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Impact of a Group Medical Visit Program on Latino Health-Related Quality of Life
ORIGINAL RESEARCH
IMPACT OF A GROUP MEDICAL VISIT PROGRAM ON LATINO HEALTH-RELATED QUALITY OF LIFE Jeffrey S. Geller, MD,1# Ariela Orkaby, MD,2 and G. Dean Cleghorn, EdD1
Context: Movement toward the Medical Home and group medical visits (GMV). Objective: To investigate the impact of a GMV program in an underserved Latino community. Design: Year-long observational community-based research pilot study evaluating the impact of twice weekly GMVs on quality of life, depression, and loneliness in Latinos with diabetes and other risk factors for heart disease. Setting: The Greater Lawrence Family Health Center in Lawrence, MA. Approved by the Tufts University review committee on human subjects as part of the CDC funded Latino Health 2010 initiative to evaluate and eliminate health disparities in minority populations. IRB # 5243. Patients: Fifty-seven Latino adults with diabetes and heart disease risk factors. Interventions: Participants had two intervention opportunities weekly, including the GMV. Main Outcome Measures: Despite a high dropout rate, and baseline differences between groups, we found reduced depres-
INTRODUCTION There has been a recent increase in interest in the utilization of the medical home and the group medical visit model, particularly in the treatment of those with chronic illnesses in poor underserved areas and ethnic minorities.1-4 One reason for this increase is that current models of care are unsatisfactory in treating the underserved. This is likely because they do not take into account factors relating to a one’s ability to make changes to their lives that we refer to as disempowerment. The ability to make changes to lifestyle when faced with chronic illness is likely a key to healing and the group medical visit may be one part of the solution. We will review the history of group visits and discuss some of the factors associated with poverty and how they relate to diabetes and heart disease. The group medical visit has been incorporated into some clinical practices, particularly pediatrics, since the 1970s.5 The idea of patient empowerment has become a model for some
1 Greater Lawrence Family Health Center, Lawrence, MA 2 Boston Medical Center, Boston, MA # Corresponding author. Address: 73D Winthrop Avenue, Lawrence, MA 01842 e-mail: [email protected]
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© 2011 Elsevier Inc. All rights reserved. ISSN 1550-8307/$36.00
sion and loneliness and improved quality-of-life indicators for participants with high attendance to GMVs during one year compared to those with low attendance. Mean depression scores in high attendees, measured by the Zung Depression Scale, improved from 46.83 to 38.85 (p ⬍ .001). Mean loneliness scores for high attendees, measured by the UCLA Loneliness Questionnaire, improved from 49.61 to 37.6 (P ⬍ .001). Quality-oflife indicators, measured by SF 36, showed statistically significant improvement in general health, vitality, bodily pain, mental health, and role-emotional (P ⬍ .05). High attendees also maintained constant weight with the average decreasing slightly during the year-long intervention. Results: Attending GMVs regularly was associated with improved health-related quality of life, decreased loneliness, decreased depression, and no weight gain. Despite a high dropout rate there were many participants mainly female. More research is needed. Key words: Latino, group medical visit, depression, loneliness, health-related quality of life (Explore 2011; 7:94-99. © 2011 Elsevier Inc. All rights reserved.)
group medical visits6 and may improve access to care.7 Group visits have been tried in various populations, including, for example, the underserved Latino and Hmong, with varying outcomes.8 Underserved communities with a predominant Latino population may particularly benefit from such an approach to their medical care, as groups with self-management training programs have shown some promise.9 Studies have tried to focus their outcomes on improvement of quality of life and depression as well as measurable metabolic control with mixed results.10-13 For the purposes of this article, our definition of the group medical visit consists of three main parts: registration with our full-time patient service representative, the group experience, and an individual medical visit (IMV). The group experience comprises of check-in and activities portions, and the IMV consists of an initial assessment with a medical assistant and a medical visit with the provider with varying intervals for subsequent visits determined by the patient. Our definition of empowerment is the ability to try new things. This ability comes from having strong relationship building skills and from the experience of trying new things and succeeding. The group model tries to do both by introducing new things and having the participants work on projects or activities together. There is less of a focus on education specific to an illness, and more of a focus on building a relationship with the doctor and other participants.
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Previous research shows that Latinos are more likely to have diabetes and risk factors for heart disease than other populations.14-16 The lifetime risk for diabetes for Latinos is 45.4% for men and 52.5% for women, which is the highest of any US ethnic population.17 In Massachusetts, the prevalence of diabetes among Latinos age 18 and over is 8.1%, which is much greater than that among white non-Hispanics age 18 and over at 5.9%.18 These numbers are comparable to nationwide data where a 10.4% prevalence of diabetes was found in Hispanics age 20 and over versus 9.8% in non-Hispanic Whites age 20 and over.19 It is unclear what is contributing to this disparity, but it appears to be a multifactorial issue involving social, cultural, economical, and biological factors. Depressive symptoms are strongly inversely associated with patient-reported health status and quality of life.20 Mental illness increases healthcare utilization significantly, is associated with poorer outcomes in almost all chronic illness,21 and is more closely associated with one’s health-related quality of life than are nonmental (physical) factors such as physical ability or function.22-24 In keeping with this theme there is also a higher prevalence of depression in people with diabetes.25,26 This interrelationship between diabetes, depression, and health-related quality of life is quite complexly interwoven, making it difficult to know if the depression leads to diabetes, vice versa, or both,27 and which of these then causes poor life quality. One study showed that people with high numbers of depressive symptoms are roughly twice as likely to develop diabetes as those with low numbers of depressive symptoms.28 However, such a statement cannot be easily interpreted for our target population. The study was not broken down into ethnic categories, nor did it control for education level or social status, and therefore may not be applicable to Latinos. Another study that controlled for social and physically known risk factors for diabetes using NHANES I data showed no increased incidence of diabetes in those who were depressed.29 The results of these two studies together may imply that it was the social factors that are critical to the development of diabetes or heart disease. Obviously, depression is the product of many factors which all ethnic groups face, including Latinos. In one study looking at Latino patients with diabetes, factors such as low education level and high financial stress independently predicted depression, but not as much as the functional impact of the diabetes itself.30 There are many other social factors that play into depression, health-related quality of life, and diabetes/heart disease. According to the 2008 US Census Bureau, 23.2% of Latinos were living below the poverty level versus 11.2% of Whites.31 Only 59% of Latinos over the age of 25 had attained a high school degree compared to the 85% U.S. average.32 Lower income and lower education levels tend to result in poorer healthcare and health outcomes according to the CDC BRFSS.33 More specifically, lower health literacy independently leads to higher mortality and morbidity from type-2 diabetes.34 In an underserved area where there are fewer economic advantages and more language barriers, one might expect a significantly higher incidence of anxiety and depression than in other settings. This may explain why Hispanics living inside the US have a higher prevalence of affective disorders and anxiety.35 In the setting of diabetes, levels of stress, anxiety, and depression are even higher. About 25% of
