Sharon A. Watts

Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk

Objective: The epidemic proportions and management complexity of diabetes have prompted efforts to improve clinic throughput and efficiency. One method of system redesign based on the chronic care model is the Shared Medical Appointment (SMA) in which groups of patients (8–20) are seen by a multi-disciplinary team in a 1–2 h appointment. Evaluation of the impact of SMAs on quality of care has been limited. The purpose of this quality improvement project was to improve intermediate outcome measures for diabetes (A1c, SBP, LDL-cholesterol) focusing on those patients at highest cardiovascular risk. Setting: Primary care clinic at a tertiary care academic medical center. Subjects: Patients with diabetes with one or more of the following: A1c >9%, SBP blood pressure >160 mm Hg and LDL-c >130 mg/dl were targeted for potential participation; other patients were referred by their primary care providers. Patients participated in at least one SMA from 4/05 to 9/05. Study design: Quasi-experimental with concurrent, but non-randomised controls (patients who participated in SMAs from 5/06 through 8/06; a retrospective period of observation prior to their SMA participation was used). Intervention: SMA system redesign Analytical methods: Paired and independent t tests, χ2 tests and Fisher Exact tests. Results: Each group had up to 8 patients. Patients participated in 1–7 visits. At the initial visit, 83.3% had A1c levels >9%, 30.6% had LDL-cholesterol levels >130 mg/dl, and 34.1% had SBP ⩾160 mm Hg. Levels of A1c, LDL-c and SBP all fell significantly postintervention with a mean (95% CI) decrease of A1c 1.4 (0.8, 2.1) (p<0.001), LDL-c 14.8 (2.3, 27.4) (p = 0.022) and SBP 16.0 (9.7, 22.3) (p<0.001). There were no significant differences at baseline between control and intervention groups in terms of age, baseline intermediate outcomes, or medication use. The reductions in A1c in % and SBP were greater in the intervention group relative to the control group: 1.44 vs –0.30 (p = 0.002) for A1c and 14.83 vs 2.54 mm Hg (p = 0.04) for SBP. LDL-c reduction was also greater in the intervention group, 16.0 vs 5.37 mg/dl, but the difference was not statistically significant (p = 0.29). Conclusions: We were able to initiate a programme of group visits in which participants achieved benefits in terms of cardiovascular risk reduction. Some barriers needed to be addressed, and the operations of SMAs evolved over time. Shared medical appointments for diabetes constitute a practical system redesign that may help to improve quality of care.

Nurse practitioner-led multidisciplinary teams to improve chronic illness care: the unique strengths of nurse practitioners applied to shared medical appointments/group visits.

Purpose: To describe the roles of nurse practitioners (NPs) in a novel model of healthcare delivery for patients with chronic disease: shared medical appointments (SMAs)/group visits based on the chronic care model (CCM). To map the specific skills of NPs to the six elements of the CCM: self‐management, decision support, delivery system design, clinical information systems, community resources, and organizational support. Data sources: Case studies of three disease‐specific multidisciplinary SMAs (diabetes, heart failure, and hypertension) in which NPs played a leadership role. Conclusions: NPs have multiple roles in development, implementation, and sustainability of SMAs as quality improvement interventions. Although the specific skills of NPs map out all six elements of the CCM, in our context, they had the greatest role in self‐management, decision support, and delivery system design. Implications for practice: With the increasing numbers of patients with chronic illnesses, healthcare systems are increasingly challenged to provide necessary care and empower patients to participate in that care. NPs can play a key role in helping to meet these challenges.

Building a Diabetes Registry from the Veterans Health Administration's Computerized Patient Record System

Background: Little information is available describing how to implement a disease registry from an electronic patient record system. The aim of this report is to describe the technology, methods, and utility of a diabetes registry populated by the Veterans Health Information Systems Architecture (VistA), which underlies the computerized patient record system of the Veterans Health Administration (VHA) in Veteran Affairs Integrated Service Network 10 (VISN 10). Methods: VISN 10 data from VistA were mapped to a relational SQL-based data system using KB_SQL software. Operational definitions for diabetes, active clinical management, and responsible providers were used to create views of patient-level data in the diabetes registry. Query Analyzer was used to access the data views directly. Semicustomizable reports were created by linking the diabetes registry to a Web page using Microsoft asp.net2. A retrospective observational study design was used to analyze trends in the process of care and outcomes. Results: Since October 2001, 81,227 patients with diabetes have enrolled in VISN 10: approximately 42,000 are currently under active management by VISN 10 providers. By tracking primary care visits, we assigned 91% to a clinic group responsible for diabetes care. In the Cleveland Veterans Affairs Medical Center (VAMC), the frequency of mean annual hemoglobin A1c levels ≥9% has declined significantly over 5 years. Almost 4000 patients have been seen in diabetes intervention programs in the Cleveland VAMC over the past 4 years. Conclusions: A diabetes registry can be populated from the database underlying the VHA electronic patient record database system and linked to Web-based and ad hoc queries useful for quality improvement.

Improving Outpatient Diabetes Care

More than 20% of patients in the Veterans Health Administration (VHA) have diabetes; therefore, disseminating “best practices” in outpatient diabetes care is paramount. The authors’ goal was to identify such practices and the factors associated with their development. First, a national VHA diabetes registry with 2008 data identified clinical performance based on the percentage of patients with an A1c >9%. Facilities (n = 140) and community-based outpatient clinics (n = 582) were included and stratified into high, mid, and low performers. Semistructured telephone interviews (31) and site visits (5) were conducted. Low performers cited lack of teamwork between physicians and nurses and inadequate time to prepare. Better performing sites reported supportive clinical teams sharing work, time for non-face-to-face care, and innovative practices to address local needs. A knowledge management model informed our process. Notable differences between performance levels exist. “Best practices” will be disseminated across the VHA as the VHA Patient-Centered Medical Home model is implemented.

