Diabetes Group Visits: An Alternative to Managing Chronic Disease Outcomes

Diabetes Group Visits: An Alternative to Managing Chronic Disease Outcomes Chris Simmons, FNP-BC, and Jane Faith Kapustin, CRNP ABSTRACT Diabetes mellitus is a chronic disease with an ever-expanding prevalence and financial burden for our health care system. Because patients with diabetes often require similar education and disease management, group visits or shared medical appointments have been piloted as an alternative to standard office visits. This article reviews the evidence from clinical trials involving the group visit model. Specific outcomes measured include the evaluation of diabetes care standards, associated costs, overall blood glucose and glycosylated hemoglobin levels, and patient satisfaction scores. Implications for nurse practitioners are highlighted, with emphasis on best practices in the era of health care reform. Keywords: American Diabetes Association, chronic care, diabetes group visit, patient self-management, shared medical appointment © 2011 American College of Nurse Practitioners ype 2 diabetes mellitus (T2DM) is a costly disease associated with multiple comorbidities that can be dramatically reduced through appropriate management of blood glucose. Delayed diagnosis can further increase complications, creating additional stresses on patients’ well-being and increasing the financial burden for the patient, the health care system, and the community as a whole. An estimated 23.6 million people in the United States have diabetes, accounting for approximately 8% of the population and costing in excess of $174 billion a year in expenditures.1,2 Diabetes was the seventh leading cause of death in 2006, as documented on 72,507 death certificates.3 Many experts view this to be a gross underestimation since it is often the complications of diabetes that are recorded as the cause of death. Common com-

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plications of diabetes that compound costs include diabetic retinopathy and blindness, nephropathy, heart disease, and stroke. Diabetes is the leading cause of both blindness and kidney failure in the US.1,3 Good glycemic control of diabetes, defined by the American Diabetes Association (ADA) as maintenance of a glycosylated hemoglobin A1c (HbgA1c) less than 7%, has been shown to reduce micro- and macrovascular complications.4,5 According to the United Kingdom Prospective Diabetes Study (UKPDS), patients with T2DM can reduce their risk for serious microvascular complications by 35%, myocardial infarction risk by 14%, and any diabetes-related end point by 21% for every 1 percentage point decrease in HbgA1c.5,6 It is clear that diabetes represents one of the nation’s largest health care concerns, but less than 10% of patients The Journal for Nurse Practitioners - JNP

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with diabetes meet recommended treatment goals for maintenance of glucose levels.4 Alternative methods to meet the needs of patients with chronic disease are needed because traditional outpatient visits do not seem to be sufficient.6 Diabetes has a high morbidity and mortality rate, but with improvement in management strategies, evidence suggests that many co morbidities can be reduced or avoided.1 As diabetes persists as a public health threat, and with ever-increasing numbers of people affected by T2DM, the US health care system needs to explore more cost-effective and efficient alternatives for providing comprehensive care.6-8 The reality of providing adequate care for all patients is becoming compromised, especially given the relative shortage of primary care providers. Because patients with T2DM frequently have other comorbidities, such as hypertension and hyperlipidemia, they need additional time than is allowed in the typical office visit in primary care. Diabetes group visits (DGVs), originally developed in managed care arenas, are growing in popularity and provides an alternative to routine 1-on-1 office visits while addressing treatment effectiveness and efficiency.7,8 In DGVs, a group of patients “share” a medical appointment where education is provided, but individual concerns are still addressed and patient confidentiality is still maintained. It has been suggested that peer support and group dynamics are driving factors in the success.5,6,8 Instead of the typical 15-minute office visit, the DGV can be arranged as a shared appointment among up to 20 patients in which education and other concerns are addressed for up to 2 hours.8 Group visits (GVs) can be held annually or more frequently as needed, and a variety of chronic illnesses can be addressed, such as asthma, heart failure, or obesity.9 The curriculum can be developed in advance and can include such topics as diabetes self-management, pharmaceutical/insulin management, foot care, nutrition management, exercise, and social concerns.8,9 If documented appropriately with individualized flow charts or other standardized materials, the GV can be a billable visit. Adequate support staff need to be present to manage the GV, and the physician or nurse practitioner (NP) must be present to discuss the plan of care, make changes in therapy, sign charts, and complete encounter forms. Time should also be allowed at the end of the GV for 1 or 2 patients to discuss urgent or unrelated matters with personnel.8,9 672