Latinos with diabetes have depression. High functional impact of diabetes, low education, and high financial stress were the most important factors that independently and significantly predicted depression.36 The Latino culture in particular with relation to risk factors for heart disease and treatment has unique characteristics not seen in other ethnic groups. The Multi-Ethnic Study of Atherosclerosis showed that Latinos with cardiovascular risk factors, including hypercholesterolemia, hypertension, and/or diabetes, whose primary language was Spanish and/or those who lived a short time in the United States have higher systolic blood pressure, low-density lipoprotein cholesterol, and fasting glucose than those who are English speakers and have lived in the United States for a longer period of time.37 Issues in treating Latinos in the United States that differ from other groups include language barriers, a lack of social support, and emotional barriers surrounding physician trust specific to the Latino culture.38 Little is known about loneliness specifically in the Latino culture, but social support seems to be a major barrier to treatment in other populations. It is becoming apparent that treatment for Latinos with diabetes needs to be around the support necessary for changes in lifestyle and diet, and less so for educational reenforcement.39 Latinos who speak Spanish are significantly less satisfied with communication with health care providers.40 For diabetics, poor communication is associated with less patient participation with a medical provider, and is an independent predictor of poor self-management.41 A lack of bilingual/bicultural doctors and other medical professionals is another area that may contribute to disparity.42 Both depression and diabetes are poorly controlled and under treated with only 21.6% of depressed patients receiving adequate therapy43 and only 7.3% of diabetic reaching target HbA1c of less than 7.0.44 Lifestyle change seems more effective in the prevention of diabetes than medical intervention.45 Data analysis from the NHANES III indicates that as much as 91% of incidence of type 2 diabetes is preventable with lifestyle modification, making it clear that genetics is just a small part of the story.16 It has been suggested that life style changes, most importantly weight loss, may be the best way to prevent onset of type 2 diabetes.46 It has also been shown that depression is also modifiable using community based integrated programs.47 Preliminary studies show favorable outcomes using group intervention in underserved uninsured populations.48 Therefore, our goals were to create a new model of care that could better address an ethnic minority population in poverty and evaluate that model for changes in health-related quality-oflife factors associated with poor outcomes in diabetes and other cardiac risk factors. Specifically addressing the higher rates of chronic illness and depression, poor control of these illnesses, social factors related to education and language, difficulty in addressing lifestyle change, as well as cultural considerations.
METHODS This study was conducted in Lawrence, Massachusetts, at the GLFHC and approved by Tufts University review committee on human subjects as part of the CDC funded Latino 2010 initiative to evaluate and eliminate health disparities in minority pop-
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ulations. The Greater Lawrence Family Health Center has been a leader in offering group visits to the poor and underserved with visits starting in 1997. GLFHC is now the largest medical group visit site in the country. From 5/9/2002 until 6/23/03 we sought to enroll adults with risk factors for heart disease, which included diabetes, hypertension, hypercholesterolemia, low physical activity, strong family history, or age greater than 55 years old. Qualifying adults were referred from their primary care physicians at our health center. We also recruited self-referred individuals who had heard of our program by word of mouth through the community or other participants already in the groups. Participants, who were eligible, having at least one risk factor for heart disease, not suffering from severe developmental delay or illness such as schizophrenia, and provided written informed consent, completed three baseline questionnaires to evaluate depression, loneliness, and health-related quality of life. We utilized the Zung depression scale, UCLA Loneliness questionnaire version II, and the SF-36. The same questionnaires were then repeated at a minimum of one year after the intervention. Those who were unable to fill in the forms for various reasons were assisted by trained research associates. Attendance was kept to track participation in the intervention over the one-year period between assessments. A chart review using a computerized and paper medical record was performed to compare pre and postintervention weights and blood pressures. Also collected were baseline characteristics such as number of years in our practice, number of chronic illnesses, number of risk factors for heart disease, as well as demographic information. Data was then divided into two groups based on level of participation using median number of visits and further evaluated for factors relating to depression, loneliness, and healthrelated quality of life. We estimated that the comparative intervention would require 42 patients to have a power of 0.90 and significance of 0.05 using two-tailed paired t test for significance to detect a 25% difference in SF-36 factors with typical standard deviations. We planned to enroll as many patients as possible with a minimum of 84 anticipating 50% patient attrition. (We estimated that we would need 16 participants based on a correlation of 0.5 to do regression analysis comparing attendance to changes in loneliness and depression.) Data analysis was performed using SPSS version 10.0. Intervention Each participant had two intervention opportunities each week. The first was a once weekly 1.5-hour physician run group medical visit that featured tai chi exercise, patientoriented medical education, and a group relaxation component including hypnosis, meditation, art, or guided imagery. The second intervention was a once weekly hour-long exercise class that offered culturally appropriate activities chosen by the participants. For this group the activity they chose was rigorous exercises such as dancing or “Latino Tai-Bo.” The groups were structured to have participant check-in time and cooperative games to assist with group socialization followed by relaxation and then exercises.
