Physician-led Group Research Articles

Self-Directed Virtual Reality-Based Training versus Traditional Physician-Led Teaching for Point-of-Care Cardiac Ultrasound: A Randomized Controlled Study

To assess the learning efficacy of self-directed virtual reality ultrasound simulators as an alternative to traditional physician-led teaching for cardiac point-of-care ultrasound (POCUS) training. Single blinded (observer), noninferiority, parallel group, randomized controlled study. Tertiary university hospital in Singapore. Forty-three medical students with no prior formal ultrasound training. Participants first completed an e-learning module on basic ultrasonography. Participants' baseline knowledge was subsequently assessed using a multiple-choice question (MCQ) test. Participants were then randomized to either physician-led (PL) teaching or independent learning with a virtual-reality (VR) simulator to learn the 4 cardiac POCUS views. A post-training MCQ test and a practical skills test scored by 2 blinded assessors were conducted. Students repeated the MCQ test and skills test 1 month later. The VR group had higher baseline MCQ scores compared to the PL group (mean, 13.4 v 10.7). Immediately post-training, the PL group had a greater improvement in mean MCQ scores (from baseline) and higher total practical scores compared to the VR group (p = 0.03 and p < 0.01, respectively). At 1 month post-training, the PL group similarly had a greater mean change from baseline MCQ scores, but this difference was not statistically significant (p = 0.12). For practical scores, the VR group scored higher than the PL group, although this difference was not statistically significant (p = 0.06). Our study demonstrates that at 1 month post-training, self-directed VR training was noninferior to PL training. Although differences observed were not significant, there were trends to suggest enhanced retention of knowledge and skills with VR learning.

Abstract WP38: Nurse-Driven Emergency Evaluation Improves Timely Acute Stroke Response

Background: Stroke is associated with high rates of death and disability; prompt and effective interventions are imperative. Depending on emergency department (ED) physicians to initiate stroke codes may delay critical time targets, especially for patients arriving by private vehicle (POV). This study examines existing stroke care protocols in the ED of a Comprehensive Stroke Center and evaluates a new nurse-driven acute stroke response protocol. Purpose: The primary goal of this initiative was to improve outcomes for patients arriving by POV, by reducing triage delays and accelerating time-sensitive acute stroke interventions. Methods: This retrospective study implemented a nurse-led stroke activation process, in lieu of the conventional physician-led method. Nurses received comprehensive training in intervention goals and identification of stroke symptoms and last known-well times. The nurse-led model targeted patients presenting to the ED with a minimum of 2 stroke symptoms within 6 hours of symptom onset—an assessment tool, incorporating the FAST algorithm (Face, Arm, Speech, Time) and key National Institutes of Health Stroke Scale (NIHSS) exam components, enhanced symptom specificity. Critical intervention times were evaluated for improvement. Results: ED POV arrival patients with acute stroke symptoms were studied from 11/7/21-7/31/23; the nurse-driven process was implemented on 11/7/22. Pre-intervention review included 247 patients with 216 patients in the post-intervention review. Median door-to-activation times fell from 17 to 10 minutes, door-to-CT from 24 to 19 minutes, and door-to-needle times from 49 to 43.5 minutes. Median NIHSS scores in tPA-treated patients were compared pre- and post-intervention. In the physician-led group, initial median NIHSS scores were 6, reducing to 1 at discharge. The nurse-led group showed an initial median NIHSS score of 5, also reducing to 1 at discharge. Conclusions: The nurse-driven method effectively shortened critical time metrics in the stroke code process, while maintaining optimal patient outcomes. A paradigm shift towards ED triage nurse-led stroke code activation for acute stroke may lead to higher quality acute stroke care.

