The Impact of Planned Visits on Patients with Type 2 Diabetes Mellitus

ORIGINAL RESEARCH
The Impact of Planned Visits on Patients with Type 2
Diabetes Mellitus
Jim Nuovo
From the Chronic Disease Management Program, UC Davis Health System, 4860 Y Street, Suite 2300,
Sacramento, CA 95817, U.S.A.
Objectives: To investigate whether planned visits improve glycemic, blood pressure and lipid control among patients with
type 2 diabetes mellitus (DM).
Methods: The study was conducted from July 2007 to February 2008 at a primary care clinic in Rancho Cordova, California.
One hundred eighty-three patients were invited to come to a planned visit. On the day of the visit, they were provided a
copy of their most recent test results and information on American Diabetes Association recommendations for A1C, lipid,
and blood pressure control. Afterwards, they met with their physician for a 15-minute focused appointment. Finally, they
met with a diabetic nurse educator. There was no subsequent contact with the nurse educator after the planned visit. We
compared the baseline measurements to those from a follow-up visit with the primary care provider at a follow-up over a
6 month period. The comparison group in this study were those who did not accept the invitation for a planned visit. Their
outcomes were monitored over the same time horizon.
Results: One hundred eighty-three patients attended one of a total of fi ve planned visit sessions. There were 212 patients
in the comparison group. There were no signifi cant differences for the measured baseline characteristics. There were sig-
nifi cant improvements in A1C, LDL-C, and diastolic blood pressure control in the planned visit group. The mean A1C
change was −0.61% (95% confi dence interval, −0.28, −0.70); P 0.001). The mean LDL-C change was −8.8 mg/dL (95%
confi dence interval, −12.2, 6.1); P 0.05. The mean diastolic blood pressure change was −2.0 mmHg (95% confi dence
interval, −4.7, 6.7); P 0.05. Patients who participated in a planned visit also reported a signifi cantly higher frequency of
self-care behaviors and greater understanding about diabetes care.
Discussion: Planned visits led to improvements in glycemic, lipid and blood pressure control over a 6 month observation
period. Patients attending planned visits also reported improvements in self-care behaviors and a greater understanding
about diabetes care.
Introduction
Many patients with type 2 diabetes mellitus (DM) fail to receive care consistent with published
guidelines.1 Many of these patients have poor glycemic control and poor control of comorbid hyperten-
sion and hyperlipidemia. Primary care providers face many challenges in fi nding ways to deliver more
effective care to these patients. What often gets in the way of focusing on optimal diabetes care has
been called the “tyranny of the urgent.”2 Specifi cally, multiple competing agendas of the patient and
provider impair chronic care efforts. As stated by Bodenheimer, “given the demands of acute, chronic,
and preventive services, the provision of consistent, high-quality, guideline-compliant care in a 15-minute
visit is beyond the reach of most primary care physicians, however, well trained and well intentioned
they may be.”3 One method to deal with these competing agendas is the planned visit.4 The planned
visit is an appointment with one agenda; the management of the patient’s chronic condition. This study
investigated the impact of planned visits in a primary care practice.
Patients and Methods
Subjects
The study was conducted from July 2007 to February 2008 at the UC Davis Health System Primary
Care Clinic in Rancho Cordova, California. The Rancho Cordova Clinic is one of eleven primary care
Correspondence: Jim Nuovo, MD, Department of Family and Community Medicine, 4860 Y Street; Suite 2300,
Sacramento, CA 95817, U.S.A. Tel: 916-734-3248; Fax: 916-734-5641; Email: james.nuovo@ucdmc.ucdavis.edu
Copyright in this article, its metadata, and any supplementary data is held by its author or authors. It is published under the
Creative Commons Attribution By licence. For further information go to: http://creativecommons.org/licenses/by/3.0/.
Clinical Medicine: Endocrinology and Diabetes 2009:2 7–14
7

