
-2
0
2
4
6
8
10
12
LDL Cholesterol (mg/dL) A1c (%) SBP (mm Hg)Chan
ge af
ter I
nter
vent
ion MEDIC E
Controls
P = NS p < 0.05
6 month follow up
P = NS between groups,
P < 0.05, for MEDIC-E compared to baseline
Targeting in Diabetes with Depression Targeting in Diabetes with Depression (MEDIC-D)(MEDIC-D)
-2
0
2
4
6
8
10
12
14
LDL Cholesterol
(mg/dL)
A1c (%) SBP (mm Hg)
Ch
an
ge a
fter
Inte
rven
tio
n
MEDIC D
Controls
P = NS between groups,
P < 0.05, for MEDIC-D compared to baseline
P = NS
P = NS
6 month follow up
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
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
Continuum of Quality Improvement and
Research:Rigor vs. Relevance
Operations“Relevant”
Context-Dependent Problem Solving
Quantitative >, <, or = Qualitative
Pre-test post-test or quasiexperimental designsTends to be NON-LINEAR
Research“Rigorous”
Identify generalizable knowledge, i.e.,
Eliminate ContextPublishable
Quantitative>QualitativeRCTs
Tends to be LINEAR Continuum not a dichotomyContinuum not a dichotomy Goal is relevance moving as close to rigor as one canGoal is relevance moving as close to rigor as one can
Potential
Synergy
*** Danger ****** 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.
A P
S D
APS
D
A P
S DD S
P ADATA
The journey up the ramp of complexity is NOT linear.
Com
ple
xit
y
Time
Com
plex
ity
Time
APS
D
P PS D
A P
S DP
SD
AP
SD
Challenges
Opportunities
P
D
AS
PD
Revised Conceptual Model of Rapid Cycle ChangeTomolo, 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 feedforwardDifferent Sizes of letters and cycles and bolding of letters = denotes differences in importance/impact
ResearchResearch
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 VAMCCleveland 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 Characteristics continuedcontinued
•Leadership of the Clinic Director and strong team support critical promoting factors
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 Conclusions/Lessons LearnedLearned
Tailoring the intervention alone will not ensure sustainability; system adjustments are required.
Qualitative work adds another dimension that makes quantitative data more meaningful
SQUIRE guidelinesSQUIRE 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 Why Do Shared Medical Appointments Work?Appointments Work?
Who do they work for?Who do they work for? When you have a hammer, When you have a hammer,
everything looks like a nail……everything looks like a nail…… Targeting patients to differentTargeting patients to different
interventionsinterventions
Short Answer–Short Answer–
We don’t know.We don’t know.
Possible Mechanisms of Possible Mechanisms of ActionAction
Patient-to-provider interactionsPatient-to-provider interactions Patient-to-patient interactionPatient-to-patient interaction
Self-management groups, with an Self-management groups, with an educator only, have a well-documented educator only, have a well-documented modest effectmodest effect
Not discussed further hereNot discussed further here Other?Other?
Patient-to-Provider Patient-to-Provider InteractionsInteractions
Multidisciplinary ApproachMultidisciplinary Approach Having a doc, a pharmacist, and a nurse is better Having a doc, a pharmacist, and a nurse is better
than usual, MD-based carethan usual, MD-based care Group leader may function as a “specialist”Group leader may function as a “specialist”
Having someone really interested in (eg) diabetes Having someone really interested in (eg) diabetes may be better than usual primary caremay be better than usual primary care
Lack of distractionsLack of distractions Care of only (eg) diabetes may be better diabetes Care of only (eg) diabetes may be better diabetes
care than the ADHD environment of primary carecare than the ADHD environment of primary care More is betterMore is better
Just having more care for a chronic illness may be Just having more care for a chronic illness may be better care for that chronic illnessbetter care for that chronic illness
Multidisciplinary Multidisciplinary ApproachApproach
Theory– each provider brings a Theory– each provider brings a special expertise, increasing chance special expertise, increasing chance that each patient’s best approach to that each patient’s best approach to improvement may be availableimprovement may be available
At least one small RCT assessed thisAt least one small RCT assessed this Intervention 1.5% better A1c Intervention 1.5% better A1c
compared to controlcompared to control Other studies involving subspecialty Other studies involving subspecialty
MDs are similar in resultsMDs are similar in results It’s plausible that this is part of the It’s plausible that this is part of the
effecteffect
““Specialty Referral”Specialty Referral”
Theory– a provider interested Theory– a provider interested enough to run a group might be a enough to run a group might be a better provider for that disease than better provider for that disease than the usual PCPthe usual PCP
Untested theory to my knowledgeUntested theory to my knowledge Many group interventions rotate Many group interventions rotate
providers or have patients see their providers or have patients see their own PCPsown PCPs
My guess is that this is not a big part My guess is that this is not a big part of the effectof the effect
Care FocusCare Focus Theory– without the distractions of Theory– without the distractions of
usual primary care (acute issues, usual primary care (acute issues, meeting quality guidelines, etc.) it is meeting quality guidelines, etc.) it is easier to improve a single target easier to improve a single target
Not much literature on thisNot much literature on this May come out in qualitative May come out in qualitative
evaluations of group processesevaluations of group processes Plausible, but hard to really knowPlausible, but hard to really know
““More is Better”More is Better” Theory– what you really need to Theory– what you really need to
manage chronic illness is more manage chronic illness is more patient-provider contact, ANY contact.patient-provider contact, ANY contact.
A wide variety of diabetes structural A wide variety of diabetes structural interventions have worked in RCTs (eg interventions have worked in RCTs (eg case management, pharmacist clinics)case management, pharmacist clinics)
More probably is better, to a pointMore probably is better, to a point Point of diminishing returns unknownPoint of diminishing returns unknown
SummarySummary Probably a number of factors add up to Probably a number of factors add up to
provide the effects of shared medical provide the effects of shared medical clinicsclinics
Some of these are probably independent Some of these are probably independent of patient interactions within groupsof patient interactions within groups
From a cost perspective, would be nice From a cost perspective, would be nice to know what pieces are the most “bang to know what pieces are the most “bang for the buck”for the buck”
Future study should focus on thisFuture study should focus on this
How do you answer this How do you answer this question?question?
Quantitative measurementQuantitative measurement Measure patients’ perception of care and see what Measure patients’ perception of care and see what
changeschanges Or, develop predictive models in an effort to Or, develop predictive models in an effort to
match patients with intervention (SMA, case-match patients with intervention (SMA, case-management, pharmacist)management, pharmacist)
Qualitative measurementQualitative measurement If you want to know what’s working for the If you want to know what’s working for the
patients, just ask thempatients, just ask them Don’t botherDon’t bother
““Just Do It,” treat groups as a “black box” Just Do It,” treat groups as a “black box” intervention intervention