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TRH 01-173 – HSR&D Study

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TRH 01-173
Group Visits to Improve Hypertension Management
Mary K. Goldstein MD MS
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: April 2003 - August 2006

BACKGROUND/RATIONALE:
Many veterans with hypertension have poorly controlled blood pressure (BP); new strategies for quality improvement are needed. A new model of care delivery, Group Medical Visits, holds promise as a means to improve blood pressure control by enhancing patients' self-efficacy for self-management of their chronic disease.

OBJECTIVE(S):
The overriding goal of this implementation project is to translate research findings about management of hypertension into practice and thereby to improve patient outcome, i.e., adequacy of control of BP, in patients with hypertension. Specific objectives are to develop and implement a model of group medical visits in iterative steps; to evaluate whether group medical visits improve patient adherence to prescribed antihypertensive medications and improve BP control; and to assess patient, physician, and health care system factors involved in successfully making organizational changes to encompass group medical visits.

METHODS:
Study site: primary care clinics at VA Palo Alto.

Study Design: staircase design with 2 steps of design/implementation/formative-evaluation/redesign with increasing numbers of participants, followed by a 3rd step evaluating the final model. Participants: primary care providers (MDs and RNPs) and their patients with hypertension. Participating primary care providers (PCPs) are randomly allocated 2:1 Group Visits (GV)intervention:control; patients of intervention PCPs are also randomly allocated 2:1, yielding 3 study arms (patients of GV-PCPs enrolled in GVs; patients of GV-PCPs not in GVs, and patients of non-GV-PCPs). This design allows for comparison between control patients of primary care providers conducting group visits with primary care providers who do not participate in the group medical appointment intervention. Two formative evaluations of the program will occur at 6 and 12 months after initiation of the first group medical appointment. These evaluations will be used to redesign the intervention. A final summative evaluation will be conducted at 18 months.

Intervention: group medical visits of patients with their own PCP. Group visits include both education and medical care components.

Organizational component: tracking of organizational issues in establishing the program of group visits; interviews with key stakeholders to identify barriers and facilitators to implementing the new model of care.

Outcome measures: patients' blood pressures (BPs), medication adherence, satisfaction, and health-related quality of life; PCP satisfaction; qualitative analysis of themes from interviews for patient, physician, and medical center factors involved in making organizational changes to encompass group visits. This data will be used to analyze change in patient's blood pressures and medication adherence by comparing control group patients with patients attending group medical appointments. In addition, physician, patient, and health care factors will be evaluated to determine the elements involved in successfully making organizational change to implement the group visits model in a primary care setting at the VA

FINDINGS/RESULTS:
We exceeded the target enrollment for primary care providers (PCPs) with a total of 16 (11 intervention, 5 control). We enrolled 296 patients; 7 had incomplete baseline data leaving 289 patients: 145 allocated to GVs, 73 control patients of GV-PCPs, and 71 control patients of control PCPs. We have also enrolled an additional 12 staff members for interviews, including the one PCP who did not elect to participate. In formative evaluations we found that patient medical needs were met in the group setting and that both patients and PCPs were satisfied with the GV format. PCPs and patients have requested that the GVs continue after the study ends. Space for the GVs has been a major barrier particularly in light of ongoing construction in the clinic building.

Preliminary qualitative analysis of data from interviews with participating primary care providers (PCPs) shows the following: the majority of positive comments focus on the patient's experience (eg, group visits presented opportunity for patients to learn from one another). PCPs also identified many positives for themselves and for other clinical staff (eg, group visits were very efficient; gave PCP an opportunity to hear and see patients interact; allowed high degree of focus on a specific health condition.) PCPs also noted some negative factors (eg, limited time to ask in-depth questions of individual patients). PCPs also provided suggestions for logistics of the visits.

The study used a staircase design with 3 Steps, the first 2 being followed by a formative evaluation and re-design of the intervention model. Data from the third and final Step were used for the summative evaluation. We applied a log-linear model for the main analyses. For the main study outcome, patient blood pressure at goal, we found a significant difference favoring group visits. Patient's medication adherence showed a trend toward greater adherence but did not reach 0.05 p-value.

IMPACT:
Group Medical visits are a new model of health care delivery that hold promise for improving patient access, patient and provider satisfaction, and clinical outcomes. The group visits program has the potential to enhance quality of care for patients.

PUBLICATIONS:

Conference Presentations

  1. Goldstein M, Fenn C, Olin I, Hoffman B. Initiation of group medical visit model for patients with hypertension: Organizational change and patient/physician satisfaction. Poster session presented at: VA HSR&D National Meeting; 2005 Feb 16; Baltimore, MD.
  2. Goldstein MK. Patient and Physician Satisfaction with Initiation of a Group Medical Visit Model for Patients with Hypertension. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD.


DRA: Health Systems
DRE: none
Keywords: Cardiovasc’r disease
MeSH Terms: none