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METHODS DGVs have been shown to improve patient satisfaction, increase quality of care indicators, decrease emergency department (ED) visits and specialty care utilization, and improve control in disease specific outcomes. Because they are focused on chronic disease management, GVs reinforce information received in individual sessions and allow for more group interactions, problem solving, and self-efficacy.9 In addition, costs related to typical visits can be reduced, and higher routine standards of care can be achieved. A clear advantage of GVs is that patients benefit from discussions with peers and can learn successful coping strategies from their interactions. The longer timeframes can also facilitate the overall learning process.6,10 For this synthesis, the MEDLINE, Cochrane Systematic Reviews, PubMed, and CINAHL databases were searched for studies on GVs. Studies that assessed the effectiveness of GVs had to meet acceptable criteria for search terms (“diabetes,” “group visits,” and “shared medical appointments”) and include a health care provider in the GV. Review articles were excluded. A total of 18 studies were reviewed, and 9 studies met acceptable criteria of group education and elements of an individual office visit (Table 1). Of the studies that met the inclusion criteria, there were inconsistencies in the size and structure of the GVs, and the populations varied in terms of insurance and access to care. In general, the size of the group ranged from 8-20 patients, and visits typically lasted for 2 hours. Criteria rating scores per the Agency for Healthcare Research and Quality (AHRQ)11 were applied and are summarized in Table 2, along with the study location, patient/group demographics, and GV structure. REVIEW OF EVIDENCE Patient Satisfaction/Patient Education Improved patient satisfaction and enhanced overall patient knowledge were demonstrated in studies by Clancy et al,7 Trento et al,18 and Wagner et al.19 Clancy and colleagues7 were able to show significant improvements in patients’ perception of continuity of care, cultural competency, and provider trust. Trento et al16 showed increased patient satisfaction and statistically significant improvements in diabetes knowledge and improvements in health care behaviors from a modified version of Diabetes Quality of Life Survey. Overall Volume 7, Issue 8, September 2011

Table 1. Diabetes Group Visits Summary Table

Authors Bray et al, 200512

Location

Study Design, Number of Subjects, Groups Studied

North Carolina

Non-experimental

5 rural outpatient clinics; FQHCs

N ⫽ 314 Mean age: 61 years 72% AA 54% female

GV Structure 4 GVs over 1 year 10 patients per group Nurse case management Unclear length of visits NP conducted visits

Primarily underinsured

Clancy et al, 200313

South Carolina

Randomized clinical trial (80% follow up)

2 hour GVs Held every month for 6 months

N ⫽ 120 Type 2 diabetes

Clancy et al, 200814

South Carolina Adult primary care center

Randomized clinical trial

2-hour visits 14-17 patients per group Monthly x12 months

N ⫽ 186 Control n ⫽ 90 Intervention n ⫽ 96

Physician- and RN-led groups

72% women

Edelman et al, 201015

Outcomes

82% AA Mean A1c 9.1%

15-minute warm up/socialization 30-45 minute interactive discussion 60-minute 1-on-1 sessions

North Carolina and Virginia

Randomized control trial

7-8 patients per group

2 VA medical centers

N ⫽ 239 with poorly controlled diabetes and blood pressure

12.8 months

Structured GVs led by educator Pharmacist and physician adjusted medication at visits

quality of life was reported as significantly improved in this study as well. Wagner and colleagues19 also demonstrated that patients were very satisfied with diabetes spewww.npjournal.org

Improved documentation of foot exams, lipid testing; improved aspirin use; improved provider productivity. Clinical and patients embraced concept; better billable visits and increased productivity

III/B Lack of patientoriented evidence/focused on feasibility only

Improved adherence to ADA standards; improved sense of trust in providers (A1c, lipids, and other patient perceptions of care not significant)

I/B Lack of patient outcomes Only focused on patient acceptance

GV patients had higher outpatient expenditures (by $699 per year), 49% lower ED costs, 30.2% lower total expenditures compared to controls.