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RESULTS Baseline Characteristics Ninety-seven patients enrolled in the program and filled out enrollment questionnaires. No patients died and 40 were lost to follow-up. Fifty-seven individuals completed both pre- and postquestionnaires. Of the 57 participants in the intervention, 49 of them were members of our medical practice and chart review was performed. The average age was 56.53 years (SD ⫽ 10.43), 96.5% female, 100% met qualification for poverty, 100% were Latino. The average participant was in our practice for 6.77 years (SD ⫽ 4.78), had 2.71 risk factors for heart disease including diabetes, hypertension, hypercholesterolemia, low physical activity, strong family history, or agegreater than 55 (SD ⫽ 1.33), and had 2.40 chronic medical conditions (SD ⫽ 1.34). Baseline weight was 173.73 (SD ⫽ 33.80) and baseline diastolic blood pressure was 81.72 (SD ⫽ 10.57). The average participant attended 21.5 group sessions (SD ⫽ 27.3) with a median ⫽ 8. 29 patients participated more than the median with a mean number of visits ⫽ 43.37 (SD ⫽ 25.57) and 27 participated less than the median with a mean number of visits ⫽ 1.8 (SD ⫽ 2.57). There were no statistically significant differences in the following baseline characteristics between the low participants (less than or equal to eight visits) and the high participants (more than eight visits): number of years in our practice, number of risk factors for heart disease, number of chronic medical conditions, weight, or diastolic pressure. The only exception was age. The mean age of the low participants was 53.57 (SD ⫽ 11.49) and the mean age of the high participants was 59.86 (SD ⫽ 8.08, P ⫽ .03). Outcome Measures Depression as measured by the Zung Depression Scale: Baseline depression scores were 46.83 with SD ⫽ 17.01, where mild depression is a score between 50 and 59, moderate depression is a score between 60 and 69, and severe depression is classified as equal to or greater than 70. Postdepression scores improved to 44.67 with SD ⫽ 18.07 (P ⫽ .32). Those who participated more than the mean number of visits had a mean baseline depression score of 44.3, whereas those who participated in fewer than the mean number of visits had mean baseline score of 49.9 (P ⫽ .25). Those who participated more than the mean had a decreased depression score to 38.85 after one year at the end of the intervention (P ⬍ .001). Those who participated in fewer than the mean number of visits had no statistically significant increased change in depression score to 50.9 (see Figure 1). Loneliness as measured by the UCLA Loneliness Questionnaire: baseline loneliness score was 49.61 (SD ⫽ 18.95) where mild loneliness is characterized as a score of 50 or more. Post loneliness scores improved to 45.91(SD ⫽ 18.35, P ⫽ .11). Those who participated more than the mean number of visits had a mean baseline loneliness score of 46.0, whereas those who participated in fewer than the mean number of visits had a mean baseline score of 54.1 (P ⫽ .13). Those who participated more than the mean had a decreased loneliness score to 37.6 after one year at the end of the intervention (P ⬍ .001). Those who participated in fewer than the mean number of visits had no change in loneliness score at 54.9 (see Figure 1).
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Figure 1. Changes in depression and lonliness based on level of participation. (Color version of figure is available online).
Health-related quality-of-life outcomes as measured by SF-36: Baseline characteristics in all eight aspects of quality of life were significantly worse than US norms for normal population (women ages 55-64) and US norms for type 2 diabetes (P ⬍ .001) (see Figure 2) Postintervention scores improved in all eight aspects of the SF-36 (physical functioning [PF], role physical [RP], bodily pain [BP], general health [GH], vitality [VT], social functioning [SF], role-emotional [RE], and mental health [MH]). There were statistically significant improvements in GH (P ⫽ .001), VT (P ⫽ .003), BP pain (P ⫽ .025), MH (P ⫽ .04), and RE (P ⫽ .04) (see Figure 2). When evaluating patients by level of participation, there were no statistical differences in any of the eight SF-36 factors at baseline. Those who attended the group medical visits more than the median number of times had significant improvements in almost all aspects of HRQL with the exception of physical function (P ⫽ .287), and physical role (P ⫽ .15) (see Figure 3). In those who attended the group medical visit fewer than the median amount of times there was no statistically significant change in any of the factors from baseline (see Figure 3).
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Physical Markers As Measures Of Health Using Paired t Test for Comparison The mean baseline weight at the start of the group medical visit intervention (n ⫽ 46) was 179.56 lbs (SD ⫽ 33.72). Postinter-
SF-36 Factors Figure 2. Health-related quality of life compared to US norms. Physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), mental health (MH). (Color version of figure is available online).
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SF-36 factor Figure 3. Participation level and SF-36. Physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), mental health (MH). (Color version of figure is available online).
vention weight was 181.45 lbs (SD ⫽ 35.30, P ⫽ .20). High participants (n ⫽ 20) had a baseline weight of 186.50 (SD ⫽ 33.1) and a postintervention weight of 185.57 (SD ⫽ 35.85, P ⫽ .70). Low participants (n ⫽ 25) had a baseline weight of 173.73 (SD ⫽ 33.79) and a postintervention weight of 177.98 (SD ⫽ 35.18), which was significantly increased over baseline (P ⫽ .01). Baseline diastolic blood pressure was 81.72 mmHg (SD ⫽ 10.57) and postintervention diastolic blood pressure was 80.50 mmHg (SD ⫽ 10.98, P ⫽ .27). High participants (n ⫽ 22) had a baseline pressure of 76.45 (SD ⫽ 11.06) and a postintervention pressure of 74.80 (SD ⫽ 12.05, P ⫽ .38). Low participants (n ⫽ 25) had a baseline diastolic blood pressure of 81.72 (SD ⫽ 10.57) and a postintervention pressure of 80.50 (SD ⫽ 10.98, P ⫽ .48).
