1. Do Group Visits Improve Care? Results of a Diabetes Group Visit Model in a Family Medicine Residency Authors: Josephine Agbowo MD, Grace Chen Yu, MD Location: San Jose O’Connor Family Medicine Residency, San Jose, CA A total of 215 adult patients were identified as having type II diabetes mellitus (ICD-9 code of 250.xx) in our Diabetes Registry. Of these, 21 patients had attended 2 or more diabetes group visits in the past year and comprised the cohort group. Of the remaining 194 patients, 85 had poor follow- up (fewer than 2 visits for diabetes follow- up in 1 year or missing laboratory values) and were excluded. The remaining 109 patients comprised the usual care group. Baseline values of hemoglobin A1c (HbA1c), LDL, and blood pressure were collected in the fall of 2009. Primary outcomes included change in HbA1c, LDL, and blood pressure in 1 year, ordering of HbA1c within the last year, and presence of documented fundoscopic and detailed foot exam within the last year. In addition, a focus group of 4 of the 21 patients in the cohort group was convened to obtain qualitative data regarding patient experience in the Diabetes Group. The focus group was led by a non-Diabetes Group Visit facilitator, and a 10-item survey, including 7 knowledge questions and 3 self-efficacy questions, was administered to each patient before and after the diabetes group session. Background The group visit has recently become a hot topic in family medicine education. Although the literature suggests that group medical care can lead to improved outcomes for chronic illnesses, there is little documentation of proven benefits of this model in an educational setting. Our community-based residency clinic has been conducting diabetes group visits for approximately 4 years, with the dual goals of improving patient understanding and self-management of their chronic illness and training residents in a novel form of chronic care delivery. Although there were improvements in metabolic outcomes (HbA1c and LDL) in both groups, patients who attended the Diabetes Group at least twice in one year more often reached goals of care for process outcomes, such as having labs done and foot and eye exams completed at the appropriate time interval. Although implementation of a group model of care presents logistical challenges within a residency program setting, it may improve clinical outcomes of patients with diabetes and enhance patient self-management of chronic illness. What is a changed habit since attending the group? Why are some people’s hemoglobin A1c or LDL worse and others’ are better?  More motivated to exercise  Eating less, lost weight  Sleeping more  Not as frail since taking Metformin  Not taking medications on an empty stomach  Attitude has improved/less stress  Not attending the group  Eating less food more often  Eating at different times of the day What is a “good” food for diabetics?What is a “bad” food for diabetics?  Vegetables (3)  Chicken  Fish  Fruit  Starch Potatoes  White foods Tortillas  Bread  Rice Topics to be discussed at future groups?Any changes to the structure of the group?  How to keep blood sugar at a normal level  Which meds for different types of diabetics  Just want to learn as much as I can  No MethodsDiscussionConclusion Focus Group Results Metabolic Outcomes To determine if the group visit model improves process and metabolic outcomes for patients attending at least 2 diabetes group visits within a one-year timeframe, compared to patients receiving traditional one-on-one care in our clinic To determine if patients objectively and subjectively had a better understanding of diabetes at the end of one group visit ObjectivesProcess Outcomes Group visit patients started out with higher mean baseline HbA1c (10%) compared to usual care patients (8.8%). This is most likely because patients with poorer control of their diabetes are referred to the group at a higher rate than those with better control. While it is possible that the larger improvement may have been due to having more room to decrease blood glucose, results from our focus group and patient survey suggest that the group visit intervention may have improved patient knowledge and self-efficacy, leading to improved glycemic control. Usual care patients had a higher percentage reduction in LDL, but the absolute difference between the two groups was approximately the same. There was no significant difference in systolic or diastolic blood pressures between the group and usual care patients. Overall, group visit patients had a higher percentage of documented foot exams, eye exams, and HbA1c within 1 year, suggesting an improved attention to process outcomes with participation in the group visit. Qualitative feedback from group participants in the focus group indicate that we are succeeding in our goal of improving patient understanding of their chronic illness and perceived self-efficacy. Limitations of our study include a small cohort. Results for the metabolic parameters may also have been skewed as many of the patients had only 2 visits within the study timeframe. Baseline (Fall 2010) Most Recent (Fall 2010) % Change from Baseline Mean HbA1c Group Visit (21 patients) Usual Care (109 patients) 10 7.93 8.8 7.86 -12% -0.9% Mean LDL Group Visit Usual Care 111 94 105 86 -5.4% -8.5% Mean Blood Pressure Group Visit Usual Care 138/83 138/75 133/76 135/73 -- % of Patients 10-Item Patient Survey Results: Improvement in 7 knowledge questions, no change in self- efficacy questions before and after the group visit