I/B Focused on managed care perspective, not on patient outcomes

Improved trust in physician and improved patient perception of care Improved adherence to ADA standards of care

Team: internist, pharmacist, nurse, or CDE

Intervention ⫽ group visit Control ⫽ usual care

AHRQ Rating11 and Limitations

Mean A1C improved by 0.8% in treatment group and 0.5% in usual care (not significant); baseline systolic BP improved 13.7 mmHg and 6.4 mmHg in treatment group (statistically significant)

I/B Measurements blinded to research personnel

cific care in the GV format compared to routine care, documenting improvements from 50% to 61% of patients satisfied in GV cohort before and after, prospectively, The Journal for Nurse Practitioners - JNP

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Table 1. Diabetes Group Visits Summary Table (continued)

Authors Kirsh et al, 200716

Location Cleveland, OH VA medical center

Study Design, Number of Subjects, Groups Studied

GV Structure

Mixed method quasiexperimental design

8 patients per group

N ⫽ 44

1-7 visits over 5 months for 1-2 hours

Outcomes

AHRQ Rating11 and Limitations

Statistically significant reduction in A1C and BP control in intervention group

II/B Low sample size

73% patients significantly lowered A1C (average decreased from 12.1% to 8.3%) Adequate BP control rose from 15% to 38% of cases; LDL levels decreased in ⬎ 60% cases

I/B Statistics and analyses not included in study

Decreased HgA1C by 1.3%, increased medication compliance, increased glucose monitoring, increased satisfaction with diabetes control, lowered frequency of hospital visits, overall decreased use of medical care

I/B

Increased problemsolving skills, increased health behaviors, less progression to retinopathy, stable A1c compared to controls, increased quality of life and diabetes knowledge, decreased hypoglycemic events

I/B

Interprofessional team: internist, NP, PharmD, psychologist LoneyHutchinson et al, 20096

Kings County Hospital Center

Randomized clinical trial

Average 6 visits per patient

Compared usual care and GVs

Followed for 18 months

N ⫽ 66 HgA1c ⬎ 10% No care in clinic for at least 1 year Sadur et al, 199917

Kaiser Permanente, California HMO

Randomized clinical trial N ⫽ 185 Cluster visits Mean age 56 years 41% women 71% Caucasian Mean A1c 9.5% Type 2 DM patients HgA1C ⬎8.5%

Trento et al, 200218

Turin, Italy

Randomized clinical trial T2DM Mean age 62 years 46% women Mean A1c 7.4% Compared usual care with GVs N ⫽ 112 56 GVs 56 Routine care

while the control group satisfaction decreased from 57% to 53%. Also, the study subjects had significantly fewer specialists and emergency department visits. 674

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10-18 patients per month 2-hour cluster visits 6 months Team led by diabetes nurse educators, psychologist, dietitian, pharmacist 9-10 patients 2 hours every 3 months for 4 years Systematic group education Physician and clinical educator 4 parts to visit: 1. Intro/social 2. Interactive learning 3. Patient experiences 4. Directions for f/u -homework

Clancy’s7 study also showed a decrease in patients’ locus of control by the Diabetes-Specific Locus of Control Survey (DCL). This survey measures 5 domains Volume 7, Issue 8, September 2011

Table 1. Diabetes Group Visits Summary Table (continued)