DISCUSSION There is a strong association between frequently participating in this group medical visit and trends toward favorable outcomes. Those with high participation in the group medical visit intervention had improvement in their quality of life both mentally and physically by self-report using the SF-36. Although those that came less than seven times (most only once) had general worsening, frequent participants were less lonely and depressed than at the start of the group intervention. Those with low participation had no statistical change, but trended toward being worse off in terms of quality of life, loneliness, and depression at the conclusion of the one-year intervention. High participants also had trending toward improvement in many of the parameters indicating better health such as weight loss and improved blood pressures. Low participants also had similar trends toward improvements in blood pressure but seemed to gain weight overall. Therefore, those who participated, and participated more frequently in the group medical visit had the greatest benefit. This finding is similar to the “dosage effects” of attendance to sessions for teaching self-management to Mexican Americans with diabetes.49 As this is community-based research we were also able to answer the question of whether such an intervention could happen in this community and who would attend. Participants were
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almost exclusively women and were significantly more disabled than the US norm when comparing their age and number of risk factors for heart disease. It is unclear whether these group visits resonated more with those who were lonely, depressed, or had poor health-related quality of life, or perhaps this is a reflection of the baseline characteristics of those in our community. In any event it was quite startling to see where our patients starting points were prior to our intervention. Using the SF-36 we saw that the average participant in our study at baseline claimed they could not dress themselves or cook adequately without help, and they were unable to walk two blocks without taking a rest. The high participants were able to walk greater than a mile by the end of the program. These results certainly raise many questions as to which aspect of the group visit program were effective for those who chose to attend. Perhaps it was simply the opportunity to exercise that was afforded by the group format,which was the most important intervention. It is quite likely that participants would not be able to afford a gym or exercise class otherwise, due to scarcity and finances. Certainly, however, there were many participants who only came to an initial session or two and then did not continue to take advantage of the opportunity being offered. Although participants had common baseline characteristics, it is difficult to know what factors led people to participate more frequently versus those who did not at all. Another intriguing aspect was that those who participated really had a chance to get to know the physician who led the group. In the group medical visit setting it is very likely that the physician was more approachable to answer questions or teach about health. Each week patients had 1.5 hours of contact with the physician in the group setting. By being with other patients the physician is essentially outnumbered and thus could be perceived as less intimidating and more approachable for questions. The teaching setting was also different than that found in a typical office visit. The patients were fully clothed and dressed casually, and the environment was that of an open exercise space. The physician led the exercise portion of the groups as well, and therefore served as a role-model that may be an effective teaching style. Limitations This is a community-based research project and as such has some inherent limitations. Patient selection could not be randomized, but is rather a reflection of who would actually participate in an intervention such as ours. We had a very high number of participants lost to follow-up and therefore there is less data to compare those who completed both initial and follow up surveys and those who did not. We also had eight participants who were not health center patients who came by word of mouth and likely pretended to be health center patients to receive free services. This might actually be typical of what would happen in an underserved community. All of this makes it difficult to assess any bias in our patient selection other than looking at baseline data. We may conclude that such issues may be typical of a communitybased research project in a poor immigrant community. There was also a much higher degree of variation among participants than we had anticipated. This made standard deviations greater than expected and made our estimates for a sample
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size too small for some types of data analysis. Particularly, it made for nonlinear relationships among variables, making regression analysis unreliable. Therefore, although the two groups of participants at baseline were statistically the same, there were differences that may have approached significance with a bigger sample size. Additionally, it is hard to say at what point the depression, loneliness, and health-related quality of life improved in frequent participants. We only have beginning and end-point data, which leaves an incomplete story. More research with data taken at closer intervals might be helpful in future studies. This may further clarify if those who participated had greater degrees of improvement corresponding to their degree of participation.
CONCLUSION Many people in our Latino community with risk factors for heart disease participated in our group medical visits. The vast majority of attendees were women, and although there was a high dropout rate, many attended frequently. Attending the intervention more frequently was associated with improved health-related quality of life, decreased loneliness, decreased depression, and weight loss. Those not attending the intervention frequently had no statistically significant changes from baseline, but tended toward worse health-related quality of life, more depression, more loneliness, and weight gain. Therefore, we conclude that group medical visits in a largely Latino underserved community seem effective at improving factors associated with better health outcomes for heart disease, especially for those who attended often. Although this is a difficult area to research, more efforts are needed to evaluate fully the factors involved in the improvement seen with group medical visits.
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9. Gilmer TP, Walker C, Johnson ED, Philis-Tsimikas A, Unützer J. Improving treatment of depression among Latinos with diabetes using project Dulce and IMPACT. Diabetes Care. 2008;31:1324-1326. 10. Clancy DE, Huang P, Okonofua E, Yeager D, Magruder KM. Group visits: promoting adherence to diabetes guidelines. J Gen Intern Med. 2007;22:620-624. 11. Wheelock C, Savageau JA, Silk H, Lee S. Improving the health of diabetic patients through resident-initiated group visits. Fam Med. 2009;41:116-119. 12. Salinas-Martínez AM, Garza-Sagástegui MG, Cobos-Cruz R, Núñez-Rocha GM, Garza-Elizondo ME, Peralta-Chávez DF. [Effects of incorporating group visits on the metabolic control of type 2 diabetic patients] [Article in Spanish]. Rev Med Chil. 2009;137: 1323-1332. 13. Masley S, Phillips S, Copeland JR. Group office visits change dietary habits of patients with coronary artery disease-the dietary intervention and evaluation trial (D.I.E.T.). J Fam Pract. 2001;50:235-239. 14. Quinn L. Behavior and biology: the prevention of type 2 diabetes. J Cardiovas Nurs. 2003;18:62-68. 15. Tucker KL, Bermudez OI, Castenada C. Type 2 diabetes is prevalent and poorly controlled among Hispanic elders of Caribbean origin. Am J Public Health. 2000;90:1288-1293. 16. Karter AJ, Ferrara A, Liu JY, et al. Ethnic disparities in diabetic complication in an insured population. JAMA. 2002;287:2519-2527. 17. Venkat Narayan KM, Boyle JP, Thompson TJ, Sorensen SW, Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA. 2003;290:1884-1890. 18. Massachusetts Department of Public Health. Massachusetts Community Health Information Profile. Boston, MA: Division of Research and Epidemiology, Bureau of Health Statistics, Research and Evaluation; 2005-2009. 19. National Diabetes Statistics; 2007. 20. Ruo B, Rumsfeld JS, Hlatky MA, Liu H, Browner WS, Whooley MA. Depressive symptoms and health-related quality of life: The heart and soul study. JAMA. 2003;290:215-221. 21. Lustman PJ, Clouse RE. Depression in diabetic patients: the relationship between mood and glycemic control. J Diabetes Complicat. 2005;19:113-122. 22. Bierman T, Bubolz T, Fisher E, Wasson J. How well does a single question about health predict the financial health of Medicare managed care plans? Effect Clin Pract. 1999;2:56-62. 23. Spitzer R, Williams JB, Kroenke K, et al. Health related quality of life in primary care patients with mental disorders. JAMA. 1995; 274:1511-1517. 24. Coulehan JL, Schulberg HC, Block MR, Madonia MJ, Rodriquez E. Treating depressed primary care patients improves their physical, mental, and social functioning. Arch Intern Med. 1997;157:1113-1120. 25. Gavard JA, Lustman PJ, Clouse RE. Prevalence of depression in adults with diabetes: an epidemiological evaluation. Diabetes Care. 1993;16:1167-1178. 26. Ali S, Stone MA, Peters JL, Davies MJ, Khunti K. The prevalence of co-morbid depression in adults with Type 2 diabetes: a systematic review and meta-analysis. Diabetes Med. 2006;23:1165-1173. 27. Mezuk B, Eaton WW, Albrecht S, Hill Golden S. Depression and type 2 diabetes over the lifespan: a meta-analysis. Diabetes Care. 2008;31:2383-2390. 28. Carnethon MR, Kinder LS, Fair JM, Stafford RS, Fortmann SP. Symptoms of depression as a risk factor for incident diabetes: findings from the National Health and Nutrition Examination Epidemiologic Follow-up Study, 1971-1992. Am J Epidemiol. 2003;158: 416-423. 29. Saydah SH, Brancati FL, Golden SH, Fradkin J, Harris MI. Depressive symptoms and the risk of type 2 diabetes mellitus in a US sample. Diabetes/Metab Res Rev. 2003;19:202-208.
