Transcript Document

Shared Medical
Visits
Jauch Symposium – May 17, 2014
Personal information
• Stephen Sorensen, MD
• Family Physician
• Faculty member of Genesis Family Medicine Residency Program,
Davenport, Iowa
• Director of Quality and Clinic Operations
• No financial obligations to report
Current state of medicine in
the United States
• Problem:
• Significant shortage of primary care physicians
• AAFP projects a shortage of 150,000 physicians by 2020
• HRSA projects a shortage of 65,000 PCP by 2020
• Physicians are being asked to see more patients in the same
amount of time
• Accountable Care Act – an additional strain on clinics as
additional patients are seeking to establish care with PCP’s
Current patient experience:
• Typical office visit
• Present to front desk
• Asked to arrive early
• Bottle neck – 5-10 minutes of waiting
• Sit in waiting room
• Read an out-of-date magazine – 10-15 minutes of waiting
• Brought back to exam room
• Wait for physician – 10-15 minutes of waiting
• Physician in the room
• 15-20 minutes
• Total time in office – 40 to 60 minutes, less than half that time
is actually spent talking to the physician!
What has to occur during an
office visit for Diabetes?
• A physician is asked to address:
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Blood glucose control
Nutrition
Physical activity
Foot care
Eye care
Address co-morbidities:
• Hypertension
• Hyperlipidemia
• Cardiovascular disease
• Order additional lab work
• Review and establish goals
• Arrange for follow up appointment
Another way to look at this?
• During a typical diabetes follow-up appointment, a physician:
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Addresses 17 topics, questions or symptoms
Writes on average 2 prescriptions
Discusses nutrition and medication changes
All within 17 minutes
Parchman ML, et al: Encounters by patients with type 2 diabetes – complex and demanding: an observational
study. Ann Fam Med 4:40-45, 2006.
One possible
solution?
Shared Medical Visits
• Multiple names for this:
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Shared Medical Visits
Shared Medical Appointments
Group Medical Visits
Group Medical Appointments
• Not common in the Midwest – (yet!)
• Much more common in areas with HMO’s
• Now a requirement for family medicine residency programs to
teach
Shared Medical Visits
• Can take many different forms:
• Acute care visits:
• (i.e.: URI’s)
• Chronic care visits:
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Asthma
COPD
Heart Failure
Type 2 Diabetes
Pregnancy
• We have chosen to focus on conducting SMV’s with diabetic
patients, now in our 8th year.
Shared Medical Visits
• What do they look like
• 8-10 patients per visit
• All given the same appointment time (i.e.: 10:30 – 12:00)
• Each patient seen individually for 2-3 minutes on arrival by
physician
• Very brief physical exam
• Ask if there are any questions they have about their care
• Patients gather in a conference room for remainder of visit
• Vast majority of the visit (60 minutes) spent on education, group
discussion, visiting experts, etc.
• Each visit attended by a physician, an observing resident
physician, behavioral scientist, nurse and health coach
Is there any evidence
that these actually
work?
Randomized Trials
• Managed Care Setting:
• Monthly, 2 hour SMA’s with multidisciplinary team vs.. usual care
• A1C’s > 8.5%
• Results for SMA patients:
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Greater reduction in A1C (1.3% to 0.2%, p < 0.001)
Lower hospital admission rates (P = 0.04)
Improved self efficacy in balancing food intake (P = 0.003)
Improved self-treatment of hypoglycemia (P = 0.03)
Improved management of glucose when ill (P = 0.001)
Sadur CN, et al: Diabetes management in a health maintenance organization: efficacy of care management using
cluster visits. Diabetes Care 22:2011-2017, 1999
Randomized Trials
• Five year follow-up study, 112 patients with Type 2 DM
• Group appointments vs. usual care
• Received four educational sessions on weight control, meal
planning, improved glycemic control, preventing complications
• Results for the group appointments:
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Knowledge of DM2 improved (+12.4 vs. -3.4, P =0.001)
Improved problem solving ability (+5.7 vs. -2.3, P = 0.001)
Improved quality of life over 5 years (-23.7 vs. +19.2, P = 0.001)
Improved A1C control (-0.1% vs. +1.7%, P = 0.001)
Trento, M, et al: A 5 year randomized controlled study of learning, problem-solving ability, and quality of life
modifications in people with type 2 diabetes managed by group care. Diabetes Care 27:670-675, 2004.