Authors Wagner et al, 200119

Location Seattle, Washington HMO 14 primary care clinics

Study Design, Number of Subjects, Groups Studied Randomized trial compared GV with usual care N ⫽ 707 14 practices 24 months Mean age 61 years 44% women 30% nonCaucasian T1DM, T2DM Mean A1c 7.5%

GV Structure 6-10 patients per group 1-2 hour visits Every 3-6 months x2 years GV led by physician: nurse, pharmacist involved

Outcomes Increased quality of care (number of preventive procedures ordered, more patient education), fewer disability days, lowered specialty visits, lower ED visits, improved general health status (selfrated), improved patient satisfaction

AHRQ Rating11 and Limitations I/B Multiple providers across 14 centers Difficult to maintain consistent intervention

FQHC ⫽ federally qualified health center; GV ⫽ group visit; ED ⫽ emergency department; AA ⫽ African American; VA ⫽ Veterans Affairs; CDE ⫽ certified diabetes educator; HMO ⫽ health maintenance organization.

and revealed a statistically significant number of patients who viewed their health care provider to be a powerful locus of control over their health care. High scores in this domain have been associated with poor knowledge of diabetes and decreased willingness to take control of care.20 Clancy and colleagues did acknowledge this finding, suggesting that the underserved/underinsured population being evaluated typically lacked continuity, and that increased perception of locus of control may actually indicate increased provider confidence, rather than an unwillingness to participate in self-management.7 Bray et al12 were able to demonstrate increased patient knowledge by improvements in self-management strategies on before and after surveys, which improved from 0% to 42% on willingness to monitor blood sugar, to keep appointments, and to participate in self-care. Financial Outcomes Four studies were able to demonstrate positive financial impact of GVs by showing a decrease in both ED visits and hospital admissions, as well as improved clinic productivity. Wagner and colleagues in 200119 demonstrated that, on a large-scale managed care model, DGVs resulted in cost savings. In this study of 714 patients, over 14 practices were randomized. It was noted in the intervention groups that there were statistically fewer specialty visits, ER visits, and hospital admissions. Clancy and colleagues14 also demonstrated a decrease in total health care costs that were accomplished by reduced number of ER visits and specialty care utilization. Sadur and colwww.npjournal.org

leagues17 demonstrated reduced utilization of hospital visits and overall use of medical care. In 2008, Bray and colleagues,12 with a 12-month feasibility study, demonstrated that providers’ productivity increased from an average of 20.17 visits to 31.55 visits on the days the DGVs were conducted. Using standard evaluation and management codes (EM) at the level of a 99214 outpatient visit at Medicare reimbursement rate of $73.72 yield, an additional $737.20 of services per day during GVs were conducted according to Medicare standards. Patient Outcomes Trento et al18 and Kirsh et al16 reported disease-specific outcomes, such as A1c, systolic blood pressure, high density lipoprotein (HDL), triglycerides, and low density lipoprotein (LDL), which either improved or maintained stability compared with control patients. Trento did not show improvements in A1c, but rather was able to maintain levels over 2 years at 7.4%, while mean A1c in the control patients increased from 7.4% to 8.3%. Slight improvements were noted in HDL and triglyceride levels.16 Kirsh and colleagues16 demonstrated a significant reduction in A1c (-1.4, p ⫽ 0.05) and modest improvements in systolic blood pressure (-16.7, p ⫽ 0.001) and LDL (-4.8, p ⫽ 0.02) among subjects at a VA medical center in Ohio. Bray and colleagues12 showed improvements in the ADA quality indicators by improving documentation of a lipid panel from 55% at baseline to 76% and documentation of foot exams from 15% to 54%, despite a The Journal for Nurse Practitioners - JNP

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Table 2. Agency for Healthcare Research and Quality Scale11 Strength of the Evidence Level I

Experimental study/randomized controlled trial or meta-analysis of randomized controlled trial

