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

Feedback modeling of non-esterified fatty acids in rats after nicotinic acid infusions

A feedback model was developed to describe the tolerance and oscillatory rebound seen in non-esterified fatty acid (NEFA) plasma concentrations following intravenous infusions of nicotinic acid (NiAc) to male Sprague-Dawley rats. NiAc was administered as an intravenous infusion over 30 min (0, 1, 5 or 20 μmol kg−1 of body weight) or over 300 min (0, 5, 10 or 51 μmol kg−1 of body weight), to healthy rats (n = 63), and serial arterial blood samples were taken for measurement of NiAc and NEFA plasma concentrations. Data were analyzed using nonlinear mixed effects modeling (NONMEM). The disposition of NiAc was described by a two-compartment model with endogenous turnover rate and two parallel capacity-limited elimination processes. The plasma concentration of NiAc was driving NEFA (R) turnover via an inhibitory drug-mechanism function acting on the formation of NEFA. The NEFA turnover was described by a feedback model with a moderator distributed over a series of transit compartments, where the first compartment (M1) inhibited the formation of R and the last compartment (MN) stimulated the loss of R. All processes regulating plasma NEFA concentrations were assumed to be captured by the moderator function. The potency, IC50, of NiAc was 45 nmol L−1, the fractional turnover rate kout was 0.41 L mmol−1 min−1 and the turnover rate of moderator ktol was 0.027 min−1. A lower physiological limit of NEFA was modeled as a NiAc-independent release (kcap) of NEFA into plasma and was estimated to 0.032 mmol L−1 min−1. This model can be used to provide information about factors that determine the time-course of NEFA response following different modes, rates and routes of administration of NiAc. The proposed model may also serve as a preclinical tool for analyzing and simulating drug-induced changes in plasma NEFA concentrations after treatment with NiAc or NiAc analogues

Effects of shared medical appointments on quality of life and cost-effectiveness for patients with a chronic neuromuscular disease. Study protocol of a randomized controlled trial

Contains fulltext : 96862.pdf (publisher's version ) (Open Access)BACKGROUND: Shared medical appointments are a series of one-to-one doctor-patient contacts, in presence of a group of 6-10 fellow patients. This group visits substitute the annual control visits of patients with the neurologist. The same items attended to in a one-to-one appointment are addressed. The possible advantages of a shared medical appointment could be an added value to the present management of neuromuscular patients. The currently problem-focused one-to-one out-patient visits often leave little time for the patient's psychosocial needs, patient education, and patient empowerment. METHODS/DESIGN: A randomized, prospective controlled study (RCT) with a follow up of 6 months will be conducted to evaluate the clinical and cost-effectiveness of shared medical appointments compared to usual care for 300 neuromuscular patients and their partners at the Radboud University Nijmegen Medical Center. Every included patient will be randomly allocated to one of the two study arms. This study has been reviewed and approved by the medical ethics committee of the region Arnhem-Nijmegen, The Netherlands. The primary outcome measure is quality of life as measured by the EQ-5D, SF-36 and the Individualized neuromuscular Quality of Life Questionnaire. The primary analysis will be an intention-to-treat analysis on the area under the curve of the quality of life scores. A linear mixed model will be used with random factor group and fixed factors treatment, baseline score and type of neuromuscular disease. For the economic evaluation an incremental cost-effectiveness analysis will be conducted from a societal perspective, relating differences in costs to difference in health outcome. Results are expected in 2012. DISCUSSION: This study will be the first randomized controlled trial which evaluates the effect of shared medical appointments versus usual care for neuromuscular patients. This will enable to determine if there is additional value of shared medical appointments to the current therapeutical spectrum. When this study shows that group visits produce the alleged benefits, this may help to increase the acceptance of this innovative and creative way of using one of the most precious resources in health care more efficiently: time. TRIAL REGISTRATION: DutchTrial Register http://www.trialregister.nlNTR1412

Hearing aid effectiveness after aural rehabilitation - individual versus group (HEARING) trial: RCT design and baseline characteristics

