Learning Objectives. What are Medical Group Visits?

Transcription

1 2:30-3:15pm Medical Group Visits: Moving into Primary Care, Are You Ready? Disclosures The following relationships exist related to this presentation: Paula M. Gardiner, MD, MPH: No financial relationships to disclose. SPEAKER Paula M. Gardiner, MD, MPH Off-Label/Investigational Discussion In accordance with pmicme policy, faculty have been asked to disclose discussion of unlabeled or unapproved use(s) of drugs or devices during the course of their presentations. Learning Objectives What are Medical Group Visits? Define a Medical Group Visit Discuss the strengths of Medical Group Visits Discuss limitations to MGVs in primary care settings 5

2 5 motivations for group visits Patient efficiency of care i.e. Prenatal group, suboxone group, acupuncture Patient education i.e. Asthma inhaler use, Nutrition class for diabetics Provide services / experiential opportunities. Pharmacy education, patient navigation Patient support Living with chronic disease. Loneliness / Depression / Anxiety undermines health. Health provider training. Medical Group Visits Access and amount of time with a clinician Patient satisfaction Health services utilization (ED visits, repeat admissions) Medication adherence Health behaviors (BP, dietary modifications, exercise) Quality of life Disease specific outcomes Jaber R, Braksmajer A, Trilling JS. Group visits: a qualitative review of current research. The Journal of the American Board of Family Medicine May 1;19(3): Cramer H, Lauche R, Haller H, Dobos G. A systematic review and meta analysis of yoga for low back pain. The Clinical journal of pain May 1;29(5): Yeh GY, McCarthy EP, Wayne PM, Stevenson LW, Wood MJ, Forman D, Davis RB, Phillips RS. Tai chi exercise in patients with chronic heart failure: a randomized clinical trial. Archives of internal medicine Apr 25;171(8): Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Annals of internal medicine Dec 21;141(12): la Cour P, Petersen M. Effects of mindfulness meditation on chronic pain: a randomized controlled trial. Pain Medicine Apr 1;16(4): Tsao JC. Effectiveness of massage therapy for chronic, non malignant pain: a review. Evidence based complementary and alternative medicine. 2007;4(2): Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, Sherman KJ, Witt CM, Linde K, Acupuncture Trialists' Collaboration FT. Acupuncture for chronic pain: individual patient data meta analysis. Archives of internal medicine Oct 22;172(19): Systematic Review on MGV (excludes pregnancy, DM, CA) 12 Growth in publications by year TERMS Shared Medical Appointment(s) 19 Shared Medical Visit(s) 2 Shared Appointments 1 Medical Group Visit(s) 2 Group Appointment(s) Group Visit(s) Group Medical Visit(s) Integrative Medical Group Visit(s) 4 Group Clinic Appointment(s) 1 Group Medical Appointment(s) 2 Group Office Visit(s) 2 Shared appointment(s) 1 STUDIES (N=55) Gardiner, P et al Systematic Review on MGV, submitted JAMC, under review

3 Duration of MGVs Location of MGVs Number of Providers in a MGV 13 14

4 Types of topics Curriculum Psychological 13 Mind Body /Integrative medicine Physical activity lifestyle change 39 medical topic 34 didactics 15 Mindfulness MBSR has been studied in numerous populations. Core curriculum of MBSR consists of eight weekly sessions taught by a trained instructor and one silent retreat day. Major techniques: sitting and walking meditation, body scans, and mindful yoga. Integrated Medical Group Visits (IMGV) Model Structure of group visits patients per group 2 facilitators: NP or MD or PA (a prescriber) and a co facilitator (CHW, SW, PT, psychologist, nutritionist) Discuss health topics Learn self monitoring Learn self management techniques Social Support (Healthy Meal) Gardiner P, Lestoquoy AS, Gergen Barnett K, Penti B, White LF, Saper R, Fredman L, Stillman S, Lily Negash N, Adelstein P, Brackup I, Farrell Riley C, Kabbara K, Laird L, Mitchell S, Bickmore T, Shamekhi A, Liebschutz JM. Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression. Contemp Clin Trials Mar; 54:25 35 Fjorback LO, Arendt M, Ørnbøl E, Fink P, Walach H. Mindfulness Based Stress Reduction and Mindfulness Based Cognitive Therapy a systematic review of randomized controlled trials. Acta Psychiatrica Scandinavica Aug;124(2):