Level II

Quasi-experimental study

Level III

Non-experimental study, qualitative study, or meta synthesis

Level IV

Opinion of nationally recognized experts based on research evidence or expert consensus panel (systematic review, clinical practice guidelines)

Level V

Opinion of individual expert based on non-research evidence (includes case studies, literature review, organizational experience [eg, quality improvement and financial data], clinical expertise, or personal experience)

Quality of the Evidence A. High

B. Good

C. Lowquality or major flaws

Research

Consistent results with sufficient sample size, adequate control, and definitive conclusions; consistent recommendations based on extensive literature review that includes thoughtful reference to scientific evidence

Summative reviews

Well-defined, reproducible search strategies; consistent results with sufficient numbers of well-defined studies; criteria-based evaluation of overall scientific strength and quality of included studies; definitive conclusions

Organizational

Well-defined methods using a rigorous approach; consistent results with sufficient sample size; use of reliable and valid measures

Expert opinion

Expertise is clearly evident

Research

Reasonably consistent results, sufficient sample size, some control, with fairly definitive conclusions; reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence

Summative reviews

Reasonably thorough and appropriate search; reasonably consistent results with sufficient numbers of well-defined studies; evaluation of strengths and limitations of included studies; fairly definitive conclusions

Organizational

Well-defined methods; reasonably consistent results with sufficient numbers; use of reliable and valid measures; reasonably consistent recommendations

Expert opinion

Expertise appears to be credible

Research

Little evidence with inconsistent results; insufficient sample size; conclusions cannot be drawn

Summative reviews

Undefined, poorly defined, or limited search strategies; insufficient evidence with inconsistent results; conclusions cannot be drawn

Organizational

Undefined or poorly defined methods; insufficient sample size; inconsistent results; undefined, poorly defined, or measures that lack adequate reliability or validity

Expert opinion

Expertise is not discernable or is dubious

*A study rated an A would be of high quality, whereas a study rated a C would have major flaws that raise serious questions about the believability of the findings and should be automatically eliminated from consideration.

large number of uninsured patients. Edelman et al15 also studied specific disease outcomes at several VA medical centers, and Loney-Hutchinson et al6 obtained improvements in A1c levels and LDL levels in their GV model. OVERALL SYNTHESIS Results from these studies indicate that the DGV concept is a viable alternative to standard primary care; however, the data are heterogenous and limited. 676

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More studies are needed to replicate the findings, and there is a lack of standardization in what the “GV” consists of and what level of interprofessional collaboration is needed to obtain the results reported. Medical professionals participating in these GVs included physicians, NPs, pharmacists, psychologists, and registered nurses. The studies differed in the type of GV used and the overal structure, curriculum style, presentation methods, and populations studied. In addition, the Volume 7, Issue 8, September 2011

