Chronic Care Clinics for Diabetes in Primary Care

Abstract

OBJECTIVE -To evaluate the impact of primary care group visits (chronic care clinics) on the process and outcome of care for diabetic patients.RESEARCH DESIGN AND METHODS -We evaluated the intervention in primary care practices randomized to intervention and control groups in a large-staff model health maintenance organization (HMO). Patients included diabetic patients Ն30 years of age in each participating primary care practice, selected at random from an automated diabetes registry. Primary care practices were randomized within clinics to either a chronic care clinic (intervention) group or a usual care (control) group. The intervention group conducted periodic one-half day chronic care clinics for groups of ϳ8 diabetic patients in their respective doctor's practice. Chronic care clinics consisted of standardized assessments; visits with the primary care physician, nurse, and clinical pharmacist; and a group education/peer support meeting. We collected self-report questionnaires from patients and data from administrative systems. The questionnaires were mailed, and telephoned interviews were conducted for nonrespondents, at baseline and at 12 and 24 months; we queried the process of care received, the satisfaction with care, and the health status of each patient. Serum cholesterol and HbA 1c levels and health care use and cost data was collected from HMO administrative systems.RESULTS -In an intention-to-treat analysis at 24 months, the intervention group had received significantly more recommended preventive procedures and helpful patient education. Of five primary health status indicators examined, two (SF-36 general health and bed disability days) were significantly better in the intervention group. Compared with control patients, intervention patients had slightly more primary care visits, but significantly fewer specialty and emergency room visits. Among intervention participants, we found consistently positive associations between the number of chronic care clinics attended and a number of outcomes, including patient satisfaction and HbA 1c levels.CONCLUSIONS -Periodic primary care sessions organized to meet the complex needs of diabetic patients improved the process of diabetes care and were associated with better outcomes. Diabetes Care 25:695-700, 2001

Group Visits: A Qualitative Review of Current Research

“…Wagner, in a study of 707 diabetic patients, reported that group visit participation was positively associated with subjects receiving preventive procedures, having medications reviewed, and having a microalbuminuria test recorded in the diabetes registry. 42 Similarly, Clancy found that diabetic patients participating in group visits demonstrated improvement in 10 American Diabetes Association processes of care indicators. 30 -32 A study by Sadur showed that poorly controlled diabetics (average HbA1C greater then 8.5%), who attended group visits significantly increased intake of insulin, sulfonylureas, and metformin compared with controls, 35 whereas another study of relatively well-controlled type 2 diabetic patients attending group visits demonstrated lowered dosage of hypoglycemic agents than in standard care.…”

“…35 Wagner's investigation of diabetic patients demonstrated lower frequency of specialty and emergency department visits, but no significant differences in primary care visits (which approached significance), hospitalization frequency, rates of foot and retinal exams, or medication reviews. 42 Maizels reported that a group visit intervention designed for chronic headache resulted in dramatically lower outpatient and emergency department utilization, although significance was not assessed. 44 The study done by Blumenfeld and Tischio of a group visit program for headache also reported decreased primary care visits, emergency visits, and CT scans, but neurology visits and use of injected and oral narcotics increased.…”

“…Patients who attended more sessions reported higher levels of satisfaction. 41 Two large randomized studies involving diabetics 42 and frail elderly at high risk for hospitalization 43 found no significant differences between controls and group visit participants regarding patient satisfaction. These 2 studies, however, featured half-day group visits with long intervals between sessions (3 to 4 and 3 to 6 months), and attendance rate was poor in both; among diabetics, 35% of intervention subjects attended no sessions and participation was even lower in the elder study.…”

Effectiveness of group versus individual hearing aid visits

“…These results are not surprising in light of findings from a number of large managed care organizations using group appointments for chronic disease management. They have found not only lower costs [27][28][29] and reduced utilization [27,[29][30][31] but also improved patient satisfaction [27,[31][32][33], self-efficacy [29,31], health status, [28,31,[33][34][35][36][37][38], compliance [39], and quality of life (QOL) [29]. For example, in a randomized trial comparing group versus individual outpatient visits for patients with a variety of chronic illnesses, patients treated in group appointments had fewer emergency room and subspecialty visits, fewer hospital admissions, greater patient and provider satisfaction, and lower overall costs [27].…”

Use of medical informatics for management of multiple sclerosis using a chronic-care model

“…To accomplish this mission, the MSCoE West is implementing a model of care adapted from other chronic-care models that have been successful in managing large populations with chronic diseases such as diabetes and asthma [1][2]. Wagner and colleagues have described a system approach to the care of populations with chronic disease that is built around two essential elements: (1) "prepared, proactive, practice teams" that use tools such as evidence-based guidelines, data repositories, and an electronic medical record (EMR) to manage high-risk groups with specific conditions and (2) "an educated and empowered patient" who receives education and training and is an active participant in his or her healthcare [3][4].…”