Group Visits: Promoting Adherence to Diabetes Guidelines

BACKGROUND: Current diabetes management guidelines offer blueprints for providers, yet type 2 diabetes control is often poor in disadvantaged populations. The group visit is a new treatment modality originating in managed care for efficient service delivery to patients with chronic health problems. Group visits offer promise for delivering care to diabetic patients, as visits are lengthier and can be more frequent, more organized, and more educational. OBJECTIVE: To evaluate the effect of group visits on clinical outcomes, concordance with 10 American Diabetes Association (ADA) guidelines [American Diabetes Association, Diabetes Care, 28:S4–36, 2004] and 3 United States Preventive Services Task Force (USPSTF) cancer screens [U.S. Preventive Services Task Force, http://www.ahrq.gov/clinic/uspstf/resource.htm, 2003]. RESEARCH DESIGN AND METHODS: A 12-month randomized controlled trial of 186 diabetic patients comparing care in group visits with care in the traditional patient–physician dyad. Clinical outcomes (HbA1c, blood pressure [BP], lipid profiles) were assessed at 6 and 12 months and quality of care measures (adherence to 10 ADA guidelines and 3 USPSTF cancer screens) at 12 months. RESULTS: At both measurement points, HbA1c, BP, and lipid levels did not differ significantly for patients attending group visits versus those in usual care. At 12 months, however, patients receiving care in group visits exhibited greater concordance with ADA process-of-care indicators (p < .0001) and higher screening rates for cancers of the breast (80 vs. 68%, p = .006) and cervix (80 vs 68%, p = .019). CONCLUSIONS: Group visits can improve the quality of care for diabetic patients, but modifications to the content and style of group visits may be necessary to achieve improved clinical outcomes

Safety and efficacy of alternative alglucosidase alfa regimens in Pompe disease

AbstractEmerging phenotypes in long-term survivors with Pompe disease on standard enzyme replacement therapy (ERT) (alglucosidase alfa 20 mg/kg/2 weeks) can include patients with worsening motor function. Whether higher doses of ERT improve skeletal function in these patients has not been systematically studied. This exploratory, randomized, open-label, 52-week study examined the safety and efficacy of 2 ERT regimens of alglucosidase alfa (20 mg/kg/week or 40 mg/kg/2 weeks) in 13 patients with Pompe disease and clinical decline or a lack of improvement on standard ERT: late-onset (n = 4), infantile-onset (n = 9). Cross-reactive immunologic material assay-negative patients were excluded. Eleven of 13 patients completed the study. Trends for improvement were seen in total gross motor function, but not mobility; however, 6 (late-onset, 2; infantile-onset, 4) of 11 patients (55%) who met the entry criteria of motor decline (late-onset, 4; infantile-onset, 7) showed improvement in motor and/or mobility skills. No between-regimen differences in efficacy emerged. Two case studies highlight the benefits of increased ERT dose in patients with Pompe disease experiencing clinical decline. Both alternative regimens were generally well tolerated. This study was limited by the small sample size, which is not uncommon for small clinical studies of rare diseases. Additionally, the study did not include direct assessment of muscle pathology, which may have identified potential causes of decreased response to ERT. Results were inconclusive but suggest that increased ERT dose may be beneficial in some patients with Pompe disease experiencing motor decline. Controlled studies are needed to clarify the benefits and risks of this strategy