research methodology, measurement tools, and analyses There are data to suggest that incorporating CCM varied. The financial impact of GVs was not a primary aspects of care into primary care practices will improve outcome for most of the studies, so fiscal outcomes patient care outcomes,21-23 and it is reasonable to specwere not sufficiently demonstrated in this summary. ulate that using elements from each model will assist Further research in the area of with enhancing diabetes outfinancial considerations is comes as well as provide indicated. viable alternatives for seeing In general, the studies all the increasing number of GVs produce some demonstrated overall patient patients burdened with promising data and satisfaction with GV formats. the disease. outcomes appear to be at It is unclear if the findings In the literature, the DGV were a result of the group follows one of several models least as good as routine dynamics or the team that of delivery. In 1 model, the care, if not better. delivered the visit; however, it GV is managed by individual is speculated that GVs allow primary care practices and the for more patient-provider staff is provided by the practices. In another model, groups of practices in the same contact. Also, some of the providers may have had more general location offered DGVs and refer eligible time to apply motivational interviewing techniques, patients to the DGV. The staff can be sponsored by the futher increasing patient satisfaction. group of practices, and often, the GV addresses the Although the exact factors that led to positive perception are unclear, GVs produce some promising data needs of patients with other chronic disease conditions and outcomes appear to be at least as good as routine such as chronic obstructive pulmonary disease, heart care, if not better. In all studies, patients were accepting disease, and gastrointestinal reflux disease.8 The GV concept offers alternatives to the typical and most authors commented in their discusions that 15-minute office visit by offering medical care and they would continue conducting GVs in their practice. advice/education for several or up to 20 patients. Time is allowed for education and group discussion wherein IMPLEMENTATION MODELS the dynamics of the group are monitored and moderBased on the review of the evidence, it appears that the ated by a trained healthcare professional, such as a GV structure for diabetes care is a viable option to physician, NP, dietitian, or nurse educator.6,9,25 routine, 1-on-1 care. In a time of increased budgetary constraints, where expectations of doing more for less GVs have been highly successful with enhancing is common, the GV model should be considered for many aspects of patient self-care, such as dietary comimplementation, particularly as more people are diagpliance, self-glucose monitoring, and understanding the nosed with diabetes. Diabetes is a common major pubmedication regimen; however, the meetings and curlic health concern, and new strategies for care need to riculum must be planned in advance to be successful. be considered. GVs have been shown to be wellThe goals of care and targets must be discussed with received by both patients and providers and produce participants in advance so they understand the basic desirable outcomes, such as decreased emergency premise of the visit. Patients need to be identified department visits, improved productivity, and improved who would benefit from the GV, and a registry can be overall diabetes outcomes. created. Typically, about two thirds of invited patients A model receiving attention is the chronic care will actually participate. Scheduling needs to be conmodel (CCM). Originally developed by Wagner and ducted carefully so that patients with similar needs will colleagues21 at the Group Health Cooperative of Puget be grouped together and appointment intervals are Sound, the CCM combines the concepts of chronic spaced as appropriately as insurers will permit.6,9,25 care management, such as using registered nurses to Evaluation of the GV projects consists of careful support patient self-management skills, tracking core data collection. Patient self-monitoring of glucose components of care, and offering telephone follow up. levels, engagement in exercise, biophysical markers of www.npjournal.org

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each patient (blood pressure, A1c, lipids, weight), and use of specialists and visits to the emergency department should be noted. These indicators can be used for comparison to routine care. DIABETES GROUP VISIT CASE Consider the case of a GV model as established in a family practice setting on the East Coast, where NPs conducted visits for patients with combined problems such as T2DM. At the time, GV was developed as a response to a very high patient load coupled with a reduction in provider resources. In a short period, 1 physician had became ill and a Reserve Army nurse was recalled to active duty. In order to accommodate the shift in patient load and to continue to provide high quality care, the GV concept was introduced and piloted as a short-term solution. The GV pilot was led by an experienced family NP, and patients were recruited and placed in groups of 8 to 10 after the concept was explained and consent was obtained. One evening per week, a 2-hour block was set aside for GVs. In collaboration with pharmaceutical and product representatives, dietitians and chefs served light, healthy snacks along with cooking tips, and sometimes food-preparation demonstrations were offered. Before the start of the GV, all the participants’ charts were made available, and lab forms along with prescription refills were prepared in advance. Upon arrival, patients were triaged by medical assistants who checked vital signs and blood sugar and recorded any specific individual concerns. Approximately 20 minutes was spent on diabetes education, followed by a group discussion. Questions and comments from the group stimulated other ideas and perhaps more questions from other members that otherwise would not have been addressed. About 45 minutes into the session, the dietitian or chef made a presentation as individual patients were systematically placed into examination rooms. Very brief (5- to 10-minute) individual exams were conducted, and then each patient subsequently returned to the group. While this was not a part of a research study and data were not collected, it was reviewed anecdotally as a well-received process. Of note, a large percentage of the patients who participated returned to a GV forum for the follow up. This pattern was continued for almost a full year until new providers were hired. In 678

