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• Sit in waiting room• Read an out-of-date magazine – 10-15 minutes of waiting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!

Questions?sorensens@genesishealth.com