<p>Abstract</p> <p>Background</p> <p>Hearing impairment is the most common body system disability in veterans. In 2008, nearly 520,000 veterans had a disability for hearing loss through the Department of Veterans Affairs (VA). Changes in eligibility for hearing aid services, along with the aging population, contributed to a greater than 300% increase in the number of hearing aids dispensed from 1996 to 2006. In 2006, the VA committed to having no wait times for patient visits while providing quality clinically-appropriate care. One approach to achieving this goal is the use of group visits as an alternative to individual visits. We sought to determine: 1) if group hearing aid fitting and follow-up visits were at least as effective as individual visits, and 2) whether group visits lead to cost savings through the six month period after the hearing aid fitting. We describe the rationale, design, and characteristics of the baseline cohort of the first randomized clinical trial to study the impact of group versus individual hearing aid fitting and follow-up visits.</p> <p>Methods</p> <p>Participants were recruited from the VA Puget Sound Health Care System Audiology Clinic. Eligible patients had no previous hearing aid use and monaural or binaural air-conduction hearing aids were ordered at the evaluation visit. Participants were randomized to receive the hearing aid fitting and the hearing aid follow-up in an individual or group visit. The primary outcomes were hearing-related function, measured with the first module of the Effectiveness of Aural Rehabilitation (Inner EAR), and hearing aid adherence. We tracked the total cost of planned and unplanned audiology visits over the 6-month interval after the hearing aid fitting.</p> <p>Discussion</p> <p>A cohort of 659 participants was randomized to receive group or individual hearing aid fitting and follow-up visits. Baseline demographic and self-reported health status and hearing-related measures were evenly distributed across the treatment arms.</p> <p>Outcomes after the 6-month follow-up period are needed to determine if group visits were as least as good as those for individual visits and will be reported in subsequent publication.</p> <p>Trial Registration</p> <p>NCT00260663</p

Can we improve management and control of chronic diseases?.

[ES] Objetivo: Investigar la efectividad de diferentes estrategias destinadas a mejorar la calidad y los resultados de las intervenciones en el tratamiento de las enfermedades crónicas. Metodología: Revisión sistemática de la bibliografía. Criterios de inclusión: Ensayos clínicos en lengua inglesa o española que evalúen la efectividad de distintas intervenciones para mejorar los resultados asistenciales del asma, la diabetes, la hipertensión y la insuficiencia cardíaca. Las intervenciones se clasifican de acuerdo con un modelo conceptual en 6 categorías: cambios organizativos, participación comunitaria, sistemas de información, diseño de la práctica clínica, apoyo a la toma de decisiones y de autocontrol. Los resultados evaluados fueron: utilización de servicios de salud, tratamiento clínico, resultados clínicos, calidad de vida, satisfacción e indicadores de capacidad de autocontrol. Resultados: Se incluyeron 37 estudios que incorporaban 38 intervenciones. Las intervenciones más frecuentes son las que investigan los cambios en el de diseño asistencial, seguidas de las que analizan el efecto de los sistemas de información y apoyo a la toma de decisiones. Las intervenciones más complejas en número de intervenciones, incluido el apoyo para el autocontrol, mostraron una mayor probabilidad de tener efectos positivos en el tratamiento y en los resultados clínicos. Pocas intervenciones consiguen mejoras en utilización de servicios, aunque sí se observaron sustanciales mejoras en los resultados percibidos. Conclusiones: Para mejorar la calidad asistencial y la efectividad en el control de las enfermedades crónicas es preciso adoptar una visión sistemática que incluya un sistema sanitario proactivo y pacientes protagonistas activos del tratamiento de su enfermedad. Los programas así diseñados deben combinar, al menos, estrategias organizativas, de diseño asistencial y de autocontrol. [EN] To evaluate the effectiveness of interventions aimed at improving the quality and outcome of chronic disease management. Systematic review of the literature. Clinical trials in English and Spanish that assess the effectiveness of 1 or more strategies for improving quality and outcome in asthma, diabetes, hypertension, and congestive heart failure. Interventions were classified in line with a conceptual model in 6 categories: organizational changes, community participation, information systems, clinical practice design, decision-making support, and self-management. The outcomes considered were: health service utilization, chronic disease management, clinical outcomes, quality of life, satisfaction, and self-management indicators. Thirty seven studies with 38 interventions were included. The most common interventions were those that investigated changes in health care design, followed by those analysing information systems and decision-making support. The most complex interventions, in terms of the overall number of strategies, including support for self-management, showed more likelihood of positive effects in clinical management and clinical outcomes. Few interventions achieved improvements in use of health care services, though patients perceived substantial improvements. In order to improve quality and effectiveness of chronic disease management, it is necessary to take a systematic view including proactive health care systems and patients taking an active role in managing their disease. These programmes should combine, at the least, organizational strategies, design of clinical practice and patient self-management.S