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all, the GV concept was found to be viable and wellreceived by patients as an acceptable alternative to traditional 1-on-1 visits. CARE INNOVATIONS AND CONSIDERATIONS The future of chronic disease management has opportunity in innovative care models supported by social networks and virtual worlds. Diabetes care and education can be delivered by cell phones, the Internet, and smart glucose meters. These devices or technological systems can be supported with algorithms of diabetes care that prompt patients for appropriate actions, depending on glucose levels.26 The important feature is that demonstration projects using these modes highlight the willingness of patients to participate and experiment with nontraditional delivery platforms. Second Life, a 3D world created by its residents and managed with the use of avatars, can support diabetes education. Patients can attend GVs designed to deliver specific information on topics such as hypoglycemia management, self-care skills, insulin injection, and dietary choices. Through the use of their Second Life avatars, patients can experience firsthand the effects of low glucose levels or poor sight from damage related to retinopathy. The “lived” experience may provide patients with additional motivation to avoid diabetes complications. Second Life offers great promise for DGV education; however, there are disadvantages to consider. As with any virtual or Internet experience, authentication of who is actually leading the session can be problematic. Patients will need to be directed to choose expert sources such as the ADA or hospitals to ensure safety and accuracy.26 RECOMMENDATIONS FOR PRACTICE The practice problem of limited resources for a growing burden of chronic disease and increasing demand for adequate health care is highlighted in the case of T2DM. Despite attempts to effectively manage this chronic illness, its prevalence is predicted to grow exponentially over the next several years, given the rise in obesity rates.3 With recent economic challenges and strains on state budgets, community and public health groups are expected to do more with fewer resources. The rising prevalence of comorbidities associated with T2DM demands innovations for strategies that deliver quality health care and provide cost savings. New approaches, such as shared medical appointments for patients with Volume 7, Issue 8, September 2011

T2DM, can maximize impact and meet growing demand for services but need to be refined.9 The DGV shows great potential for managing patient care. Many important patient outcomes demonstrated improvement in most of the studies reviewed, and GVs may represent an innovative care model to meet the needs of patients with chronic illnesses. NPs are well-positioned to participate in and lead GV pilot projects since chronic disease management and patient teaching are essential elements of the patient care in which NPs excel. Establishing more effective modes of care for all chronic illnesses is an urgent problem facing the health care system. This is especially vital as more residents secure health insurance and health care reform initiatives evolve. Innovative techniques such as GVs, virtual world encounters, and social media sessions hold great promise as the search continues to create patient-centered learning environments.26,27 References 1. American Diabetes Association. Clinical practice recommendations. Diabetes Care. 2010;33(Suppl 1):S1-S99. 2. American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care. 2008;31(3):596-615. 3. Centers for Disease Control and Prevention. 2007 National Diabetes Fact Sheet. http://www.cdc.gov/diabetes/pubs/estimates07.htm. Accessed September 12, 2010. 4. Sidorov J, Shull R, Tomcavage J, Girolami S, Lawton N, Harris R. Does diabetes disease management save money and improve outcomes? A report of simultaneous short-term savings and quality improvement associated with a health maintenance organization-sponsored disease management program among patients fulfilling health employer data and information set criteria. Diabetes Care. 2002;25(4):684-689. 5. United Kingdom Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837-853. 6. Loney-Hutchinson LM, Provilus AD, Jean-Louis G, Zizi F, Ogedegbe O, McFarlane SI. Group visits in the management of diabetes and hypertension: Effect on glycemic and blood pressure control. Current Diabetes Report. 2009;9:238-242. 7. Clancy DE, Yeager DE, Huang P, Magruder KM. Further evaluating the acceptablity of group visits in an uninsured or inadequately insured patient population with uncontrolled type 2 diabetes. Diabetes Educator. 2007;33(2):310-314. 8. Masley S, Sokoloff, J, Hawes C. Planning group visits for high-risk patients. Fam Pract Manage. 2000;7(6):10-17. 9. Jaber R, Braksmajer A, Trilling JS. Groups visits: A qualitative review of current research. J Am Board Fam Med. 2006;19:276-290. 10. Davis AM, Sawyer DR,Vinci LM. The potential of group visits in primary care. Clin Diabetes. 2008;26(2):58-62. 11. Agency for Healthcare Research and Quality. Rating the strength of scientific research findings. AHRQ Publication No. 02-P022. Rockville, MD: Agency for Healthcare Research and Quality. http://archive.ahrq.gov/clinic/epcsums/ strenfact.htm. Accessed July 12, 2011. 12. Bray P, Roupe M, Young S, Harrell JC. Feasibility and effectiveness of system redesign for diabetes care management in rural areas. Diabetes Educator. 2005:31(5):712-717. 13. Clancy DE, Cope DW, Maruder KM, Huang P, Salter KH, Fields AW. Evaluating group visits in an uninsured or inadequately insured patient population with uncontrolled type 2 diabetes. Diabetes Educator. 2003;29:292-302. 14. Clancy DE, Dismuke CE, Magruder KM, Simpson KN, Bradford D. Do diabetes group visits lead to lower medical care charges? Am J Managed Care. 2008;14(1):39-44.