30. Lawrence F, Chesla C, Mullan J, Skaff M, Kanter RA. Contribtors to depression in Latino and European-American patients with type 2 diabetes. Diabetes Care. 2001;24:1751-1757. 31. U.S. Census Bureau Income, Poverty, and Health Insurance Coverage in the United States; 2008. 32. US Census Press Release. Earnings Gap Highlighted by Census Bureau Data on Educational Attainment. March 17, 2007. 33. Liao Y, Tucker P, Okoro CA, et al. REACH 2010 Surveillance for health status in minority communities—United States, 2001-2002. MMWR. 2004;53:1-36. 34. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002;288:475-482. 35. Kessler R, McGonagle K, Zhao S, et al. Lifetime and 12-month prevalence of DSM-IIIR psychiatric disorders in the United States: results from the National Co-morbidity Survey. Arch Gen Psychiatry. 1994;51:8-19. 36. Fisher L, Chesla CA, Mullan JT, et al. Contributors to depression in Latino and European-American patients with types 2 diabetes. Diabetes Care. 2001;24:1751-1757. 37. Eamranond PP, Legedza AT, Diez-Roux AV, et al. Association between language and risk factor levels among Hispanic adults with hypertension, hypercholesterolemia, or diabetes. Am Heart J. 2009; 157:53-59. 38. Lipton RB, Losey LM, Giachello A, Mendez J, Girotti MH. Attitudes and issues in treating Latino patients with type 2 diabetes: view of healthcare providers. Diabetes Educ. 1998;24:67-71. 39. Weller S, Baer RD, Pachter LM, et al. Latino beliefs about diabetes. Diabetes Care. 1999;22:722-728. 40. Morales LS, Cunningham WE, Brown JA, et al. Are Latinos less satisfied with communication by health care providers? J Gen Intern Med. 1999;14:409-420. 41. Heisler M, Bouknight RR, Hayward RA, Smith DM, Derr EA. The relative importance of physician communication, participatory decision making, and patient understanding in diabetes self-management. J Gen Intern Med. 2002;17:243-256. 42. Fernandez A, Schillinger D, Grumbach K, et al. Physician language ability and cultural competence. An exploratory study of communication with Spanish-speaking patients. J Gen Intern Med. 2004;19: 167-174. 43. Kessler RC, Berglund P, Demler O, et al.; National Comorbidity Survey Replication. The epidemiology of major depressive disorder: results from the National Comorbidity Survey Replication (NCSR). JAMA. 2003;289:3095-3105. 44. Saydah SH, Fradkin J, Cowie CC. Poor control of risk factors for vascular disease among adults with previously diagnosed diabetes. JAMA. 2004;291:335-342. 45. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393-403. 46. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 2001;345:790-797. 47. Ciechanowski P, Wagner E, Schmaling K, et al. Community-integrated home-based depression treatment in older adults. JAMA. 2004;291:1569-1577. 48. Clancy DE, Cope DW, Magruder KM. Evaluating concordance to American Diabetes Association standards of care for type 2 diabetes through group visits in an uninsured patient population. Diabetes Care. 2003;26:2032-2036. 49. Brown SA, Blozis SA, Kouzekanani K, et al. Dosage effects of diabetes self-management education for Mexican Americans. Diabetes Care. 2005;28:527-532.
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IMPACT OF A GROUP MEDICAL VISIT PROGRAM ON LATINO HEALTH-RELATED QUALITY OF LIFE Jeffrey S. Geller, MD,1# Ariela Orkaby, MD,2 and G. Dean Cleghorn, EdD1
Context: Movement toward the Medical Home and group medical visits (GMV). Objective: To investigate the impact of a GMV program in an underserved Latino community. Design: Year-long observational community-based research pilot study evaluating the impact of twice weekly GMVs on quality of life, depression, and loneliness in Latinos with diabetes and other risk factors for heart disease. Setting: The Greater Lawrence Family Health Center in Lawrence, MA. Approved by the Tufts University review committee on human subjects as part of the CDC funded Latino Health 2010 initiative to evaluate and eliminate health disparities in minority populations. IRB # 5243. Patients: Fifty-seven Latino adults with diabetes and heart disease risk factors. Interventions: Participants had two intervention opportunities weekly, including the GMV. Main Outcome Measures: Despite a high dropout rate, and baseline differences between groups, we found reduced depres-
INTRODUCTION There has been a recent increase in interest in the utilization of the medical home and the group medical visit model, particularly in the treatment of those with chronic illnesses in poor underserved areas and ethnic minorities.1-4 One reason for this increase is that current models of care are unsatisfactory in treating the underserved. This is likely because they do not take into account factors relating to a one’s ability to make changes to their lives that we refer to as disempowerment. The ability to make changes to lifestyle when faced with chronic illness is likely a key to healing and the group medical visit may be one part of the solution. We will review the history of group visits and discuss some of the factors associated with poverty and how they relate to diabetes and heart disease. The group medical visit has been incorporated into some clinical practices, particularly pediatrics, since the 1970s.5 The idea of patient empowerment has become a model for some
1 Greater Lawrence Family Health Center, Lawrence, MA 2 Boston Medical Center, Boston, MA # Corresponding author. Address: 73D Winthrop Avenue, Lawrence, MA 01842 e-mail: [email protected]
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sion and loneliness and improved quality-of-life indicators for participants with high attendance to GMVs during one year compared to those with low attendance. Mean depression scores in high attendees, measured by the Zung Depression Scale, improved from 46.83 to 38.85 (p ⬍ .001). Mean loneliness scores for high attendees, measured by the UCLA Loneliness Questionnaire, improved from 49.61 to 37.6 (P ⬍ .001). Quality-oflife indicators, measured by SF 36, showed statistically significant improvement in general health, vitality, bodily pain, mental health, and role-emotional (P ⬍ .05). High attendees also maintained constant weight with the average decreasing slightly during the year-long intervention. Results: Attending GMVs regularly was associated with improved health-related quality of life, decreased loneliness, decreased depression, and no weight gain. Despite a high dropout rate there were many participants mainly female. More research is needed. Key words: Latino, group medical visit, depression, loneliness, health-related quality of life (Explore 2011; 7:94-99. © 2011 Elsevier Inc. All rights reserved.)
