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