The Power of Groups in Managing Diabetes
The Power of Groups in Managing Diabetes
Abstract & Commentary
By Joseph E. Scherger, MD, MPH, Clinical Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study.
Synopsis: Group visits of diabetic patients have the power to foster lifestyle change, improve the control of diabetes and related cardiovascular risk factors, and lower health care costs.
Source: Wheelock C, et al. Improving the health of diabetic patients through resident-initiated group visits. Fam Med 2009;41:116-119.
Group visits have been shown to improve the management of diabetic patients including lower HbA1c levels, improved systolic blood pressure, and lower LDL-cholesterol.1,2 Group visits have also been shown to lower health care costs by reducing ER visits and overall outpatient charges.3
A primary care residency program in urban Worcester, MA, initiated resident-run group visits to improve patient education and get patients more involved with their care. Six 2-hour group visits were held in the evening scheduled 2 months apart. Twenty-five patients participated to the end of the trial and had data available to evaluate their care. Comparison was made with a control group of diabetic patients. Evaluation of the patients was made at baseline and 1 year after the intervention. Compared with no changes in the control group, the patients attending the group visits reported making lifestyle changes such as better nutrition and physical activity. The intervention group had an average 0.9% drop in HbA1c levels (8.2% to 7.3%) and a 10-point drop in LDL-cholesterol levels (101 mg/DL to 91 mg/dL). Given the small sample size, these changes did not reach statistical significance.
Commentary
James Surowiecki has written in his 2004 book, The Wisdom of Crowds, that many people together are smarter than few, even when the few have special expertise.4 Social networking is using this same phenomenon to show that people together motivate change and desired behaviors better than individuals working alone. The Chronic Care Model made famous by Ed Wagner, MD, MPH, and his team at the McColl Institute in Seattle has shown that informed and activated patients have better outcomes when connected to a prepared and proactive team.5
All of this emerging wisdom challenges the individual physician-patient process of care. Is there a better way to manage chronic illness and improve the health of populations? I am not suggesting that we "throw the baby out with the bath water" and do away with individual face-to-face visits. Health care is a private matter and the individual relationship with the physician is powerful. However, with only a small percentage of our patients with a chronic illness such as diabetes achieving desired outcomes through the traditional care process, we need all the help we can get.
To use a well-worn phrase, "it takes a village" to manage complex problems such as diabetes. Primary care physicians would be wise to get their patients into groups and become involved with social networking to help manage their diabetes. I think the secret ingredient here is patient activation through greater knowledge and a feeling that they can change because others have. We can only inspire our patients so far. People like them are more powerful as role models. If we have the staff or resources, starting group visits may be a powerful way to improve the health of our patients and if not provided through our office, maybe through our local hospital. There is an emerging literature including randomized clinical trials that can guide us in doing group visits right.6
References
1. Kirsh S, et al. 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. Qual Saf Health Care 2007; 16:349-353.
2. Trento M, et al. Group visits improve metabolic control in type 2 diabetes: A 2-year follow-up. Diabetes Care 2001;24:995-1000.
3. Clancy DE, et al. Do diabetes group visits lead to lower medical care charges? Am J Manag Care 2008;14:39-44.
4. Surowiecki J. The Wisdom of Crowds. New York: Random House; 2004.
5. Improving Chronic Illness Care. Available at: www.improvingchroniccare.org. Accessed June 24, 2009.
6. Neveleff DJ. Group Visits Help Improve Care. Diabetes Options; April, 2009. Available at: www.diabetesoptions.net/cgi-bin/article.cgi?article_id=2135. Accessed June 24, 2009.
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