Hypertension Control and Medication Titration Associated With Lifestyle Medicine Virtual Group Visits and Home Blood Pressure Monitoring

Less than a quarter of the 116 million adults with hypertension in the United States have blood pressure (BP) lower than the guideline-recommended goal of 130/80 mmHg. There is a critical need for novel interventions that integrate evidence-based recommendations—such as lifestyle medicine and home BP monitoring (HBPM)—into clinical care. In this study, we tested the hypothesis that a four-part, primary care physician-led Virtual Group Visit (VGV) series combining lifestyle medicine, Health and Wellness Coaching (HWC), and HBPM could lead to a reduction in BP and antihypertensive medications. There was a decrease in systolic (β = −.108 mmHg per day; P = .046) and diastolic (β = −.058 mmHg per day; P = .026) BP. Thirteen of the 22 patients (59%) who started the VGV series on medications had at least one medication dosage reduced or discontinued during the VGV series, and 8 of the 18 patients (44%) who finished the VGV series on medications had at least one medication dosage reduced or discontinued in the 180 days after the VGV series. This pilot study demonstrates for the first time that lifestyle medicine VGVs, coupled with HWC and HBPM, are associated with improved BP control and medication deprescribing.

Diagnosis and management of sleep apnea by a clinical nurse: a noninferiority randomized clinical trial.

References for the evaluation of obstructive sleep apnea often exceed the sleep clinic's capacity. We aimed to assess the noninferiority of a nurse-communicated model compared with a traditional physician-led model for the initial management of uncomplicated obstructive sleep apnea in the sleep clinic. In this noninferiority, open-label randomized controlled trial, patients referred for the evaluation of uncomplicated obstructive sleep apnea (home sleep apnea test with respiratory event index ≥ 20 events/h) were randomized to a nurse-communicated or a physician-led management. The primary endpoint was noninferiority in the mean change from baseline of the Epworth Sleepiness Scale score at 3 and 6 months, assuming a noninferiority margin of -2.0 points. Secondary outcomes included quality of life (Quebec Sleep Questionnaire) and positive airway pressure adherence. Two hundred participants were randomized to a nurse-communicated (n = 101) or physician-led management (n = 99). Overall, 48 participants were lost at follow-up (27.7% and 20.4% in the nurse-communicated and physician-led groups, respectively). Most participants were treated with positive airway pressure (78.2% and 80.6% in the nurse-communicated and physician-led management groups, respectively). There was substantial missing data for the Epworth Sleepiness Scale (33% and 58% at 3 and 6 months in the nurse-communicated group and 29% and 55% in the physician-led group) and Quebec Sleep Questionnaire (86% and 91% at 3 and 6 months and 79.6% and 85.7% in the physician-led group). The difference in mean change between groups for the Epworth Sleepiness Scale was -0.71 (95% confidence interval -2.25 to 0.83) at 3 months and -0.21 (95% confidence interval -1.85 to 1.45) at 6 months. For each domain of the Quebec Sleep Questionnaire at 3 and 6 months, the lower bound of the 95% confidence interval was greater than the prespecified noninferiority margin. Positive airway pressure adherence was similar between groups. Among patients with uncomplicated obstructive sleep apnea, nurse-communicated management was noninferior to physician-led management in terms of sleepiness, quality of life, and positive airway pressure adherence at 6 months. Registry: ClinicalTrials.gov; Name: Management of Sleep Apnea Patients by a Clinical Nurse (Supernurse), URL: https://clinicaltrials.gov/ct2/show/NCT03455920; Identifier: NCT03455920. Lajoie AC, Privé A, Roy-Hallé A, Pagé D, Simard S, Séries F. Diagnosis and management of sleep apnea by a clinical nurse: a noninferiority randomized clinical trial. J Clin Sleep Med. 2022;18(1):89-97.

Physician-led prehospital management is associated with reduced mortality in severe blunt trauma patients: a retrospective analysis of the Japanese nationwide trauma registry

BackgroundAlthough the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management.MethodsThis retrospective cohort study analyzed the data of Japan’s nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics.ResultsA total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78–1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management.ConclusionsPhysician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.

