Can Group Visits Improve Outcomes of Veterans With Diabetes

Background:

Diabetes is a common, morbid and expensive disease among veterans. Achieving adequate
glycemic control and blood pressure control can reduce the devastating complications of
diabetes. Because the majority of patients do not achieve adequate control of blood sugar and
blood pressure, innovative strategies to improve control are needed. One strategy with great
potential for veterans receiving VA care is the group clinic. Group clinics have been
developed over the last 5-10 years, and have been shown to improve clinical outcomes and
reduce outpatient utilization in geriatric settings. Group medical clinics involve a cohort
of 8-20 patients who have 1-2 hour group visits. These clinics are distinguished from
traditional group education visits for diabetes by the fact that these visits involve one
physician and one or more additional health care professionals, usually a nurse practitioner
and/or a pharmacist, and are designed to make management changes for a number of people with
the same disease in a short period of time. The effect of group medical clinics on blood
sugar, blood pressure, and the cost of diabetes care, is unknown.

Objectives:

Our primary objectives in this project were to determine the effectiveness and
cost-effectiveness of a group visit intervention in improving rates of control of diabetes
and high blood pressure in patients with both illnesses.

Methods:

We performed a two-site, randomized, controlled trial of group medical visits for diabetes
management. Patients were patients in primary care at the Durham or Richmond VAMC's who had
inadequate control of both their blood sugar and their blood pressure. We excluded patients
with life-limiting illness. Patients randomized to the control arm received usual primary
care. Patients randomized to the intervention arm were assigned to attend a group medical
clinic every two months for one year. In the clinic, a primary care physician, with the
assistance of a nurse and a pharmacist, measured blood pressure at the point of care,
reviewed blood sugar logs, and then made all necessary medical changes for patients with
diabetes. The primary outcomes were hemoglobin A1c and systolic blood pressure. Additional
outcomes will be serum LDL-cholesterol, diabetes-specific quality of life, and health
services utilization. Formative evaluation was undertaken to determine the mechanism of the
intervention and to prepare for more successful dissemination if the intervention is
effective. Formal cost analysis will be performed and cost-effectiveness analysis will be
undertaken. All outcomes were measured at baseline, and 6 and 12 months after the beginning
of the intervention.

Status:

All patient contact complete. Project is in analysis phase.

Inclusion Criteria:

- Primary care at one of two participating sites,

- HbA1c >= 7.5%, Systolic BP > 140 OR Diastolic BP > 90 on 2 consecutive measurements

Exclusion Criteria:

-Primary care provider excludes patient from study, -Patient states that primary care is
shared with non-VA primary care provider, -New enrollment in endocrine clinic within the
last 6 months, -Patient is reluctant to participate in group visit for any reason, -Reduced
life expectancy, as determined by any of the following: -New York Heart Association Class
IV congestive heart failure, -Lung disease requiring supplemental oxygen, -End-stage renal
disease on dialysis, -Current malignancy with any evidence of disease or currently
undergoing chemotherapy or radiation therapy, -Cirrhosis of the liver, or -AIDS (HIV
disease does not exclude a patient in the absence of an AIDS diagnosis), -Five or more
errors on Short Portable Mental Status Questionnaire, Psychotic illness with
hospitalization within three years prior to enrollment