---

Nuovo
practice sites within the UC Davis Health System. visit. Members of this group met the same
There are six primary care physicians at this facility eligibility criteria as those who attended a planned
who provide approximately 15,000 offi ce visits visit and had outcomes available over the study’s
each year. One hundred eighty-three patients with longitudinal horizon.
DM were identifi ed from an electronic registry.
Eligible participants were 35 to 77 years old, had
type 2 DM, were designated as receiving their Outcomes
primary care at this facility, and had not had a The primary outcomes were glycemic control,
specifi c appointment for their DM in the previous blood pressure, and LDL-cholesterol (LDL-C)
year. Patients who had transferred their care to a measured during the 6 month period after the
primary care provider at another facility were planned visit. Patient’s DM medication regimens
excluded.
were catalogued during the study period. We also
assessed patient’s reporting of self-care activities
and knowledge of DM through the use of a survey
Study design
(Appendix A).
The patients were invited by a letter from their
primary care provider to come to a planned visit
to discuss their DM care. The clinic staff instructed Survey overview
the patients who called for an appointment to obtain A Diabetes Care Survey (Appendix A) was mailed
a baseline glycosylated hemoglobin (A1C) and to all patients with a diagnosis of diabetes who were
lipid profi le prior to the planned visit. On the day being seen by a primary care physician in the Ran-
of the planned visit, the staff provided the physician cho Cordova Clinic in the planned visit or within
with a copy of these test results which were to be the previous calendar year. This survey was based
handed to each patient. The results included infor-
on the Patient Assessment of Chronic Illness Care
mation on the American Diabetes Association (PACIC), developed and validated by the MacColl
(ADA) recommendations for A1C, blood pressure, Institute for Healthcare Innovation.5 There were
and lipid control. Patients then met with their phy-
three primary sections to the survey. In Section 1
sician for a 15-minute focused appointment for there were six questions related to the frequency
diabetes. The physicians were not prompted to of self-care behaviors. Each question was prefaced
follow any specific guideline for medication by the phrase “How many of the last 7 days did
therapy or asked to consider a more intensive you.” Numeric responses ranged from 0–7. In
regimen. After the encounter was concluded, the Section 2 there were eight questions related to
patients met with a diabetic nurse educator. This patient’s understanding of self-care activities. Each
encounter lasted approximately 45 minutes. The question was prefaced by the phrase “How well do
nurse educator reinforced the ADA recommendations, you understand each of the following?” Responses
discussed healthy eating, stress reduction, and led ranged from 1 = “I don’t understand at all” to
a discussion on how to develop an action plan for 4 = “I understand completely.” In Section 3 there
a health behavior change. There was no subsequent were six questions related to patient’s perception
contact with the diabetic nurse educator after the of care coordination and teamwork. Each question
planned visit. Physicians followed-up with their was prefaced by the phrase “In the last six months
patients in their usual course of practice. The prac-
when you received care for your diabetes, were
tice standard was to recommend a follow-up you?” Responses ranged from 1 = “Never” to
appointment in 3 to 6 months. We collected base-
5 = “Always.” We compared the survey responses
line data on A1C, blood pressure, and lipid profi le, of patients who had attended a planned visit
at the time of the planned visit. We extracted this compared to those patients who had not.
information from follow-up visits with the primary
care provider from the electronic medical record Statistical analysis
over a 6 month time span.
Statistical analysis was performed using the STATA
software, version 8.2 (StataCorp, College Station,
Comparison group
Texas). Pre and post planned visit means of A1C,
The comparison group in this study were those LDL-C, blood pressure, the change from baseline
who did not accept the invitation for the planned for these measures, the differences between the
8
Clinical Medicine: Endocrinology and Diabetes 2009:2

---

The impact of planned visits on patients with type 2 diabetes mellitus
treatment and comparison groups, and survey or number of offi ce visits in the prior 12 month
results were assessed using t-tests, with signifi -
period.
cance set at 0.05.
Changes in key outcomes before and after the
planned visits are presented in Table 2. There were
signifi cant improvements in A1C, diastolic blood
Results
pressure, and lipid control. There was no signifi cant
Baseline demographics of the 183 patients with change in systolic blood pressure. There was no
DM who attended one planned visits are presented signifi cant change in medication regimen after the
in Table 1. The mean age was 59 years. Nearly planned visit. The results for the comparison group
58% were women. More than two-thirds of the are presented in Table 3. There were no signifi cant
group had hypertension and hyperlipidemia in changes in A1C, blood pressure, lipid control, or
addition to their DM. There were 212 patients in medication regimen during the observation period.
the comparision group; those who did not accept The changes from baseline in these outcome
the invitation for a planned visit. There were no measures between the planned visit and compari-
signifi cant differences between these two groups sion groups are presented in Table 4. There were
for age or gender or other characteristics such as signifi cant improvements in A1C, lipid control, and
percentage with hypertension, dyslipidemia, or diastolic blood pressure. There was no signifi cant
smoking. There were also no signifi cant differences change in systolic blood pressure. The results from
between these two groups for medication regimens the Diabetes Self-Care Survey are presented in
Table 1. Characteristics of study population.
Attended
Did Not Attend
P