Effectiveness and Safety of Physician-Led Versus Patient-Led Titration of Insulin Glargine in Indian Patients with Type 2 Diabetes Mellitus: A Subanalysis of the Asian Treat to Target Lantus Study (ATLAS).

Background: Titration of basal insulin led by either the physician or the patient is not well understood in India. This analysis of Indian subset of Asian Treat to Target Lantus Study (ATLAS) compared effectiveness of patient-led with physician-led titration of once-daily insulin glargine 100 U/mL (Glargine-U-100) in patients with type 2 diabetes mellitus (T2DM) uncontrolled on oral antidiabetes drug (OAD). Methods: In this open-label parallel group study, randomized patients (either physician-led or patient-led [self-titration] group) followed the same dose titration algorithm (fasting blood glucose [FBG] target 110 mg/dL [6.1 mmol/L]). The primary endpoint was change in mean glycated hemoglobin (HbA1c) at week 24 in the patient-led group versus the physician-led group. Results: Patients (40-75 years) were randomized to either the physician-led group (n = 39) or the patient-led group (n = 36). At week 24, self-titration led to a greater decline in HbA1c than physician-led titration (-1.3% vs. -1.1%). Mean decrease in FBG was more in the patient-led group than in the physician-led group (-53.7 mg/dL vs. -35.5 mg/dL). Mean daily dose of Glargine-U-100 at week 24 was higher in the patient-led group than in the physician-led group (30.0 U vs. 23.8 U). At any time during the study, 30.6% and 7.7% of patients in the patient-led and physician-led groups, respectively, showed target HbA1c level of <7.0% without severe hypoglycemia. Treatment satisfaction and quality of life improved in both groups. Overall, treatment was safe and well tolerated, and none of the events led to treatment discontinuation. Conclusion: Patient-led adjustment of Glargine-U-100 in outpatient setting can be a safe and effective method for glycemic control in Indian patients with T2DM uncontrolled on OADs.

Increasing Undergraduate Exposure to Oncology: the Role of Oncology Interest Groups.

This study describes a medical school oncology interest group (OIG) and assesses its influence on student perceptions of oncology, interest in pursuing oncology as a career, and comfort levels with oncology topics such as breaking bad news. From 2015 to 2017, the OIG annual event took place at a satellite campus of a larger Canadian undergraduate medical school. The event provided a question and answer period with a panel of physicians from multiple oncology specialties-discussions focused around lifestyle, training, clinical work, lifestyle, and career focus. Small physician-led groups taught breaking bad news using the SPIKES framework. The interest group also provided a mentoring and networking opportunity to interested students. Pre- and post-event surveys were distributed to students and physicians. For three consecutive years, the student-run, and physician-mentored OIG successfully recruited student and physician participants, providing a clinical skill teaching session as well as mentorship opportunities to students. Pre-event surveys found that only 20% of students believed their current curriculum was adequate as it relates to oncology education. In pre-session, 13% (6/45) of students indicated comfort with the skill of breaking bad news, compared with that in post-session with 81% (34/42) of students feeling comfortable. When asked "How likely are you to pursue a future elective opportunity in oncology?" 49% (20/41) of students indicated "likely" as their response in the pre-session. This response increased post-session to 70% (28/40). The event highlighted the potential for OIGs to increase student interest in pursuing oncology electives and student-perceived comfort with breaking bad news. OIGs are important in promoting interest in the field of oncology and in improving confidence in breaking bad news. This medical student-created, run and maintained oncology interest group supplemented standard curriculum by providing relevant educational and mentorship opportunities to students. This study highlights the feasibility of implementing a self-sustaining medical school oncology interest group and its potential to positively impact student learning and interest in oncology.