group medical visits6 and may improve access to care.7 Group visits have been tried in various populations, including, for example, the underserved Latino and Hmong, with varying outcomes.8 Underserved communities with a predominant Latino population may particularly benefit from such an approach to their medical care, as groups with self-management training programs have shown some promise.9 Studies have tried to focus their outcomes on improvement of quality of life and depression as well as measurable metabolic control with mixed results.10-13 For the purposes of this article, our definition of the group medical visit consists of three main parts: registration with our full-time patient service representative, the group experience, and an individual medical visit (IMV). The group experience comprises of check-in and activities portions, and the IMV consists of an initial assessment with a medical assistant and a medical visit with the provider with varying intervals for subsequent visits determined by the patient. Our definition of empowerment is the ability to try new things. This ability comes from having strong relationship building skills and from the experience of trying new things and succeeding. The group model tries to do both by introducing new things and having the participants work on projects or activities together. There is less of a focus on education specific to an illness, and more of a focus on building a relationship with the doctor and other participants.
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Previous research shows that Latinos are more likely to have diabetes and risk factors for heart disease than other populations.14-16 The lifetime risk for diabetes for Latinos is 45.4% for men and 52.5% for women, which is the highest of any US ethnic population.17 In Massachusetts, the prevalence of diabetes among Latinos age 18 and over is 8.1%, which is much greater than that among white non-Hispanics age 18 and over at 5.9%.18 These numbers are comparable to nationwide data where a 10.4% prevalence of diabetes was found in Hispanics age 20 and over versus 9.8% in non-Hispanic Whites age 20 and over.19 It is unclear what is contributing to this disparity, but it appears to be a multifactorial issue involving social, cultural, economical, and biological factors. Depressive symptoms are strongly inversely associated with patient-reported health status and quality of life.20 Mental illness increases healthcare utilization significantly, is associated with poorer outcomes in almost all chronic illness,21 and is more closely associated with one’s health-related quality of life than are nonmental (physical) factors such as physical ability or function.22-24 In keeping with this theme there is also a higher prevalence of depression in people with diabetes.25,26 This interrelationship between diabetes, depression, and health-related quality of life is quite complexly interwoven, making it difficult to know if the depression leads to diabetes, vice versa, or both,27 and which of these then causes poor life quality. One study showed that people with high numbers of depressive symptoms are roughly twice as likely to develop diabetes as those with low numbers of depressive symptoms.28 However, such a statement cannot be easily interpreted for our target population. The study was not broken down into ethnic categories, nor did it control for education level or social status, and therefore may not be applicable to Latinos. Another study that controlled for social and physically known risk factors for diabetes using NHANES I data showed no increased incidence of diabetes in those who were depressed.29 The results of these two studies together may imply that it was the social factors that are critical to the development of diabetes or heart disease. Obviously, depression is the product of many factors which all ethnic groups face, including Latinos. In one study looking at Latino patients with diabetes, factors such as low education level and high financial stress independently predicted depression, but not as much as the functional impact of the diabetes itself.30 There are many other social factors that play into depression, health-related quality of life, and diabetes/heart disease. According to the 2008 US Census Bureau, 23.2% of Latinos were living below the poverty level versus 11.2% of Whites.31 Only 59% of Latinos over the age of 25 had attained a high school degree compared to the 85% U.S. average.32 Lower income and lower education levels tend to result in poorer healthcare and health outcomes according to the CDC BRFSS.33 More specifically, lower health literacy independently leads to higher mortality and morbidity from type-2 diabetes.34 In an underserved area where there are fewer economic advantages and more language barriers, one might expect a significantly higher incidence of anxiety and depression than in other settings. This may explain why Hispanics living inside the US have a higher prevalence of affective disorders and anxiety.35 In the setting of diabetes, levels of stress, anxiety, and depression are even higher. About 25% of
Latinos with diabetes have depression. High functional impact of diabetes, low education, and high financial stress were the most important factors that independently and significantly predicted depression.36 The Latino culture in particular with relation to risk factors for heart disease and treatment has unique characteristics not seen in other ethnic groups. The Multi-Ethnic Study of Atherosclerosis showed that Latinos with cardiovascular risk factors, including hypercholesterolemia, hypertension, and/or diabetes, whose primary language was Spanish and/or those who lived a short time in the United States have higher systolic blood pressure, low-density lipoprotein cholesterol, and fasting glucose than those who are English speakers and have lived in the United States for a longer period of time.37 Issues in treating Latinos in the United States that differ from other groups include language barriers, a lack of social support, and emotional barriers surrounding physician trust specific to the Latino culture.38 Little is known about loneliness specifically in the Latino culture, but social support seems to be a major barrier to treatment in other populations. It is becoming apparent that treatment for Latinos with diabetes needs to be around the support necessary for changes in lifestyle and diet, and less so for educational reenforcement.39 Latinos who speak Spanish are significantly less satisfied with communication with health care providers.40 For diabetics, poor communication is associated with less patient participation with a medical provider, and is an independent predictor of poor self-management.41 A lack of bilingual/bicultural doctors and other medical professionals is another area that may contribute to disparity.42 Both depression and diabetes are poorly controlled and under treated with only 21.6% of depressed patients receiving adequate therapy43 and only 7.3% of diabetic reaching target HbA1c of less than 7.0.44 Lifestyle change seems more effective in the prevention of diabetes than medical intervention.45 Data analysis from the NHANES III indicates that as much as 91% of incidence of type 2 diabetes is preventable with lifestyle modification, making it clear that genetics is just a small part of the story.16 It has been suggested that life style changes, most importantly weight loss, may be the best way to prevent onset of type 2 diabetes.46 It has also been shown that depression is also modifiable using community based integrated programs.47 Preliminary studies show favorable outcomes using group intervention in underserved uninsured populations.48 Therefore, our goals were to create a new model of care that could better address an ethnic minority population in poverty and evaluate that model for changes in health-related quality-oflife factors associated with poor outcomes in diabetes and other cardiac risk factors. Specifically addressing the higher rates of chronic illness and depression, poor control of these illnesses, social factors related to education and language, difficulty in addressing lifestyle change, as well as cultural considerations.