Planned Visits
Planned Visits

N
183
212
Gender Male
77
81
NS
Female
106
131
NS
Age Mean
59.1
56.9
NS
SD
14.2
16.3
NS
Hypertensive %
81.8
84.5
NS
Dyslipidemic %
74.7
69.8
NS
Smokers %
16.0
14.7
NS
Medications %
No
medication
12.0
12.3
NS
Metformin
32.8
35.4
NS
Any
Sulfonylurea
41.5
39.2
NS
Any
Insulin
10.4
9.9
NS
Any
Thiazolidinedione
4.6
3.2
NS
Medication Regimens %
Oral Agents
Single
Agent
16.7
15.1
NS
Two
Agents
35.5
37.9
NS
Three
Agents
28.7
30.1
NS
Insulin and Single Agent
17.3
14.1
NS
Insulin Alone
1.8
2.8
NS
Offi ce Visits in Prior 12 months
Mean
2.7
1.9
NS
Clinical Medicine: Endocrinology and Diabetes 2009:2
9

---

Nuovo
Table 2. Key outcomes before and after planned visits.
PRE
POST
P
Mean HA1C (%)
8.11
7.50
0.001
Mean LDL-Cholesterol (mg/dL)
112.2
103.4
0.05
Mean SBP (mm Hg)
129.2
127.9
NS
Mean DBP (mm Hg)
76.4
74.4
0.05
Medications %:
No
medication
12.0
11.1
NS
Metformin
32.8
34.6
NS
Any
Sulfonylurea
41.5
40.2
NS
Any
Insulin
10.4
10.8
NS
Any
Thiazolidinedione
4.6
3.9
NS
Medication Regimens %:
Oral
Agents
Single
Agent
16.7
17.5
NS
Two
Agents
35.5
36.6
NS
Three
Agents
28.7
29.4
NS
Insulin and Single Agent
17.3
16.5
NS
Insulin
Alone
1.8
2.5
NS
Table 5. Of the approximately 850 surveys mailed of care coordination and teamwork in the practice.
out, 206 completed surveys were returned. There The methodology of this student as a before and after
were 85 respondents who had been to a planned assessment does not carry the strength of a random-
visit and 121 respondents who had not been to a ized trial; therefore, biases among the patient
planned visit. Patients who attended planned visits population may have influenced outcomes. For
self-reported an increased frequency of self-care example, there may have been a selection bias in that
behaviors, an increased understanding of self-care those who participated in planned visits were more
activities, and an increased acknowledgment of activated towards changes that infl uenced their gly-
care coordination and teamwork.
cemic, lipid or blood pressure control. Also, those
who completed the survey’s may refl ect the same
selection bias.
Discussion
There are other plausible explanations for this
The main fi nding of our study is that patients with study’s fi ndings. It is possible that planned visits
type 2 DM who received care at a planned visit served to re-engaged patients in the care of their
experienced improved outcomes in measures of diabetes. This is a reasonable conclusion if there
glycemic, blood pressure, and lipid control. Patients was little evidence for any care in the previous
also reported more efforts toward self-care behaviors, year. However, both the study and comparison
understanding of self-care, and acknowledgement groups had a similar number of documented
Table 3. Key outcomes for comparison group.
Initial Value
Follow-Up Value
P
Mean HA1c
8.33
8.58
NS
Mean LDL-Cholesterol (mg/dL)
118.4
116.9
NS
Mean SBP (mm Hg)
131.2
129.8
NS
Mean DBP (mm Hg)
80.1
82.3
NS
10
Clinical Medicine: Endocrinology and Diabetes 2009:2