Shared medical appointments for patients with diabetes: Glycemic reduction in high-risk patients

Purpose:To assess the impact on glycemic control (A1c, %) in a primary care urban Veterans Affairs (VA) shared medical appointments (SMAs). Data sources:A retrospective pretest/posttest study included all patients who had attended ≥1 SMA from 4/06 to 12/10. A1cs 810 days pre‐ and postinitial SMA were obtained from 90‐day time periods. A1c levels were averaged within patient in these 90‐day intervals and data were aggregated based upon corresponding time intervals. Conclusions:Of 1290 individuals seen in SMAs, 1288 (99.8%) had ≥1 A1c levels and 1170 (90.7%) individuals had ≥1 level collected both before and after attendance. The sample was predominantly (96%) male and middle aged or older (mean [±1 SD] age of 62.6 + 9.09 years) with a mean Diabetes Severity Index 3.01 (2.34). There were significant A1c reductions (˜1%) in A1c overall (n = 1170) and for patients with ≥1 measurement in the 180‐day periods preceding and following their first SMA appointment (n = 815). Linear regression analysis showed a significant (p < .001) pre‐SMA positive trend (r2 = 0.90). Implications for practice:Limitations notwithstanding (single site and design lacking a control group), the large number of patients demonstrates SMA clinical effectiveness in improving A1c for high‐risk patients with diabetes.

Improved glycemic control in veterans with poorly controlled diabetes mellitus using a Specialty Care Access Network-Extension for Community Healthcare Outcomes model at primary care clinics

Introduction An increasing number of patients with diabetes mellitus has created a need for innovative delivery of specialized care not only by diabetes specialists but also by primary care providers (PCPs) as well. A potential avenue to address this need is training of PCPs by specialists via telehealth. The Veteran Affairs (VA) Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO) program includes education and case-based learning for PCPs by a multidisciplinary specialty team utilizing videoconferencing technology. Methods Two PCPs completed a year of SCAN-ECHO diabetes training. These two PCPs set up “diabetes mini-clinics” to treat difficult-to-control high-risk patients with diabetes mellitus from their own panel and from their colleagues in the same community-based outpatient clinic (CBOC). We utilized a retrospective program evaluation by t-test using pre/post glycated hemoglobin (HbA1c) lab values after being seen by the two PCPs. Results A total of 39 patients, all with HbA1c > 9.0%, were seen in the two PCP mini-clinics over 15 months. The mean HbA1c improved from 10.2 ± 1.4% to 8.4 ± 1.8% (p < 0.001) over the average follow-up period of five months. This was not explained by system-wide changes or improvements. Discussion Care of veteran patients with poorly controlled diabetes by PCPs who participated in SCAN-ECHO program leads to improvement in glycemic control. This model of health care delivery can be effective in remote or rural areas with limited availability of specialists.

Diabetes nurse case management: Improving glucose control: 10 years of quality improvement follow-up data

UNLABELLED The purpose of this retrospective case-control review is to determine the effectiveness of a registered nurse case managers (RNCMs) certified diabetes educator (CDE) quality improvement case management program. RNCMs have a long tradition of providing chronic care intervention, particularly for the high-risk diabetes population with glycosylated hemoglobin (A1C) of 9% or more. However, limited data are available with regard to evaluation of such programs in a Veterans Health Administration population. RESULTS A large population (N=3956) of high-risk veterans with a baseline A1C of 9% or more (mean=10.6%) was seen by the RNCMs. Paired T-tests of A1C after the last RNCM visit showed a statistically significant A1C reduction (p<0.001) (mean=8.5%), after 14-26 months of intervention. CONCLUSIONS RNCMs clinical intervention demonstrated significant A1C reduction (~2%). This is an important finding for health care policy makers for planning interventions with respect to long-term management of diabetes mellitus.

Nutrition for diabetes-all in a day's work.

Learn about counting carbohydrates and other practices your patient can use to control his blood glucose levels and maintain his health.

Improving health literacy in patients with diabetes.

LIMITED HEALTH LITERACY and lack of basic math skills (numeracy) are more pervasive problems than many nurses suspect. Combine these limitations with a largely self-managed chronic disease such as diabetes and the possible complications—such as severe hypoglycemia—can be catastrophic. In diabetes, u

Telemedicine consultation for patients with diabetes mellitus: a cluster randomised controlled trial

Introduction There is a widening discrepancy between the increasing number of patients with diabetes mellitus and the health care resources available to manage these patients. Telemedicine has been used in a number of instances to improve and deliver health care where traditional care delivery methods may encounter difficulty. We conducted a cluster randomised controlled trial of telemedicine consultation to manage patients with diabetes mellitus. Methods Eleven primary care centres attached to one Veteran Administration tertiary care centre were randomised to provide patients with diabetes consultation referral either by usual consultation in diabetes clinic or telemedicine consultations via videoconference. Results Altogether, 199 patients were managed by telemedicine consultation and 83 by usual consultation. Patients in both groups showed a small decrease in haemoglobin A1c, with no statistical difference between the groups (telemedicine consultation −1.01% vs usual consultation −0.68%, p = 0.19). Surveys of patients and semi-structured interviews with primary care providers showed better response and satisfaction with telemedicine consultations. Discussion This study shows similar clinical outcomes as measured by glycaemic control for patients with diabetes mellitus having a specialist consultation using real-time telemedicine consultation as compared to in-clinic consultation. Telemedicine consultation was also associated with better patient and primary care provider satisfaction.