Making Strides Towards Health: Expanding Physician-led Walking Groups In The Community

Making Strides Towards Health: Expanding Physician-led Walking Groups In The Community

Self- vs. Physician-Led Titration of Insulin Glargine 300 U/mL (Gla-300)—Improved or Comparable Efficacy at Week 24 without Increased Risk of Hypoglycemia, Irrespective of Age (&amp;lt;65 or =65 Years)—TAKE CONTROL

TAKE CONTROL, a 24-week, multicenter, randomized, open-label, parallel-group study, evaluated self- vs. physician-led titration of Gla-300 in people with T2DM. Efficacy and safety outcomes in people &amp;lt;65 years vs. ≥65 years were assessed. Baseline HbA1c and fasting SMPG were comparable; in the older and younger groups, HbA1c (p=0.46 and p=0.29) and fasting SMPG (p=0.56 and p=0.15) reductions were similar between self- vs. physician-led titration. Attainment of the fasting SMPG target (80-130 mg/dL) without confirmed (&amp;lt;54 mg/dL) or severe hypoglycemia was slightly higher in older people; differences in self- vs. physician-led titration were not significant in older or younger groups (p=0.19 and p=0.05). Incidences of hypoglycemia at any time of day (24 h) appeared slightly higher in the ≥65 years, physician-led group. There was no evidence of heterogeneity of effect of self- vs. physician-led titration on hypoglycemia (p&amp;gt;0.05). Adverse events were similar in each group. Self-titration of Gla-300 resulted in similar glycemic target achievement to physician-led titration, without an increased risk of hypoglycemia, irrespective of age. There was a trend for more people to reach fasting SMPG targets without hypoglycemia with self- vs. physician-led titration, including those ≥65 years. Disclosure K. Strojek: Research Support; Self; AstraZeneca. Other Relationship; Self; Sanofi-Aventis, Novo Nordisk A/S. Speaker's Bureau; Self; Servier, Eli Lilly and Company, MSD K.K., Boehringer Ingelheim GmbH. Research Support; Self; Pfizer Inc., Amgen Inc.. Speaker's Bureau; Self; Janssen Pharmaceuticals, Inc. G. Bigot: Employee; Self; Sanofi. Stock/Shareholder; Self; Sanofi. M. Bonnemaire: Employee; Self; Sanofi. Stock/Shareholder; Self; Sanofi. E. Delgado: Advisory Panel; Self; AstraZeneca. Speaker's Bureau; Self; AstraZeneca, Novo Nordisk A/S. Advisory Panel; Self; Sanofi-Aventis. Speaker's Bureau; Self; Sanofi-Aventis. Research Support; Self; Sanofi-Aventis. Speaker's Bureau; Self; Esteve, Boehringer Ingelheim Pharmaceuticals, Inc., Janssen Pharmaceuticals, Inc.. Advisory Panel; Self; Abbott. Speaker's Bureau; Self; Lilly. Research Support; Self; Menarini Group. V. Donicova: None. M. Kvapil: None. N. Papanas: None. L. Popescu: Employee; Self; Sanofi. Stock/Shareholder; Self; Sanofi. R. Ritzel: Speaker's Bureau; Self; AstraZeneca. Consultant; Self; Novo Nordisk A/S. Speaker's Bureau; Self; Novo Nordisk A/S. Consultant; Self; Sanofi. Speaker's Bureau; Self; Sanofi. Consultant; Self; Servier. Speaker's Bureau; Self; Bristol-Myers Squibb Company, Merck Sharp &amp; Dohme Corp., Boehringer Ingelheim GmbH, Eli Lilly and Company, Novartis Pharmaceuticals Corporation. B. Schultes: Advisory Panel; Self; Novo Nordisk A/S, Sanofi, AstraZeneca, Eli Lilly and Company, Bayer AG, Boehringer Ingelheim GmbH. Speaker's Bureau; Self; Sanofi, Eli Lilly and Company, MSD K.K., Bayer AG, Boehringer Ingelheim GmbH. L. Duvnjak: None.