---

The impact of planned visits on patients with type 2 diabetes mellitus
Table 4. Outcome differences between planned visit and comparison groups; change from baseline.
Planned Visit Group
Comparison Group
P
Mean HA1c Change
−0.61
0.25
0.001
95% Confi dence Interval
−0.28, −0.70
−0.03, 0.51
Mean LDL-C Change
−8.8
−1.5
0.05
95% Confi dence Interval
−12.2, 6.1
−2.9, 3.4
Mean SBP Change
−1.3
−1.4
NS
95% Confi dence Interval
−4.8, 6.7
−5.6, 8.8
Mean DBP Change
−2.0
2.2
0.05
95% Confi dence Interval
−4.7, −0.2
−0.5, 5.5
encounters for primary care in the previous year. chronic illness care.7 Over a 2-year period in a
It is also possible that planned visits led to medica-
multispecialty ambulatory physician group practice
tion intensifi cation thereby improving these out-
they found improvement in overall DM composite
come measures. There was no detectable increase quality measures for screening and improvement
in the number of oral agents or in the use of insu-
in intermediate outcomes A1C 7, LDL-C 100,
lin during this study period.
and systolic blood pressure 130.
The fi ndings of this study are similar to others
Finally, Kirsh and associates did a quasi-
involving the use of planned visits. Sadur and experimental trial involving a shared medical visit
associates performed a randomized controlled within a primary care practice.8 They found that
trial of 97 patients with poor glycemic control; A1C, LDL-C, and SBP all decreased; A1C
A1C 8.5%.6 Their intervention included a large, decreased 1.4% (95% CI 0.8, 2.1), LDL-C decreased
multidisciplinary team (dietitian, psychologist, 14.8 (95% CI 2.3, 27.4), and SBP decreased 16.0
pharmacist, and nurse educator in a 2-hour cluster (95% CI 9.7, 22.3).
visit. Between monthly meetings a diabetes educa-
While the interventions in these three studies
tor reviewed diabetes management with each were somewhat different, they were all more effort
patient by telephone twice monthly. The pharma-
intensive than our program. Further, the outcomes
cist reviewed computer-based medication profi les, of these studies compared to ours are similar. The
contacted patients to verify the medications and implication from our study is that the level of effort
alerted patients to any potential drug interactions. to achieve improved outcomes in patients with DM
A1C levels declined by 1.3% from baseline at may not require the use of a large multidisciplinary
6 months and self-reported changes in self-care team. Focused planned visits using the addition of
practices improved from baseline.
a diabetic educator may achieve similar outcomes.
In a study involving the Harvard Vanguard A randomized trial comparing elements of these
Medical Associates Kimura and associates programs will be important to perform to better
described a delivery system redesign of their understand the level of intervention needed to
primary care practice including: population obtain maximum benefi t, balancing costs, and
management, systems-based practice, and planned staffi ng requirements.
Table 5. Diabetes survey results.
Planned visits
Yes (n = 85)
No (n = 121)
P
Mean (SD) of Section 1: Self-care Behaviors
5.3 (1.2)
4.6 (1.4)
0.001
% did not smoke within past week
90.6
92.1
NS
Mean (SD) of Section 2: Self-care Activities
3.5 (0.6)
3.2 (0.7)
0.001
Mean (SD) of Section 3: Perception of Care
3.7 (1.0)
2.6 (1.2)
0.001
Coordination and Teamwork
Clinical Medicine: Endocrinology and Diabetes 2009:2
11

