THE American Association of Clinical Endocrinology (AACE) at its 20th Annual Meeting and Clinical Congress in San Diego last month issued new clinical practice guidelines for developing comprehensive care plans for patients with type 1 and type 2 diabetes. The guidelines emphasize a personalized approach to controlling diabetes and achieving blood glucose targets with care plans that take into account patients’ risk factors for complications, comorbid conditions, and psychological, social, and economic status.
While it is recognized that every individual patient’s needs are unique, there are times when simple group visits also work wonders for diabetics manage their condition. It’s a small but slowly growing trend that promises to get more attention with the tight supply of primary care physicians, who find it hard to squeeze in time to teach their patients how to deal with a complex chronic illness like diabetes.
Group visit programs are rapidly proliferating in group practice and managed care organizations throughout the United States in an effort to leverage existing resources and to provide high-value, high-quality health care in this era of increasing purchaser and patient demands for enhanced services at reduced cost. The terminology of group visits includes “group visits,” “shared medical appointments,” “cluster visits,” and “problem-solving DIGMA (drop-in group medical appointments).”
Group visits typically include group education, shared problem-solving, focused private or semi-private medical evaluations that allow individualized medication adjustment, and ordering of preventive services and referrals. Sessions may last from 60 minutes to several hours and typically include 3 to 20 patients. The draw for patients lies in the potential for group visits to provide better access and to improve counseling, between-patient learning, and self-efficacy.
What’s in it for the doctor? Dr. Ray Dorsey, a neurologist, studied the pros and cons of group appointments and found he learned more about how his Parkinson’s patients were faring by watching them interact with others than when he had them one-on-one. Indeed, group visits gave him the opportunity to observe his patients for a longer period of time and appreciate problems he may not readily have appreciated during a routine office visit.
“I can see if you’re getting worse over the course of the visit, your ability to eat, to walk, to converse and to think,” says Dorsey, who led a pilot study of group checkups for Parkinson’s patients at the University of Rochester Medical Center, adding, “This is a new way of delivering health care. People are thirsting for better ways.” Dorsey reported his findings last week in the journal Neurology.
“Many heads are better than one. They think of questions you wouldn’t normally think of by yourself,” says Jim Euken, a retired judge and Parkinson’s patient from Belmont, NY. He began exercising on a bicycle after one of Dorsey’s group visits discussed research showing some patients can still cycle when they can barely walk, for unknown reasons. “I still think I learned more and I think the process was better doing it in a group format,” he confirmed.
Research has shown patients often enjoy interacting in a group environment that can provide encouragement and tips that they may not receive in a short clinical visit. On the other hand, physicians may benefit from the change of pace and a chance to creatively and more thoroughly address the issues presented by chronic conditions common in primary care.
Peer pressure among patients helps, family physician Dr. George Whiddon of Quincy, Florida, told Associated Press. He has about 40 diabetic patients divided into groups for shared checkups at Tallahassee Memorial Family Medicine Quincy, and he wants to add more.
A group member might mention to the person next to her that I’ve been telling her to exercise more — but she hasn’t. The other person might reinforce how important it is to get regular exercise, and that’s a much better incentive than hearing it from the doctor a hundred times.
One woman with uncontrolled diabetes for years confessed to fellow patients that she’d ignored Whiddon’s eat-better-take-your-meds advice for too long. “Now I only have one toe left. I should have listened,” Whiddon recalled her saying. “That had more impact than anything I said all day.”
In a 2006 interview, Jeffrey Gelgisser, MD, at Group Health’s Eastside Primary Care in Redmond said the health improvements the participants achieved in his group’s nine monthly sessions were remarkable. “Their average glucose level was 200 at the first session, and dropped to an average of 165 by the last session — a 12.5 percent reduction. Plus their average blood pressure dropped 20 points.”
Dorothea Perry, another member of Dr. Gelgisser’s diabetes group, said she got a lot out of the monthly sessions. “I learned that I need to test my blood glucose at least three times a day, and eat smaller portions. I exercised before, but now I exercise even more. It’s a wonderful program.
Of course, group appointments don’t replace the patient’s annual in-depth physical. But many people with chronic illnesses, especially if they’re not well-controlled, are supposed to have additional follow-up visits about every three months — an opportunity for shared checkups that stress patient education.
But how well do these group visits work? Evidence is mixed. An Italian study published last year found that diabetics who took part in them lowered their blood sugar, blood pressure and cholesterol more than similar patients who got regular individual office visits.
A separate study at two Veterans Affairs Medical Centers, in North Carolina and Virginia, tracked people with poorly controlled diabetes and blood pressure and also concluded shared appointments can improve care for some people. Those in group visits significantly improved their blood pressure and needed less emergency care, but there was no difference in diabetes improvement between patients who had shared checkups or regular ones.
Shared check-ups aim to help patients who are battling certain chronic diseases, and they’re far from the typical 15-minute office visit. They’re stretched over 90 minutes or even two hours, offering more time to quiz the doctor about concerns, learn about managing the disease — and get tips from fellow patients.
What needs to be stressed, though, is that group and individual visits work well together and complement each other: the strengths of one model are often the weaknesses of the other, and vice versa.
Edward B. Noffsinger, a pioneer in the field of group medical visits, sounds a note of caution. “While a carefully thought-out group visit program can maximize benefits to patients, physicians, purchasers, insurers, and health care organizations alike, it is very important that any potential for abuse also be thoroughly examined and scrupulously prevented if these benefits are to be fully realized,” he says.
He points out that in today’s challenging, competitive health care environment, group visits can be abused in two basic ways: 1) by putting fewer resources into group visits than adequately supported, properly run programs require, or 2) by attempting to extract more from group visits than is commensurate with good care.
“If we wait until some abuse of group visits actually occurs and receives negative publicity, we could incur a public relations black eye, which could seriously undermine the credibility of all such programs in the future ‒ a predictable, preventable, and completely unnecessary injury to the image of group visit programs,” he says.
Moreover, should third-party insurers, upon recognizing the multiple economic and patient care benefits which group visits can offer, over-incentivize them relative to individual visits, abuse could result which would reduce the voluntary nature of group visits for physicians and patients alike.
“Despite all of these concerns surrounding potential abuses, group visits will undoubtedly continue to grow in importance and be ever more frequently used during the coming years. Without question, group visits have an important role to play in the future of health care,” Noffsinger concludes.
Sources: Associated Press, Neurology, American Academy of Family Physicians, NIH