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15. Eldeman D, Fredrickson SK, Melnyk SD, Coffman CJ, Jeffreys AS, et al. Medical clinics versus usual care for patients with both diabetes and hypertension: A randomized trial. Ann Intern Med. 2010;152:689-696. 16. Kirsh S, Watts S, Pascuzzi K, O’Day ME, Strauss SO. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes and high cardiovascular risk. Qual Saf Health Care. 2007;16(5):349-353. 17. Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization: Efficacy of care management using cluster visits. Diabetes Care. 1999;22:2011-2017. 18. Trento M, Passera P, Tomalino M, Bajardi M, Pomero F, Allione A, et al. Group visits improve metabolic control: a 2-year follow-up. Diabetes Care. 2001;24(6):995-1000. 19. Wagner EH, Grothaus CL, Sandhu N, Galvin MS, Mcgregor M, Artz K, et al. Chronic care clinics for diabetes in primary care: A system-wide randomized trial. Diabetes Care. 2001;24:695-700. 20. Peyrot M, Rubin R. Structure and correlates of diabetes specific locus of control. Diabetes Care. 1994;17(9):994-1001. 21. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Managed Care Q. 1996;4(2):12-25. 22. Aubert R, Herman W, Waters J, Moore W, Sutton D, Peterson BL, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: A randomized, controlled trial. Ann Intern Med. 1998;129(8):605-612. 23. Norris S, Engelgau M, Narayan K. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care. 2001;24(3):561-587. 24. Peters AL, Davidson MB. Application of a diabetes managed care program. The feasibility of using nurses and a computer system to provide effective care. Diabetes Care. 1998;21:1037-1043. 25. Wagner EH. Diversifying the options for interacting with patients. Qual Saf Health Care. 2007;16(5):322–323. 26. Mathur A, Kvedar JC, Watson AJ. Connected health: a new framework for evaluation of communication technology use in care improvement strategies for type 2 diabetes. Curr Diabetes Rev. 2007;3(4):229-234. 27. Watson AJ, Grant RW, Bello HB, Hoch DB. Brave new worlds: how virtual environments can augment traditional care in the management of diabetes. J Diabetes Sci Tech. 2008;2(4):697-702.

Chris Simmons, MS, FNP-BC, is a staff nurse practitioner at Family Medical Centers in Middleberg, FL. Jane Faith Kapustin, PhD, CRNP, BC-ADM, FAANP, is an associate professor and the assistant dean for the Master's and DNP programs at the University of Maryland School of Nursing in Baltimore. She can be reached at [email protected]. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/11/$ see front matter © 2011 American College of Nurse Practitioners doi: 10.1016/j.nurpra.2010.12.002

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