Family Physician-Led Group Visits for Lifestyle Modification in Women with Weight Problems: A Pilot Intervention and Follow-Up Study

Objective: Lifestyle modification requires extensive information sharing and counseling. However, one-on-one primary care consultations are lacking to cover all necessary components due to time constraints. This preliminary study aims to investigate the feasibility and effects of lifestyle-changing intervention by family physician-led group visits (GVs) on weight management in overweight and obese women. Methods: 60 volunteers fulfilling the inclusion criteria were enrolled. Baseline and 6th month assessments consisted of anthropometric measurements, SF-36 Health Survey, blood variables, exercise test, and resting metabolic rate. Weight maintenance was controlled at the 12th month. Results: Although weight loss among participants varied, the mean body weights were significantly decreased by 8.2% in full-attenders (n = 30). A significant increase in HDL-cholesterol and decreases in heart rate and blood pressure were found. SF-36 summary scales were significantly improved. Weight change was moderately correlated with exercise duration, compliance to diet, and baseline mental component score. It was determined that 62.5% of the participants either lost or maintained body weight at the 12th month. Conclusion: Significant weight loss and quality of life improvement was achieved in this pilot study. GVs may be a promising alternative to primary care consultations for obesity management; however, the high dropout level and diverse outcomes need further assessment.

PodCare: Structured Individual Prenatal Care for the Academic Team [22E

INTRODUCTION: Innovative models of prenatal care are needed to improve pregnancy outcomes in the U.S, while improving patient and family experience and lowering costs. We sought to improve upon the traditional prenatal model by structuring visits, coordinating care, and training residents within interprofessional teams. METHODS: Attending physicians, resident physicians, associate providers, and clinic staff were split into four “Pods”. Testing and counseling topics were assigned to appropriate visits to create a structured schedule based on gestational age. Weekly Pod meetings provided coordination of care. Data were abstracted retrospectively from Epic for all patients initiating prenatal care in the one year before and after initiation of the new model. RESULTS: 370 of 1084 patients chose the physician-led group in 2014, compared to only 260 of 1064 in 2013 (P &lt; 0.0005), when other care options included CNM and maternal-fetal medicine care. 113 more births were attributed to the Pods, with a total increase of only 48 prenatal visits. The median number of visits per pregnancy decreased, while quality remained excellent and unchanged by standard obstetric measures. Provider continuity with patients improved, and we observed a three-fold increase in the number of patients presenting for postpartum care. Generalist Ob/Gyn physicians also assumed care of more high risk patients under the model. CONCLUSION: The PodCare model is popular with patients, shows promise for improved value by decreasing visits while improving provider continuity and postpartum care, and by providing a robust experience in interprofessional education for residents. Future innovations may include incorporation of formal telehealth visits and biometric sensor data.

Impact of the introduction of a standardised ICD programming protocol: real-world data from a single centre.

Randomised trials have shown that empiric ICD programming, using long detection times and high detection zones, reduces device therapy in ICD recipients. However, there is less data on its effectiveness in a "real-world" setting, especially secondary prevention patients. Our aim was to evaluate the introduction of a standardised programming protocol in a real-world setting of unselected ICD recipients. We analysed 270 consecutive ICD recipients implanted in a single centre-135 implanted prior to protocol implementation (physician-led group) and 135 after (standardised group). The protocol included long arrhythmia detection times (30/40 or equivalent) and high rate detection zones (primary prevention lower treatment zone 200bpm). Programming in the physician-led group was at the discretion of the implanter. The primary endpoint was time-to-any therapy (ATP or shocks). Secondary endpoints were time-to-inappropriate therapy and time-to-appropriate therapy. The safety endpoints were syncopal episodes, hospital admissions and death. At 12months follow-up, 47 patients had received any ICD therapy (physician-led group, n = 31 vs. standardised group, n = 16). There was a 47% risk reduction in any device therapy (p = 0.04) and an 86% risk reduction in inappropriate therapy (p = 0.009) in the standardised compared to the physician-led group. There was a non-significant 30% risk reduction in appropriate therapy (p = 0.32). Results were consistent across primary and secondary prevention patients. There were no significant differences in the rates of syncope, hospitalisation, and death. In unselected patients in a real-world setting, introduction of a standardised programming protocol, using long detection times and high detection zones, significantly reduces the burden of ICD therapy without an increase in adverse outcomes.