5 Content of Integrative Medical Group Visit Session Elements of the IMGV Program Curriculum elements Time (min) Participant check in and vitals; time with clinician 30 Centering meditation 5 Go around 10 Home practice review and reflection 10 "Clinical talk" 30 Mind body exercise, experiential, activity 30 Review home practice for upcoming week 2 Poem shared 2 Total Time: 120 Healthy meal after end of session; time with clinician RESEARCH Reduces social isolation Creates accountability to others (within the group) Self advocacy Improves communication with provider Increases access to services Access to health care Reduces self stigma Improves health behavior Improves non prescription toolbox for pain Social Support Health Education IMGV Pain Self Efficacy Stress Management 21 Greater movement Less Pain Medication Increases mind body awareness Improves coping Reduces depression Responding non reactively 22

6 PCORI IMGV Randomized Control Trial RCT Study Flow RCT of IMGV versus Usual Care (PCP visits) for patients with chronic pain and depression. 7 Cohorts at 3 sites (Boston Medical Center, Dorchester House, Codman Square Community Health Center). Screening Exclusion Criteria: Active suicidality Bipolar disorder or current psychosis Alcohol, Cocaine or Heroin abuse Baseline and Study Enrollment Intervention or Control Intervention: Integrative Medical Group Visits Control: Usual Care (PCP Visits) 9 Week Survey Completed after 9 th group visit for all participants in cohort Maintenance 3 month period after 9 week group visits. Intervention participants continue to have access to OWL and Gabby. 21 Week Survey Completed after 10 th group visit for all participants in cohort. After all participants complete their 21 week surveys that cohort is considered completed. Gardiner P, Lestoquoy AS, Gergen Barnett K, Penti B, White LF, Saper R, Fredman L, Stillman S, Lily Negash N, Adelstein P, Brackup I, Farrell Riley C, Kabbara K, Laird L, Mitchell S, Bickmore T, Shamekhi A, Liebschutz JM. Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression. Contemp Clin Trials Mar; 54: Consort Diagram Boston Medical Center Codman Square Community Health Center DotHouse Health Patient Characteristics by Referral Variable Self Referral Provider Referral Provider Letter p value* Age (22 84) µ=48 (σ=11.3) µ=49 (σ=11.7) µ=57 (σ=11.9) ** Gender n % n % n % 0.69 Male screened 96 screened 72 screened Female Race 0.41 White enrolled 47 enrolled 41 enrolled Asian Black Other total enrolled Ethnicity 0.15 Non Latino/a Latino/a randomized to Intervention 79 randomized to Control *Statistically significant at alpha=0.05

7 Qualitative Summary Focus groups mapped to Biopsychosocial Model Dresner D, Gergen Barnett K, Resnick K, Laird LD, Gardiner P. Listening to Their Words: A Qualitative Analysis of Integrative Medicine Group Visits in an Urban Underserved Medical Setting. Pain Med Apr Perceived benefits and changes in health Reductions in pain and pain medication use Improvements in anxiety and depression Ability to self regulate (awareness and coping) Increased awareness of physical sensations and emotions Meditation and relaxation techniques to cope with stress, pain, unpleasant events

8 Attitudes about group care Un Published Preliminary Results Feeling of not being alone Enjoy increased time with provider because health questions are answered Learn from group Gain sense of perspective on own illness from hearing others stories 32 Results: Patient Characteristics Variable Total Baseline (N=159) Age (22 84) =50 (sd=12.2) Gender n % Female Male Race White Black Other Ethnicity Hispanic Non Hispanic Results: Patient Characteristics (cont.) Variable Total Baseline (N=159) Income n % Less than $5K $5K $29.99K $30K $74.99K 13 8 $75K and over 2 1 Refused/DK/No personal income Work Status Full/Part time Unemployed Retired/Homemaker Sick Leave/Disability Other 18 11

9 Week 9 Relative Risk (Confidence Interval) Week 21 Relative Risk (Confidence Interval) Outcome 9 weeks 21 weeks Reduction of Pain Average painᵖ(0 10) (0.920, 1.150) (0.884, 1.082) BPI Interferenceᵖ (0 10) (0.859, 1.164) (0.997,1.366) BPI Severityᵖ (0 10) (0.887, 1.132) (0.895, 1.136) Reduction of Depression Patient Health Ques onnaire (0.924, 1.282) (0.752, 1.059) Increase of Pain Self Efficacy and Reduced Use of Pain Medication Intention to Treat Analysis ED use 0.32 (0.12, 0.83)* 0.86 (0.33, 2.21) Perceived Stress Scale SF 12 Mental Composite Score 0.95 (0.82, 1.10) 0.95 (0.82, 1.10) 1.01 (0.95, 1.07) 1.07 (1.01, 1.24)* Pain medication use in the last 7 days 0.75 (0.33, 1.68) Odds ratio 0.42 (0.18, 0.98)* Odds ratio 36