Randomized Trials
• Primary Care Clinic
• 12 month trial, 186 patients, monthly group visits vs. usual care
• Results:
• Significantly greater concordance with ADA process of care indicators
• Primary Care Clinic
• 6 month trial, 120 patients, group medical appts vs. usual care
• Baseline A1C was 10.3% vs. 10.6%
• Results:
• No significant improvement in A1C
• Higher “trust in physician” scores (P = 0.02)
• More successful in meeting ADA care indicators (P = 0.001)
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Clancy DE, et al: Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med 22:620-624, 2007.
Clancy DE, et al: Group visits in medically and economically disadvantaged patients with type 2 diabetes and their
relationships to clinical outcomes. Top Health Inf Manage 24:8-14, 2003.
Nonrandomized Trials
• 13 month study, Hmong refugees with type 2 DM
• Group medical appointments
• Results:
• Improved anxiety scores (P = 0.05)
• No difference in A1C, BP, or lipids
• Synchronous PCP visits and educational sessions, 44 Hispanic
patients
• Results:
• Significantly improved A1C (P = 0.001)
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Culhane-Pera K, et al: Group visits for Hmong adults with type 2 diabetes mellitus: a pre-post analysis. J
Health Care Poor Underserved 16:315-327, 2005.
Gold R, et al: Synchronous provider visit and self-management education improves glycemic control in
Hispanic patients with long-standing type 2 diabetes. Diabetes Educ 3:990-995, 2008
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How about our data?
Family Medical Center
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Data collected in 2010
Pre-post evaluation of diabetic data
Used resident and faculty patients
Separated out patients who had been coming to group visits
for less than and greater than 18 months
• Evaluated for changes in:
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Weight
A1C
Blood Pressure
LDL
Pounds (lbs)
Weight
245
240
235
230
225
220
215
210 220.8
216.7
205
200
195
All
Patients
N=25
Initial Visit
240.3
229.8
211.7 210.5
< 1.5
Years
n=17
> 1.5
Years
n=8
Final Visit
% of Patient's < 7% HgA1c
80%
70%
Percent
60%
50%
63%
52%
67%
61%
56%
Initial Visit
40%
Final Visit
30%
33%
20%
10%
0%
All
patients
N=27
< 1.5
Years
n=18
> 1.5
Years
n=9
# of Patients
Patient's with Drop in HgA1c
80%
70%
60%
50%
40% 48%
30%
20%
22%
10%
0%
All
Patients
N=27
56%
44%
.5% decrease
44%
11%
< 1.5
Years
n=18
> 1.5
Years
n=9
1% decrease
Percent
Blood Pressure
(under 130/80)
80%
70%
60%
50%
56%
40%
30%
20% 30%
10%
0%
All
Patients
N=27
56%
44%
44%
22%
< 1.5
Years
n=18
> 1.5
Years
n=9
Initial Visit
Final Visit
LDL
Average LDL
120
100
80
60
40
20
0
Initial Visit
90 80
87 81
96
All
Patients
N=27
< 1.5
Years
n=18
> 1.5
Years
n=9
79
Final Visit
Patient satisfaction
• Patients uniformly enjoy shared medical visits
• Every patient that we surveyed stated that they would
recommend these to others
• However, it is a self-selecting population
• Most difficult thing is getting them to attend the first!
Shared Medical Visits
• Disadvantages of shared medical visits
• More logistics involved
• Need for appropriate space to meet with a large group
• Need to have someone review medical record before the visit to
identify opportunities for care
• Less “one-on-one” time spent with physician
Shared Medical Visits
• Benefits of shared medical visits:
• Systematic approach to diabetic patients
• May assist in meeting standards of care
• No special training required
• Offers additional support to patients
• Patients regularly discuss lifestyle changes with each other
• Structured opportunities for dieticians, pharmacists, exercise
physiologists to meet with patients
• No additional costs involved
• Reimbursement is the same as regular office visits
• Potential for increased revenue
• Patients enjoy them!
Questions?
[email protected]