Shared Medical Visits Jauch Symposium – May 17, 2014.
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Transcript of Shared Medical Visits Jauch Symposium – May 17, 2014.
Shared Medical VisitsJauch 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• Sit in waiting room• Read an out-of-date magazine – 10-15 minutes of waiting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:
• 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:
• 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:
• 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:• 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:
• 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:
• 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)
• 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)
• 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.
How about our data?
Family Medical Center• 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:
• Weight• A1C• Blood Pressure• LDL
Weight
220.8
240.3
216.7210.5
229.8
211.7
195200205210215220225230235240245
AllPatients
N=25
< 1.5Yearsn=17
> 1.5Yearsn=8
Po
un
ds
(lb
s)
Initial Visit
Final Visit
% of Patient's < 7% HgA1c
52%
33%
61%63%67%
56%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Allpatients
N=27
< 1.5Yearsn=18
> 1.5Yearsn=9
Pe
rce
nt
Initial Visit
Final Visit
Patient's with Drop in HgA1c
56%
44%48%
11%
44%
22%
0%10%20%30%40%50%60%70%80%
AllPatients
N=27
< 1.5Yearsn=18
> 1.5Yearsn=9
# of
Pat
ient
s
.5% decrease
1% decrease
Blood Pressure (under 130/80)
30%22%
44%
56%
44%
56%
0%10%20%30%40%50%60%70%80%
AllPatients
N=27
< 1.5Yearsn=18
> 1.5Yearsn=9
Perc
ent Initial Visit
Final Visit
Average LDL
90 968780 7981
0
20
40
60
80
100
120
AllPatients
N=27
< 1.5Yearsn=18
> 1.5Yearsn=9
LDL Initial Visit
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!