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Group medical visits for diabetes patients hold out promise for more efficient use of resources, improved access, and use of the group dynamic to motivate behavior change and improve outcomes, according to research presented at the recent American Diabetes Association's Scientific Sessions in Orlando, Fla.
However, Katie Weinger, RN, EdD, assistant professor of psychiatry at Harvard University School of Medicine, found mixed results in the evidence and practicality of this approach after reviewing examples of the three main group-visit models gaining traction.
One commonality for the success of any group-visit method is that staff members clearly identify what problems they are trying to solve. Treatment "can't be all things to all people," said Weinger.
The three basic group models being used to treat diabetes patients are shared medical visits; education-based visits led by either a physician or a nurse, educator, or pharmacist; and specialty or chronic-care clinics held in a primary-care setting.
Two shared medical visit models have received the most attention. The cooperative health care clinic (CHCC) was developed by John Scott, MD, of the Colorado Permanente Medical Group, and the drop-in group medical appointment (DIGMA) was pioneered by Edward Noffsinger, MD, while working for Kaiser Permanente's San Jose and Santa Clara medical groups.
The CHCC targets patients with high utilization, and groups of 15 to 20 patients see the same physician at the same time. According to Weinger, in a study of 300 patients split evenly between groups and controls, those in the group experienced fewer hospitalizations, were less likely to visit the emergency department, and generally did better than controls.
The aim of the DIGMA is to improve access by allowing patients to make an appointment the day of or the day before the group visit. During a typical 90-minute shared medical appointment, the physicians will rotate among each of the 10 to 15 patients in the group. Weinger said she found no randomized, controlled trial for the DIGMA model but that surveys showed 81% of patients were very satisfied and that wait times for the next appointment were reduced.
In an example of a nurse-led, education-based group visit, patients met monthly for 2-hour visits for 6 months. Weinger said some improvements were noted in the group patients compared to controls in terms of fewer hospitalizations and more frequent consultations with a nutritionist. Visits to urgent care, emergency departments, and ophthalmologists, however, did not differ.
In a physician-led, education-based study that followed group patients for 4 years, body weight improved and glycated hemoglobin (A1C) levels were maintained at around 7%.
"The bottom line is that they worked," Weinger said of the education-based models.
In assessing group chronic-care clinics in a primary-care setting where 6 to 10 patients met every 3 to 6 months, Weinger concluded this model did not work as well. She said the group patients in one study had fewer disability days, but noted that A1C levels among both the group patients and the individual patients deteriorated.
In addition, costs for the primary care visits initially increased for the group visits compared with the control visits, although both the group and the control arms eventually improved costs.
Overall, Weinger said costs have not been well studied for any of the group visit models. They seem to be fairly expensive to set up, she said, but may generate savings in the future with improved efficiencies. She also noted that group medical visits have been used mostly in managed care or health maintenance organization settings.
Other implementation issues Weinger emphasized include the importance of administrative, clinical, and patient buy-in to the concept; the need for skilled and trained staff; a dedicated space that can accommodate the group; and coordinated scheduling flow.
"Patient behaviors and provider behaviors—those are the things
that need changing," Weinger said. 
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| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
