Attending to power differentials: How NP-led group medical visits can influence the management of chronic conditions.

OBJECTIVE: In Canada, primary care reform has encouraged innovations, including nurse practitioners (NPs) and group medical visits (GMVs). NP-led GMVs provide an opportunity to examine barriers and enablers to implementing this innovation in primary care. DESIGN: An instrumental case study design (n=3): two cases where NPs were using GMVs and one case where NPs were not using GMVs, was completed. In-depth interviews with patients and providers (N=24) and 10 hours of direct observation were completed. Interpretive descriptive methods were used to analyse data. RESULTS/FINDINGS: Two main themes were identified: (i) acquisition of knowledge and (ii) GMVs help shift relationships between patients and health-care providers. Participants discussed how patients and providers learn from one another to facilitate self-management of chronic conditions. They also discussed how the GMV shifts inherent power differentials between providers and between patients and providers. DISCUSSION: NP-led GMVs are a method of care delivery that harness NPs' professional agency through increased leadership and interprofessional collaboration. GMVs also facilitate an environment that is patient-centred and interprofessional, providing patients with increased confidence to manage their chronic conditions. The GMV provides the opportunity to meet both team-based and patient-centred health-care objectives and may disrupt inherent power differentials that exist in primary care.

Using Group Medical Visits With Those Who Have Diabetes: Examining the Evidence.

The number of people with diabetes is expected to rise to over 592 million by the year 2035. Past work provides evidence that the conventional method of primary care delivery may not meet many patients' needs. An alternative to the conventional one-on-one appointment is care offered to a group of patients through group medical visits (GMVs). Group medical visits for diabetes have a positive impact on physiologic and self-care outcomes including improved HbA1c, blood pressure control and self-management skills. Less work has examined the impacts of GMVs on systems of care; however, evidence suggests improved primary and secondary prevention strategies and the potential for GMVs to decrease emergency room visits and hospitalizations. Additional work is needed to examine the effect of GMVs on patient reported quality of life, functional health status and cost-savings. Further work is also needed on which patients GMVs work best for and patient barriers to attending GMVs.

Complexities of Introducing Group Medical Visits With Nurse Practitioners in British Columbia.

In Canada, increasing numbers of people with chronic conditions have prompted calls for innovative approaches to delivering primary care. These approaches may include group medical visits (GMVs) and the introduction of nurse practitioners (NPs). We examined why NPs in the province of British Columbia were not using GMVs. This case study is part of a larger research project that examined the impact of GMVs with NPs for patients with chronic conditions. We completed open-ended interviews with seven NPs working in primary care. Interviews were audiotaped and transcribed. Data were analyzed using interpretive descriptive approaches. Three major themes emerged: (a) advantages of GMVs, (b) questioning the fit of GMVs in current practice contexts, and (c) navigating scope of practice and role constraints that affect NPs' ability to use GMVs. Power dynamics and hierarchies may influence NPs' ability to adapt to GMVs. Consideration of practice environments and structures that enable the NPs ability to diffuse and utilize health-care innovative care delivery methods is needed.

Group Medical Visits (GMVs) in primary care: an RCT of group-based versus individual appointments to reduce HbA1c in older people.

INTRODUCTION: Type 2 diabetes mellitus (T2DM) affects more than 1.1 million Canadians aged ≥65 years. Group Medical Visits are an emerging health service delivery method. Recent systematic reviews show that they can significantly reduce glycated haemoglobin (HbA1c) levels, but Group Visits have not been evaluated within primary care. We intend to determine the clinical effectiveness, quality of life and economic implications of Group Medical Visits within a primary care setting for older people with T2DM. METHODS AND ANALYSIS: A 2-year proof-of-concept, single-blinded (measurement team) randomised control trial to test the efficacy of Group Medical Visits in an urban Canadian primary care setting. Participants ≥65 years old with T2DM (N=128) will be equally randomised to either eight groups of eight patients each (Group Medical Visits; Intervention) or to Individual visits (Standard Care; Controls). Those administering cointerventions are not blinded to group assignment. Our sample size is based on estimates of variance (±1.4% for HbA1c) and effect size (0.9/1.4=0.6) from the literature and from our own preliminary data. Forty participants per group will provide a ß likelihood of 0.80, assuming an α of 0.05. A conservative estimation of an effect size of 0.7/1.4 changes the N in the power calculation to 59 per group. Hence, we aim to enrol 64 participants in each study arm. We will use intention-to-treat analysis and compare mean HbA1c (% glycosylated HbA1c) (primary outcome) of Intervention/Control participants at 12 months, 24 months and 1 year postintervention on selected clinical, patient-rated and economic measures. TRIAL REGISTRATION NUMBER: NCT02002143.

Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis.

BACKGROUND: Group medical visits, whereby health care professionals meet with groups of patients who have the same disease, have been introduced in primary care as a way to meet the increasing demand for health care delivery to patients with chronic diseases. We performed a systematic review and meta-analysis of the evidence on the effectiveness of such visits for patients with diabetes. METHODS: We conducted a systematic review of all relevant studies published from 1947 to February 2012 identified in a search of electronic databases and grey literature. We included randomized controlled trials (RCTs) and observational studies published in English that included patients aged 16-80 years with type 1 or 2 diabetes and that had group medical visits as the intervention. These studies were assessed for methodologic quality. We included data only from the RCTs in the meta-analysis. RESULTS: Of the 94 studies identified, we selected 26 that met our inclusion criteria, 13 of which were RCTs. Group medical visits had a positive effect on clinical and patient-reported outcomes, with significant reductions in glycated hemoglobin (HbA1c reduction -0.46%, 95% confidence interval -0.80% to -0.31%). We were unable to assess the effect of group medical visits on processes of care because of an insufficient number of RCTs that reported on this outcome. INTERPRETATION: Group medical visits for patients with diabetes were found to be effective in terms of reducing HbA1c. The results of our meta-analysis suggest that wider implementation of group medical visits for patients with diabetes will have a positive effect on patient outcomes.

Strategies for moving towards equity in recruitment of rural and Aboriginal research participants.

INTRODUCTION: Equitable recruitment strategies, designed to ensure improved opportunities to participate in the research, are needed to include First Nations (FN) communities. The purpose of this article is to report on a set of successful strategies trialed with rural and FN communities in Canada. The strategies discussed were designed as part of a larger mixed-method study examining the effectiveness of Group Medical Visits (GMVs) on the quality of primary healthcare (PHC) in both FN reserve and northern communities in British Columbia (BC). METHODS: Community partners and the study's decision-maker partners helped to identify and recruit primary care practices and reserve communities who were offering GMVs. Eleven communities (6 rural and 5 FN reserve) within the Northern Health Authority, BC participated in the study. Participants completed a survey either in person or via telephone. Content analysis was conducted on team meeting and field notes, focusing on issues related to the data collection process. Financial analysis was conducted on monetary resources spent on recruitment efforts in the various communities. Data were recorded regarding the number of times potential participants were contacted and mode of interview. Descriptive statistics were used to examine whether there were differences by mode of data collection, gender, and FN status. Logistic regression was used to examine whether FN status remained statistically significant after controlling for sex, education, employment status, age and health status. RESULTS: Once people were contacted, participation rate was 68% with 269 (n=90 men, n=179 women) people. Of those who participated in the survey, 42% were from FN communities. Content analysis revealed two overarching categories: (1) communication and coordination of the geographically dispersed research team and participating communities was maintained using synchronous and asynchronous methods; and (2) flexibility was needed to tailor recruitment strategies. Financial resources required to achieve equitable recruitment across these communities can cost up to 17 times more than travel to sites accessible by a direct flight or car. The farther away from Prince George (BC's capital in the north), the more resources were needed to ensure equitable recruitment from a community. Community partners played a critical role in recruiting potential participants. Team members, particularly those from urban areas, require support to successfully navigate working in small northern communities. CONCLUSIONS: Achieving equity in recruitment requires flexibility, trusting partnerships within each community and regular communication among the research team. A significant portion of time and resources needs to be allocated towards travel to these communities. While achieving equity in recruiting research participants poses a number of challenges, including greater costs, research that ensures participation opportunities for rural and FN communities is likely to better inform effective strategies to meet the needs of these communities.

Incorporating a health policy practicum in a graduate training program to prepare advanced practice nursing health services researchers.

Health services research benefits from the active engagement of researchers and policy makers from generation through to application of research-based knowledge. One approach to help graduate students learn about the policy world is through participation in a policy practicum. This is an opportunity to work for a defined period of time in a setting where policy decisions are made. This article focuses on the integration of the policy practicum into graduate nursing education for advanced practice nurses. Ten graduate students and two postdoctoral fellows who had recently completed their practicums and three policy makers who had recently supervised students in provincial, federal, and international practicum projects were invited to submit a narrative about the experience. Based on qualitative analysis of the narratives, this article outlines objectives of the practicum, the policy practicum journey, student learning, and finally, the benefits and challenges of the experience.