METHODS This study was conducted in Lawrence, Massachusetts, at the GLFHC and approved by Tufts University review committee on human subjects as part of the CDC funded Latino 2010 initiative to evaluate and eliminate health disparities in minority pop-
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ulations. The Greater Lawrence Family Health Center has been a leader in offering group visits to the poor and underserved with visits starting in 1997. GLFHC is now the largest medical group visit site in the country. From 5/9/2002 until 6/23/03 we sought to enroll adults with risk factors for heart disease, which included diabetes, hypertension, hypercholesterolemia, low physical activity, strong family history, or age greater than 55 years old. Qualifying adults were referred from their primary care physicians at our health center. We also recruited self-referred individuals who had heard of our program by word of mouth through the community or other participants already in the groups. Participants, who were eligible, having at least one risk factor for heart disease, not suffering from severe developmental delay or illness such as schizophrenia, and provided written informed consent, completed three baseline questionnaires to evaluate depression, loneliness, and health-related quality of life. We utilized the Zung depression scale, UCLA Loneliness questionnaire version II, and the SF-36. The same questionnaires were then repeated at a minimum of one year after the intervention. Those who were unable to fill in the forms for various reasons were assisted by trained research associates. Attendance was kept to track participation in the intervention over the one-year period between assessments. A chart review using a computerized and paper medical record was performed to compare pre and postintervention weights and blood pressures. Also collected were baseline characteristics such as number of years in our practice, number of chronic illnesses, number of risk factors for heart disease, as well as demographic information. Data was then divided into two groups based on level of participation using median number of visits and further evaluated for factors relating to depression, loneliness, and healthrelated quality of life. We estimated that the comparative intervention would require 42 patients to have a power of 0.90 and significance of 0.05 using two-tailed paired t test for significance to detect a 25% difference in SF-36 factors with typical standard deviations. We planned to enroll as many patients as possible with a minimum of 84 anticipating 50% patient attrition. (We estimated that we would need 16 participants based on a correlation of 0.5 to do regression analysis comparing attendance to changes in loneliness and depression.) Data analysis was performed using SPSS version 10.0. Intervention Each participant had two intervention opportunities each week. The first was a once weekly 1.5-hour physician run group medical visit that featured tai chi exercise, patientoriented medical education, and a group relaxation component including hypnosis, meditation, art, or guided imagery. The second intervention was a once weekly hour-long exercise class that offered culturally appropriate activities chosen by the participants. For this group the activity they chose was rigorous exercises such as dancing or “Latino Tai-Bo.” The groups were structured to have participant check-in time and cooperative games to assist with group socialization followed by relaxation and then exercises.
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RESULTS Baseline Characteristics Ninety-seven patients enrolled in the program and filled out enrollment questionnaires. No patients died and 40 were lost to follow-up. Fifty-seven individuals completed both pre- and postquestionnaires. Of the 57 participants in the intervention, 49 of them were members of our medical practice and chart review was performed. The average age was 56.53 years (SD ⫽ 10.43), 96.5% female, 100% met qualification for poverty, 100% were Latino. The average participant was in our practice for 6.77 years (SD ⫽ 4.78), had 2.71 risk factors for heart disease including diabetes, hypertension, hypercholesterolemia, low physical activity, strong family history, or agegreater than 55 (SD ⫽ 1.33), and had 2.40 chronic medical conditions (SD ⫽ 1.34). Baseline weight was 173.73 (SD ⫽ 33.80) and baseline diastolic blood pressure was 81.72 (SD ⫽ 10.57). The average participant attended 21.5 group sessions (SD ⫽ 27.3) with a median ⫽ 8. 29 patients participated more than the median with a mean number of visits ⫽ 43.37 (SD ⫽ 25.57) and 27 participated less than the median with a mean number of visits ⫽ 1.8 (SD ⫽ 2.57). There were no statistically significant differences in the following baseline characteristics between the low participants (less than or equal to eight visits) and the high participants (more than eight visits): number of years in our practice, number of risk factors for heart disease, number of chronic medical conditions, weight, or diastolic pressure. The only exception was age. The mean age of the low participants was 53.57 (SD ⫽ 11.49) and the mean age of the high participants was 59.86 (SD ⫽ 8.08, P ⫽ .03). Outcome Measures Depression as measured by the Zung Depression Scale: Baseline depression scores were 46.83 with SD ⫽ 17.01, where mild depression is a score between 50 and 59, moderate depression is a score between 60 and 69, and severe depression is classified as equal to or greater than 70. Postdepression scores improved to 44.67 with SD ⫽ 18.07 (P ⫽ .32). Those who participated more than the mean number of visits had a mean baseline depression score of 44.3, whereas those who participated in fewer than the mean number of visits had mean baseline score of 49.9 (P ⫽ .25). Those who participated more than the mean had a decreased depression score to 38.85 after one year at the end of the intervention (P ⬍ .001). Those who participated in fewer than the mean number of visits had no statistically significant increased change in depression score to 50.9 (see Figure 1). Loneliness as measured by the UCLA Loneliness Questionnaire: baseline loneliness score was 49.61 (SD ⫽ 18.95) where mild loneliness is characterized as a score of 50 or more. Post loneliness scores improved to 45.91(SD ⫽ 18.35, P ⫽ .11). Those who participated more than the mean number of visits had a mean baseline loneliness score of 46.0, whereas those who participated in fewer than the mean number of visits had a mean baseline score of 54.1 (P ⫽ .13). Those who participated more than the mean had a decreased loneliness score to 37.6 after one year at the end of the intervention (P ⬍ .001). Those who participated in fewer than the mean number of visits had no change in loneliness score at 54.9 (see Figure 1).
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Figure 1. Changes in depression and lonliness based on level of participation. (Color version of figure is available online).
Health-related quality-of-life outcomes as measured by SF-36: Baseline characteristics in all eight aspects of quality of life were significantly worse than US norms for normal population (women ages 55-64) and US norms for type 2 diabetes (P ⬍ .001) (see Figure 2) Postintervention scores improved in all eight aspects of the SF-36 (physical functioning [PF], role physical [RP], bodily pain [BP], general health [GH], vitality [VT], social functioning [SF], role-emotional [RE], and mental health [MH]). There were statistically significant improvements in GH (P ⫽ .001), VT (P ⫽ .003), BP pain (P ⫽ .025), MH (P ⫽ .04), and RE (P ⫽ .04) (see Figure 2). When evaluating patients by level of participation, there were no statistical differences in any of the eight SF-36 factors at baseline. Those who attended the group medical visits more than the median number of times had significant improvements in almost all aspects of HRQL with the exception of physical function (P ⫽ .287), and physical role (P ⫽ .15) (see Figure 3). In those who attended the group medical visit fewer than the median amount of times there was no statistically significant change in any of the factors from baseline (see Figure 3).