---

Nuovo
Acknowledgments
3. Bodenheimer T. Planned visits to help patients self-manage chronic
conditions. Am Fam Physician. 2005;72:1454–56.
I wish to acknowledge the assistance of the UC 4. Moore LG. Escaping the tyranny of the urgent by delivering planned
Davis Health System Chronic Disease Manage-
care. Fam Pract Manag. 2006;13:37–40.
ment Program and the Rancho Cordova Practice 5. www.improvingchroniccare.org/dowloads/2004pacic.doc.pdf
6. Sadur CN, Moline N, Costa M, et al. Diabetes management in a health
Group for their efforts to establish a planned visit
maintenance organization. Effi cacy of care management using cluster
program. I would like to thank Larry Taylor for his
visits. Diabetes Care. 1999;22:2011–17.
help in obtaining the registry and outcome data for
7. Kimura J, DaSilva K, Marshall R. Population management, systems-
this study and to Ronald Fong, MD, MPH for his
based practice, and planned chronic illness care: Integrating disease
management competencies into primary care to improve composite
assistance with the statistical analysis.
diabetes quality measures. Dis Manag. 2008;11:3–22.
8. Kirsh S, Watts S, Pascuzzi K, et al. Shared medical appointments based
on the chronic care model: a quality improvement project to address
Disclosure
the challenges of patients with diabetes with high cardiovascular risk.
The author reports no confl icts of interest.
Qual Saf Health Care. 2007;16:349–53.
References
1. Standards of medical care in diabetes. Diabetes Care. 2008 Jan; 31
Suppl 1:S12–54.
2. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care
for patients with chronic illness. JAMA. 2002;288:1775–79.
12
Clinical Medicine: Endocrinology and Diabetes 2009:2

---

The impact of planned visits on patients with type 2 diabetes mellitus
Appendix A
Diabetes Self-Care Survey
*Question: During the past month, how often were you able to take care of your diabetes the way you
think that you should? Was it: 1 = None of the time, 5 = All of the time.

UCDAVIS
HEALTH SYSTEM
Diabetes Care Survey
The information we gather from this survey will help us understand how we can improve the care we
provide to our patients with diabetes. Your participation is voluntary. If you choose to participate, your
responses will be kept confi dential and included only in groups of responses.
• The fi rst set of questions asks about how you have cared for your diabetes during the past 7 days. (If you
were sick during this time, please think back to the last 7 days when you were not sick). Please circle
one number for each statement.
How many of the last 7 days did you:
1. Follow a health eating plan? (low in fat and high in fi ber).
0
1
2
3
4
5
6
7
2. Exercise for at least 30 minutes of continuous activity, including walking?
0
1
2
3
4
5
6 7
3. Test your blood sugar?
0
1
2
3
4
5
6
7
4. Check your feet?
0
1
2
3
4
5
6
7
5. Take your recommended diabetes pills?
0
1
2
3
4
5
6
7
□ I don’t take pills.
6. Take your recommended insulin injections?
0
1
2
3
4
5
6
7
□ I don’t use insulin.
• We would like to learn how well you understand how to care for your diabetes.
How well do you understand each of the following? (Check 1 box for each question)
I understand
I understand
I’m still a little
No, I don’t
completely
pretty well
confused
understand at all
1. How to care for my feet.
□
□
□
□
2. How to take my medications.
□
□
□
□
3. What to do for symptoms of low blood
□
□
□
□
sugar.
4. How to make appropriate food choices.
□
□
□
□
5. How and when to test my blood sugar.
□
□
□
□
6. What the complications of diabetes are.
□
□
□
□
7. How to exercise appropriately.
□
□
□
□
8. What my target blood sugar values
□
□
□
□
should be.
• We would like to learn about the type of help you get from your diabetes health care team. This team
includes doctors, nurses, dieticians, diabetes educators and clinic staff.
Clinical Medicine: Endocrinology and Diabetes 2009:2
13

---

Nuovo
In the last six months when you received care for your diabetes, were you ….
Never
A little of Some of Most of Always
the time
the time
the time
1. Asked about your ideas about caring for your diabetes.
□
□
□
□
□
2. Given a Diabetes Summary Sheet showing your
□
□
□
□
□
personal numbers compared to recommended goals.
3. Satisfi ed that your care was well organized by the
□
□
□
□
□
clinic team.
4. Helped to set specifi c goals in caring for your diabetes,
□
□
□
□
□
such as improving your diet or exercise.
5. Encouraged to go to a specifi c group or class to help
□
□
□
□
□
you take care of your diabetes.
6. Asked how well you’re coping with living with diabetes.
□
□
□
□
□
7. During the last 6–8 months, did you participate in a Planned Visit for your diabetes? (Offi ce visit with
your doctor where educators were also available).
Yes
□ No
□
8. If Yes, what Month did you participate?
November ’06
□
January
’07
□
April
’07
□
Thank you for your help!
Please return survey in enclosed, stamped envelope
14
Clinical Medicine: Endocrinology and Diabetes 2009:2

---