56-47: Impact Of The Introduction Of A Standardised ICD Programming Protocol: Real-World Data From A Single Centre

Aims: Randomised trials have shown that empiric ICD programming, using long detection times and high detection zones, reduces device therapy in ICD recipients. However, there is less data on its effectiveness in a “real-world” setting, especially secondary prevention patients. Our aim was to evaluate the introduction of a standardised programming protocol in a “real-world” setting of unselected ICD recipients. Methods: We analysed 270 consecutive ICD recipients implanted in a single centre – 135 implanted prior to protocol implementation (Physician-Led group) and 135 after (Standardised group). The protocol included long arrhythmia detection times (30/40 or equivalent) and high rate detection zones (primary prevention lower treatment zone 200 bpm). Programming in the Physician-Led group was at the discretion of the implanter. The primary endpoint was time-to-any therapy (ATP or shocks). Secondary endpoints were time-to-inappropriate therapy and time-to-appropriate therapy. The safety endpoints were syncopal episodes, hospital admissions, and death. Results: At 12 months follow-up, 47 patients had received any ICD therapy (Physician-Led group, n = 31 vs. Standardised group, n = 16). There was a 47% risk reduction in any device therapy (p = 0.036) and an 86% risk reduction in inappropriate therapy (p = 0.009) in the Standardised compared to the Physician-led group. Results were consistent across primary and secondary prevention patients. There were no significant differences in the rates of syncope, hospitalization and death. Conclusions: In unselected patients in a “real-world” setting introduction of a standardised programming protocol, using long detection times and high detection zones, significantly reduces the burden of ICD therapy without an increase in adverse outcomes.

Physician leadership development at Cleveland Clinic: a brief review

We aim to describe the rationale for and spectrum of leadership development programs, highlighting experience at a large healthcare institution (Cleveland Clinic, Cleveland, Ohio, USA). Developing leaders is a universal priority to sustain organizational success. In health care, significant challenges of ensuring quality and access and making care affordable are widely shared internationally and demand effective physician leadership. Yet, leadership competencies differ from clinical and scientific competencies and features of selecting and training physicians-who have been called "heroic lone healers" -often conspire against physicians being effective leaders or followers. Thus, developing leadership competencies in physicians is critical.Leadership development programs have been signature features of successful organizations and various Australian organizations offer such training (e.g. The Australian Leadership Foundation and the University of South Australia), but relatively few health care organizations have adopted the practice of offering such training, both in Australia and elsewhere. As a United States example of one such integrated program, the Cleveland Clinic, a large, closed-staff physician-led group practice in Cleveland, Ohio has offered physician leadership training for over 15 years. This paper describes the rationale, structure, and some of the observed impacts associated with this program.

Accountable Care Organizations: Ensuring Focus on Cardiovascular Health.

Although unparalleled in the provision of intensive lifesaving treatments, US health care has only begun to focus on other important aspects of population health. To achieve the triple aim of better health, better care, and lower costs, payment and delivery systems must evolve. The accountable care movement is central to this evolution, and engagement by cardiovascular specialists can help to shape it. Sustained partnering with policy makers could improve patient care by appropriately directing cardiovascular medicine resources and avoiding unintended harm to well-functioning systems of care. Accountable care organizations (ACOs) are part of a new payment and delivery model that aims to improve quality of care while controlling costs for populations of patients.1,2 ACOs took conceptual shape ≈10 years ago as an approach to achieve these goals in a manner that fosters flexibility.3,4 Unlike the managed care movement in the 1990s, capitated payments have not been a foundational element of the ACO movement (although components of capitation will likely prove important5). ACOs were therefore less disruptive to the status quo ante, and, with inclusion in the Affordable Care Act of 2010, they gained considerable momentum. Although Medicare has specific requirements for ACO structure and patient attribution, state and private insurers have engaged in a variety of alternative ACO models that could drive innovation. Within ACOs, providers can be configured in a number of ways ranging from physician-led groups and integrated delivery systems to hospital-based systems coupled with independent practice associations.2–4,6 The adoption of electronic health records has been an important feature that allows ACOs to measure and integrate care for populations of patients. Regardless of structure, it is widely accepted that ACOs should (1) be provider led and accountable for the entire continuum of care for a population; …