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Physical Markers As Measures Of Health Using Paired t Test for Comparison The mean baseline weight at the start of the group medical visit intervention (n ⫽ 46) was 179.56 lbs (SD ⫽ 33.72). Postinter-
SF-36 Factors Figure 2. Health-related quality of life compared to US norms. Physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), mental health (MH). (Color version of figure is available online).
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SF-36 factor Figure 3. Participation level and SF-36. Physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE), mental health (MH). (Color version of figure is available online).
vention weight was 181.45 lbs (SD ⫽ 35.30, P ⫽ .20). High participants (n ⫽ 20) had a baseline weight of 186.50 (SD ⫽ 33.1) and a postintervention weight of 185.57 (SD ⫽ 35.85, P ⫽ .70). Low participants (n ⫽ 25) had a baseline weight of 173.73 (SD ⫽ 33.79) and a postintervention weight of 177.98 (SD ⫽ 35.18), which was significantly increased over baseline (P ⫽ .01). Baseline diastolic blood pressure was 81.72 mmHg (SD ⫽ 10.57) and postintervention diastolic blood pressure was 80.50 mmHg (SD ⫽ 10.98, P ⫽ .27). High participants (n ⫽ 22) had a baseline pressure of 76.45 (SD ⫽ 11.06) and a postintervention pressure of 74.80 (SD ⫽ 12.05, P ⫽ .38). Low participants (n ⫽ 25) had a baseline diastolic blood pressure of 81.72 (SD ⫽ 10.57) and a postintervention pressure of 80.50 (SD ⫽ 10.98, P ⫽ .48).
DISCUSSION There is a strong association between frequently participating in this group medical visit and trends toward favorable outcomes. Those with high participation in the group medical visit intervention had improvement in their quality of life both mentally and physically by self-report using the SF-36. Although those that came less than seven times (most only once) had general worsening, frequent participants were less lonely and depressed than at the start of the group intervention. Those with low participation had no statistical change, but trended toward being worse off in terms of quality of life, loneliness, and depression at the conclusion of the one-year intervention. High participants also had trending toward improvement in many of the parameters indicating better health such as weight loss and improved blood pressures. Low participants also had similar trends toward improvements in blood pressure but seemed to gain weight overall. Therefore, those who participated, and participated more frequently in the group medical visit had the greatest benefit. This finding is similar to the “dosage effects” of attendance to sessions for teaching self-management to Mexican Americans with diabetes.49 As this is community-based research we were also able to answer the question of whether such an intervention could happen in this community and who would attend. Participants were
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almost exclusively women and were significantly more disabled than the US norm when comparing their age and number of risk factors for heart disease. It is unclear whether these group visits resonated more with those who were lonely, depressed, or had poor health-related quality of life, or perhaps this is a reflection of the baseline characteristics of those in our community. In any event it was quite startling to see where our patients starting points were prior to our intervention. Using the SF-36 we saw that the average participant in our study at baseline claimed they could not dress themselves or cook adequately without help, and they were unable to walk two blocks without taking a rest. The high participants were able to walk greater than a mile by the end of the program. These results certainly raise many questions as to which aspect of the group visit program were effective for those who chose to attend. Perhaps it was simply the opportunity to exercise that was afforded by the group format,which was the most important intervention. It is quite likely that participants would not be able to afford a gym or exercise class otherwise, due to scarcity and finances. Certainly, however, there were many participants who only came to an initial session or two and then did not continue to take advantage of the opportunity being offered. Although participants had common baseline characteristics, it is difficult to know what factors led people to participate more frequently versus those who did not at all. Another intriguing aspect was that those who participated really had a chance to get to know the physician who led the group. In the group medical visit setting it is very likely that the physician was more approachable to answer questions or teach about health. Each week patients had 1.5 hours of contact with the physician in the group setting. By being with other patients the physician is essentially outnumbered and thus could be perceived as less intimidating and more approachable for questions. The teaching setting was also different than that found in a typical office visit. The patients were fully clothed and dressed casually, and the environment was that of an open exercise space. The physician led the exercise portion of the groups as well, and therefore served as a role-model that may be an effective teaching style. Limitations This is a community-based research project and as such has some inherent limitations. Patient selection could not be randomized, but is rather a reflection of who would actually participate in an intervention such as ours. We had a very high number of participants lost to follow-up and therefore there is less data to compare those who completed both initial and follow up surveys and those who did not. We also had eight participants who were not health center patients who came by word of mouth and likely pretended to be health center patients to receive free services. This might actually be typical of what would happen in an underserved community. All of this makes it difficult to assess any bias in our patient selection other than looking at baseline data. We may conclude that such issues may be typical of a communitybased research project in a poor immigrant community. There was also a much higher degree of variation among participants than we had anticipated. This made standard deviations greater than expected and made our estimates for a sample
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size too small for some types of data analysis. Particularly, it made for nonlinear relationships among variables, making regression analysis unreliable. Therefore, although the two groups of participants at baseline were statistically the same, there were differences that may have approached significance with a bigger sample size. Additionally, it is hard to say at what point the depression, loneliness, and health-related quality of life improved in frequent participants. We only have beginning and end-point data, which leaves an incomplete story. More research with data taken at closer intervals might be helpful in future studies. This may further clarify if those who participated had greater degrees of improvement corresponding to their degree of participation.
CONCLUSION Many people in our Latino community with risk factors for heart disease participated in our group medical visits. The vast majority of attendees were women, and although there was a high dropout rate, many attended frequently. Attending the intervention more frequently was associated with improved health-related quality of life, decreased loneliness, decreased depression, and weight loss. Those not attending the intervention frequently had no statistically significant changes from baseline, but tended toward worse health-related quality of life, more depression, more loneliness, and weight gain. Therefore, we conclude that group medical visits in a largely Latino underserved community seem effective at improving factors associated with better health outcomes for heart disease, especially for those who attended often. Although this is a difficult area to research, more efforts are needed to evaluate fully the factors involved in the improvement seen with group medical visits.
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