The Mental Health Needs of People Living in Extra Care Housing

Extra care housing (very sheltered housing/housing with care) is promoted as the best way of providing long-term support for older people. What happens to people if they develop dementia or other mental health problems in these settings is less clear. While promising ‘a home for life’, the reality is that many have to move on to more dependent care facilities if they experience significant problems. This paper reports data from 268 residents in ten extra care housing schemes who were judged by staff teams as being at risk from exclusion because of mental health problems. The sample included three large village schemes (greater than 170 residents) that had opened in the last five years as well as three medium schemes (60–80 residents) and four smaller schemes (under 50 residents). The overall incidence of dementia and depression was difficult to ascertain from records and from staff reports. Formal diagnosis varied substantially across schemes and staff estimates of diagnosis were variable also. Formal assessment of those residents that staff identified as being most at risk, however, showed that they had similar profiles on the Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS), Bristol Activities of Daily Living Schedule (BADLS) and Barthel Inventory, regardless of the size of scheme they lived in. Those in larger village schemes were more likely to share their apartment with a spouse but the majority of people identified as being most vulnerable lived alone. These findings imply that there is a need to take a proactive approach to people’s mental health in extra care housing in order to be serious about maintaining a good quality of life for all within housing schemes

Enriched Opportunities Programme: A Cluster Randomised Controlled Trial of a New Approach to Living With Dementia and Other Mental Health Issues in ExtraCare Housing Schemes and Villages.

People living in extra care housing have a variety of mental health needs. Whilst many people opt for extra care housing as a means of enhancing quality of life, it is recognised that around 30% will experience significant mental health problems notably dementia and depression. This often leads to them having to move out of extra care housing or becoming isolated within their apartment. The Enriched Opportunities Programme (EOP) was developed by ExtraCare Charitable Trust and Professor Brooker and her research team as a means of ensuring that people experiencing mental health problems can continue to enjoy a good quality of life. EOP brings together what is known as best practice in a structured, systematic and proactive way. Key facets of the programs include a specialist staff role ¿the EOP Locksmith¿; staff training; individualized case work; liaison with health and social care teams; activity & occupation; and leadership. This report summarises a recently completed 2 year cluster randomised controlled trial. 5 extra care housing schemes were randomly assigned to receive the EOP for an 18 month period. A further 5 housing schemes were randomly assigned to receive a placebo intervention consisting of employing an extra member of staff called a Project Support Worker Coach (PSWC) for the same time period. We followed the lives of the 268 most vulnerable residents living in all these extra care housing schemes and villages. We compared the results for people receiving the EOP intervention with the PSWC intervention and analysed the differences. The process of implementing EOP and the impact on people¿s lives has been very positive. The main advantages in the EOP schemes were that residents were Half as likely to have to move out into a care home ¿ Far less likely to spend time in hospital as an in-patient ¿ More likely to have a GP visit ¿ More likely to see a community physiotherapist, occupational therapist and a chiropodist More likely to have their mental health problems diagnosed In addition residents in the EOP schemes and villages ¿ Rated their Quality of Life more positively ¿ Reported decreased symptoms of depression over time ¿ Reported greater feelings of social support and inclusion There were also a number of advantages enjoyed by participants in both the EOP and the PSWC interventions. Residents in both interventions reported ¿ Greater opportunity to be active ¿ Greater use of community facilities ¿ More fun ¿ Greater variety of things to do. This report will be of interest to all those involved in the provision of extra care housing and to those implementing the National Dementia Strategy

BRIEF REPORT: Trainee Provider Perceptions of Group Visits

OBJECTIVE: To evaluate the effect of observing group visits on trainees' perceptions of group visits as a method of health care delivery. RESEARCH DESIGN AND METHODS: Thirty-two trainees assigned to month-long rotations at an academic Internal Medicine Primary Care Clinic serving underinsured patients were recruited to observe between 1 and 4 group visits. Prior to observation of their first, and subsequent to observation of their last group visit, each trainee completed the Patient-Physician Orientation Scale (PPOS), a validated survey evaluating their tendencies toward being patient-centered or provider-centered. Additionally, they completed a Group Visit Questionnaire (GVQ) evaluating their perceptions of group visits as a method of health care delivery. RESULTS: Trainee gender, type, and level of training were similarly represented across the study population of trainees. While there were no significant differences noted on pre- and postobservation PPOS scores, the postobservation GVQs scores were significantly improved after observing at least one group visit (P < .0001). CONCLUSION: Trainees' perceptions of group visits as a method of health care delivery improved significantly after observation of at least 1 group as measured by the GVQ