Patient-Led Versus Physician-Led Titration of Insulin Glargine in Patients with Uncontrolled Type 2 Diabetes: A Randomized Multinational Atlas Study

Self-adjustment of insulin dose is commonly practiced in Western patients with type 2 diabetes but is usually not performed in Asian patients. This multinational, 24-week, randomized study compared patient-led with physician-led titration of once-daily insulin glargine in Asian patients with uncontrolled type 2 diabetes who were on 2 oral glucose-lowering agents. Patient-led (n = 275) or physician-led (n = 277) subjects followed the same dose-titration algorithm guided by self-monitored fasting blood glucose (FBG; target, 110 mg/dL [6.1 mmol/L]). The primary endpoint was change in mean glycated hemoglobin (HbA1c) at week 24 in the patient-led versus physician-led titration groups. Patient-led titration resulted in a significantly higher drop in HbA1c value at 24 weeks when compared with physician-led titration (-1.40% vs. -1.25%; mean difference, -0.15; 95% confidence interval, -0.29 to 0.00; P = .043). Mean decrease in FBG was greatest in the patient-led group (-2.85 mmol/L vs. -2.48 mmol/L; P = .001). The improvements in HbA1c and FBG were consistent across countries, with similar improvements in treatment satisfaction in both groups. Mean daily insulin dose was higher in the patient-led group (28.9 units vs. 22.2 units; P<.001). Target HbA1c of <7.0% without severe hypoglycemia was achieved in 40.0% and 32.9% in the patient-led and physician-led groups, respectively (P = .086). Severe hypoglycemia was not different in the 2 groups (0.7%), with an increase in nocturnal and symptomatic hypoglycemia in the patient-led arm. Patient-led insulin glargine titration achieved near-target blood glucose levels in Asian patients with uncontrolled type 2 diabetes who were on 2 oral glucose-lowering drugs, demonstrating that Asian patients can self-uptitrate insulin dose effectively when guided.

Efficacy and Safety of Patient-Led Dosage Adjustments of Insulin Glargine: A Preliminary Report of Basal-Supported Oral Therapy for Japanese Type 2 Diabetes Patients

To evaluate the clinical utility for simple patient administered dose adjustment methods of insulin glargine during outpatient visits compared with a physician managed titration, changes in HbA1c and total daily dose of insulin were evaluated in 23 patients by dividing patients into physician-led (PL) group and self-titration (ST) group who were newly administered glargine basal-supported oral therapy (BOT) while continuing oral antidiabetic drugs at the discretion of their attending physician during regular outpatient visits. In the PL group, one month after initiation of glargine, HbA1c followed a declining trend, although this was not significant (P = 0.07), and decreased significantly after two and three months (P

Evaluation of Differences in Percentage of International Normalized Ratios in Range Between Pharmacist-Led and Physician-Led Anticoagulation Management Services

