University of Iowa Hospitals and Clinics Let’s Make Change: A study of intensive lifestyle intervention through resident led group visits Nicole Gastala MD, Paige Deets MD, Anne Gaglioti MD, Kate DuChene Thoma MD MME University of Iowa Hospitals and Clinics Introduction Results Discussion 25.8 million Americans have diabetes mellitus (DM), 8.3% of the population. Obesity and sedentary lifestyle are known risks for the development of DM and are important areas of health to address (1). Figure 1: Program Implementation Implementation of the program was successful with the support from residents, patients, clinic staff, faculty and administration. Only 2/10 participants achieved the goal of >7% weight loss, 3/10 achieved some weight loss and 5/10 participants gained weight. Zero participants completed the physical activity log and none reported their level of physical activity. There was no correlation with the number of sessions and magnitude or direction of weight change. Qualitative analysis of patient and resident feedback revealed the following themes: Visits were not frequent enough (biweekly rather than weekly) Readiness to change was not assessed and some individuals came for information but were not ready to make and/or maintain lifestyle changes. Most patients were in the contemplative phase by observation. There were no consequences for being absent or lack of documentation (calorie/food log and exercise log) and this may have been a barrier to change Correct coding is crucial or visits may be declined by insurance and create a barrier to attendance. Preparation Group leader training IRB approval Resident physician interest Patient population and interest Supplies – Binder, pedometer and calorie book Administrative and clinic support Space for visits Billing (99213 for each visit) - modify visit to include a 1:1 portion of the visit Faculty, resident and support staff involvement Extension of work hours for 1 front desk clerk and 2 MA by ½ hour for each session Referrals by physician and fliers Volunteer faculty staffing “It was an extremely helpful group and if it were not for the billing issues, I would be there until this very day! “ ~Patient The Diabetes Prevention Program (DPP) showed that intensive lifestyle intervention focusing on nutrition, weight loss and exercise reduced DM incidence by 58% versus placebo at 5 years and by 34% at 10 years (2). “The group was great! I loved the support from other members and the information was helpful. I have been battling weight issues my whole life and perhaps weekly sessions would have helped overcome how easy it was to return to my previous habits. I would do well for a few days and then fall back into my old routine.” ~Patient The University of Pittsburgh translated the DPP interventions into a group based intensive lifestyle program - Group Lifestyle Balance – that used the same goals of 7% weight loss and 150 minutes of physical activity per week (3). Objective: determine the effectiveness and feasibility of implementation of a group-based intensive lifestyle intervention program on increasing physical activity and decreasing weight in obese patients at risk for development of diabetes in a Family Medicine resident clinic at an academic health center. Implementation Steps “The patients were wonderful to work with and were excited and involved at each visit, however their readiness for change inhibited their ability to make lifelong sustainable changes. I learned a great deal about leading group visits, nutrition, exercise and how to help patients make change.” ~Resident Methods Conclusions Implementation of a resident led group based lifestyle intervention program was feasible in a resident clinic at an academic health center. Visit frequency was not optimal as cited in the literature and contributed to lack of lifestyle change. Barriers to increased frequency were identified as competing clinical responsibilities for the residents and initial patient preference. This program may have been more successful in achieving weight loss, exercise and nutritional goals if patients were assessed for readiness to change prior to enrollment. It will become less difficult to obtain reimbursement for this intervention with implementation of the ACA (4,5) Sustainability of programs such as this one are unpredictable when resident led – consider building into resident curriculum and identify a clinic leader to organize and maintain program. Study Design: Mixed Methods study conducted at a Family Medicine resident clinic within an academic health center Quantitative Study Design: Prospective cohort study where the main outcome measure was group attainment of: Qualitative Study Design: Patient and resident feedback was collected by or following the completion of the program and analyzed for thematic content. Figure 2: Participant Pre and Post measures by outcome category. All participants were female. Yellow indicates pre-intervention values and grey indicates post-intervention values. Patient Session Attended Weight (lbs) BMI HgbA1C Glucose Weight Goal Achieved (7% loss) 1 46 y Black 367 310 51.96 44.6 6.2 114 100 7 32 y White 2 249 198 44.3 35.08 5.4 108 85 Increasing activity to 150 min/week Decreasing weight by 7% "The patients really had a thirst for knowledge about diet and exercise which made the program very enjoyable as a participator. If we could match this with a motivation to change, it would make the experience even more worthwhile for patients and providers." ~Resident 2 57 y White 1 241 232 41.4 38.76 5.8 131 6.0 126 6 31 y White 5 242 238 57.1 43.57 98 9 55 y White 268 257 44.12 43.13 5.5 94 5.3 105 Achieved Some Weight Loss BMI over 30 kg/m2 Fasting glucose 100-125 mg/dL HgbA1C 5.7-6.4% Metabolic Syndrome Inclusion Criteria: 3 72 y Black 2 194 202 35.29 38.19 6.1 128 93 4 49 y White 5 278 283 42.73 43.5 5.6 90 48 y Black 245 255 35.9 37.44 114 115 8 42 y Black 206 209 39.55 40.01 5.8 97 Unknown 10 21 y White 233 246 39.45 41.49 5.3 105 89 OR OR Intervention: Group Based Intensive Lifestyle Intervention adapted from the Group Lifestyle Balance Program. 7 sessions were held over a 6 month period. Quantitative measures: age, gender, weight, BMI, blood pressure, self-reported weekly exercise time, and participant attendance Limitations Weight Gain Patient limitations: access to transportation, insurance coverage, patient motivation to change Study limitations: limited data as only 1 intervention group Special Thanks to Dr. James, Dr. Gaglioti, Dr. Thoma and Dr. Levy for their support in resident pursuit of research as well as the faculty who donated their time to staff our group visits . References: 1. http://www.cdc.gov/obesity/data/prevalence-maps.html 2. http://diabetes.niddk.nih.gov/dm/pubs/preventionprogram/ 3. http://www.diabetesprevention.pitt.edu/ 4. https://www.healthcare.gov/preventive-care-benefits/ 5, http://www.uspreventiveservicestaskforce.org