Effect of group visits vs. usual care to initiate insulin. Charlotte Kuo, NP San Francisco General Hospital

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1 Effect of group visits vs. usual care to initiate insulin Charlotte Kuo, NP San Francisco General Hospital ADA 5 th Disparities Partnership Forum October 23, 2012

2 Disclosure Disclosed No Conflict of Interest

3 San Francisco Department of Public Health and San Francisco General Hospital 575,000 ambulatory visits in Primary Care 4 hospital-based clinics 11 satellite public clinics 10 non-profit community clinics ereferral EMR Specialty Care SFGH

4 Delays in insulin initiation Providers Patients Systems barriers and perceptions of insulin Psychological Insulin Resistance (PIR)

5 Think outside the box Monthly 2-hour insulin introduction groups Patients not at goal A1C on max tolerated oral meds English group Nov 2008 Spanish group March 2009 Facilitated by advanced practice nurses Address PIR upfront Glycemic goals, diet, meds, self-management Support for performing mock injection Hands-on practice Follow-up Traditional 15 minute 1:1 visit

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8 Who was referred and who attended group? Attended Group n= Missed Group Visit Age 57.5 ± ±11* Gender Male 45% 49% Female 55% 51% Ethnicity White 13% 10% Black 11% 12% Hispanic 59% 66% Asian/Pacific Islander 16% 12% Native Am 0.01% 0% Baseline A1C 10 ± 2% 9.8 ±1.7% *p=0.0001

9 Either contact improved A1C A1C * ** ** * p < 0.05 ** p < Significantly decreased compared to baseline

10 Overcoming needle anxiety 148 insulin naïve patients attended group # of patients started insulin did not start insulin tried injection refused injection n=137 n=11

11 70% 60% 50% 40% 30% 20% 10% 0% Insulin start rates differ attended group usual care English group Spanish group % of patients starting insulin

12 Group benefited insulin starters English speakers Spanish speakers A1C * ϒ ** * ϒ ** *p < 0.05 ** p < 0.01 compared to baseline ϒ Significantly greater decrease compared to usual care

13 Take home points Majority of group participants did mock injection Insulin start rates are higher after group vs. usual care BUT Spanish speaking patients have lower insulin start rates vs. English speaking patients whether they attended group or not For patients who started insulin, those who attended the group visit had a greater reduction in A1C Efficiency of insulin introduction groups could be a costeffective method for improving efficacy of insulin initiation

14 Lessons learned What facilitated implementation Physician, nursing and management support Growing provider awareness about barriers to insulin therapy Patients on insulin served as peer role models On-going work Patient-related PIR (attendance rates, PIR despite group attendance, follow-up) Provider-related PIR

15 Can this be replicated? Sustainability Dedicated time and staffing Ability to bill for group medical visits Meeting space Transferability Other patient populations Primary care or subspecialty practices Peer role models Tools for cultural competency Low-literacy/low-numeracy Starting Insulin flipchart teaching tool in English, all Spanish, and Spanish/English (Chinese forthcoming)

16 Acknowledgements San Francisco General Hospital Diabetes Center for High-Risk Populations Amalia Fyles, CNS/CDE (retired), Debbie Heuerman, NP, Sarah Kim, MD, Suneil Koliwad, MD, PhD, Elizabeth Murphy, MD, DPhil, Audrey Tang, NP, Gloria Yee, RN/CDE San Francisco General Hospital Foundation grant to support the development of insulin teaching tools San Francisco Health Plan 2012 printing support of the English and Spanish versions of Starting Insulin flipchart teaching tool

17 Sex, Support and the Pursuit of Happiness: Increasing Confidence Among Women With Diabetes October 23, 2012

18 Disclosure Disclosed No Conflict of Interest

19 Learning Objectives To explain the unique mental and physical challenges often experienced by women with diabetes To review findings from a recent study, conducted by the MicroMass Health Behavior Group, on the holistic impact of diabetes on women To discuss the impact of the Weekend for Women Conference on the lives of women with diabetes 19

20 The Unique Impact of Diabetes on Women Beckles GLA, Thompson-Reid PE, eds. Diabetes and Women s Health Across the Life Stages: A Public Health Perspective. Atlanta, GA Accessed September 20, Brownson CA, Heisler M. The role of peer support in diabetes care and self-management. Patient. 2009;2(1):5-17. Penckofer S, Ferrans CE, Velsor-Friedrich B, Savoy S. The psychological impact of living with diabetes: women's day-to-day experiences. Diabetes Educ. 2007;33(4): Society for Women's Health Research. Fact Sheet: Diabetes. Accessed September 20,

21 Using Behavioral Science to Understand Women With Diabetes 21

22 The Confidence Gap* Thinking about your diabetes, please rate how confident you are in your ability to perform the following actions: N=828. *Very or completely confident. Weiss AK. Women and Diabetes: Understanding Differences to Make a Difference. MicroMass Communications, Inc Accessed September 27,

23 Knowledge Deficits N=828. Data on file, MicroMass Communications, Inc.,

24 Sex, Body Image, and Happiness N=828. Weiss AK. Women and Diabetes: Understanding Differences to Make a Difference. MicroMass Communications, Inc Accessed September 27,

25 Weekend for Women Conference: Harnessing the Power of Women Unique opportunity to connect with other women with diabetes Educational and motivational sessions with diabetes experts Fun and healthy fitness activities 25

26 Weekend for Women Conference Raleigh, NC May

27 Impacting How Women Manage and Cope With Diabetes N=58. Post Conference Questionnaire. Weekend for Women Conference; May 18-20, 2012; Raleigh, NC. 27

28 Increasing Motivation for Long-Term Success N=58. Post Conference Questionnaire. Weekend for Women Conference; May 18-20, 2012; Raleigh, NC. 28

29 Supporting Women Through the Partner s Perspective Program N=18. Post Conference Questionnaire. Weekend for Women Conference; May 18-20, 2012; Raleigh, NC. 29

30 Lessons Learned Women with diabetes are uniquely affected by the disease Behavioral science is a roadmap for understanding the needs of women with diabetes and for developing successful interventions Programs such as the Weekend for Women Conference that provide the information, motivation, skills, and support women need are critical 30

31 Contact Information Brandy Barnes, MSW DiabetesSisters 2530 Meridian Parkway, Ste Durham, NC Andi K. Weiss, MPH MicroMass Health Behavior Group Regency Parkway, Ste. 300 Cary, NC Text micromass to for a copy of these slides and the women and diabetes research white paper.