Background: The safety and efficacy of warfarin depend on maintaining the international normalized ratio (INR) in an established range. Objective: The purpose was to determine whether a coordinated pharmacist-led approach improved percentage of INRs in therapeutic range in comparison to a physician-led anticoagulation management service (AMS). Methods: A retrospective chart review was conducted for patients at a multisite primary care organization. INR data for patients receiving warfarin management by a physician were collected from December 1, 2009 to May 31, 2010. These were compared to INR results from December 1, 2010 to May 31, 2011, during which patients received warfarin management from a pharmacist. The primary end points were percentage of INRs within a goal range of 2.0 to 3.0 and an expanded goal range of 1.8 to 3.2 for the physician-led group versus the pharmacist-led group. Results: The percentage of INR results within the goal range (2.0-3.0) was greater among patients in the pharmacist-led group (n = .130) than the physician-led group (n = 96; 57.5% vs 50.0%, respectively; P = .0004). The percentage of INR results <1.5 (7.3% vs 5.1%) and >3.5 (11.4% vs 7.1%) was also statistically significant in favor of the pharmacist-led AMS, with P values of .03 and .0004, respectively. Conclusion: A pharmacist-led AMS improved the percentage of INRs in range, with significantly less out-of-range results.

Integrating into family practice: the experiences of pharmacists in Ontario, Canada

Abstract Aims and objectives This research examines the experiences of pharmacists as they integrated and adapted to meet the drug-related needs of family practice settings. Setting This research took place in physician-led group family medicine practices in Ontario, Canada. Each practice was in the process of integrating an on-site pharmacist. Methods Qualitative design using monthly pharmacist narrative reports (over the first 4months of pharmacist integration) and N-VIVO qualitative analysis software. Four independent researchers with varied professional backgrounds used descriptive thematic editing analysis to determine process and content themes. The analysis team created a draft of themes and received written feedback from each pharmacist. Key findings Four key themes emerged describing how pharmacists experienced the first several months working in family practice: (1) feelings: emotional challenges and victories; (2) establishing and building relationships: positive and negative experiences with physicians and staff; (3) learning new skills to contribute effectively and efficiently to patient care; and (4) strategies for integration: including practical demonstration of potential value to physicians to facilitate integration process. In addition, they identified a number of supports and constraints for integration. Conclusion The pharmacists' narratives demonstrate the challenges and rewards of the integration process. Adaptability and practical demonstration of potential utilization and benefit were crucial in physician acceptance of the pharmacist program. This description of the pharmacists' journey will be helpful for pharmacists, managers, policy-makers, researchers and educators as more pharmacists enter this type of primary care practice.

T EACHING ACLS S TROKE O BJECTIVES TO P REHOSPITAL P ROVIDERS : A C ASE-BASED A PPROACH

Objectives. To determine whether a case-based educational module would increase prehospital care providers' short-term and long-term knowledge about stroke and to compare the educational impact when the module was moderated by a physician versus an advanced cardiac life support (ACLS) instructor. Methods. A stroke module consisting of two case-based scenarios was administered to emergency medical services (EMS) personnel by either an ACLS instructor or a physician. Identical 25-question tests (based on 1997 ACLS prehospital stroke objectives) were administered before and after the module. Descriptive statistics were calculated by groups, and Wilcoxon tests were used to assess the significance of improvement in scores based on the paired data. Results. Two hundred six EMS personnel [112 (54%) emergency medical technician (EMT)-P, 91 (44%) EMT-B/EMT-I, and three (2%) other training levels] participated in the module, of whom 74 [30 (41%) EMT-P, 42 (57%) EMT-B/EMT-I, and two (2%) other training levels] participated in follow-up testing between six and seven months. Overall, there was a 32% improvement in test scores immediately after completion of the module (p < 0.001) and an 18% improvement at six months (p < 0.001). No significant difference in pretest scores existed between the physician-led and ACLS instructor-led groups (mean EMT-P pretest scores 69% versus 70% and EMT-B/EMT-I scores 55% versus 54%, respectively). There was no significant difference in short-term (p = 0.36) or long-term (p = 0.074) score improvements between the two groups. Conclusion. This case-based approach to EMS stroke education is effective and can achieve equal benefit when administered by a physician or an ACLS instructor.