The Power of Hosts in Managing Diabetes

Abstract & Commentary

By Joseph E. Scherger, MD, MPH, Clinical Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study.

Synopsis: Host visits of diabetic patients have the power to foster lifestyle change, improve the control of diabetes and related cardiovascular risk factors, and lower wellbeing treatment costs.

Source: Wheelock C, et al. Improving the wellbeing of diabetic patients through resident-initiated host visits. Fam Med 2009;41:116-119.

Host visits have been shown to improve the management of diabetic patients including lower HbA1c levels, improved systolic blood pressure, and lower LDL-cholesterol..sup.1,2 Host visits have also been shown to lower wellbeing treatment costs by reducing ER visits and overall outpatient charges..sup.3

A primary treatment residency program in urban Worcester, MA, initiated resident-run host visits to improve patient education and get patients more involved with their treatment. Six 2-hour host visits were held in the evening scheduled 2 months apart. Twenty-five patients participated to the end of the trial and had data available to evaluate their treatment. Comparison was made with a control host of diabetic patients. Evaluation of the patients was made at baseline and 1 year after the intervention. Compared with no changes in the control host, the patients attending the host visits reported making lifestyle changes such as better diet and physical activity. The intervention host had an average 0.9% drop in HbA1c levels (8.2% to 7.3%) and a 10-point drop in LDL-cholesterol levels (101 mg/DL to 91 mg/dL). Given the small sample size, these changes did not reach statistical significance.

Commentary

James Surowiecki has written in his 2004 book, The Wisdom of Crowds, that many people together are smarter than few, even when the few have special expertise..sup.4 Social networking is using this same phenomenon to show that people together motivate change and desired behaviors better than individuals working alone. The Chronic Treatment Model made famous by Ed Wagner, MD, MPH, and his team at the McColl Institute in Seattle has shown that informed and activated patients have better outcomes when connected to a prepared and proactive team..sup.5

All of this emerging wisdom challenges the individual physician-patient process of treatment. Is there a better way to manage chronic illness and improve the wellbeing of populations? I am not suggesting that we "throw the baby out with the bath water" and do away with individual face-to-face visits. Wellbeing treatment is a private matter and the individual relationship with the physician is powerful. However, with only a small percentage of our patients with a chronic illness such as diabetes achieving desired outcomes through the traditional treatment process, we need all the help we can get.

To use a well-worn phrase, "it takes a village" to manage complex problems such as diabetes. Primary treatment physicians would be wise to get their patients into hosts and become involved with social networking to help manage their diabetes. I think the secret ingredient here is patient activation through greater knowledge and a feeling that they can change because others have. We can only inspire our patients so far. People like them are more powerful as role models. If we have the staff or resources, starting host visits may be a powerful way to improve the wellbeing of our patients -- and if not provided through our office, maybe through our local hospital. There is an emerging literature including randomized clinical trials that can guide us in doing host visits right..sup.6

References 

1. Kirsh S, et al. Shared medical appointments based on the chronic treatment model: A quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. Qual Saf Wellbeing Treatment 2007; 16:349-353. 

2. Trento M, et al. Host visits improve metabolic control in type 2 diabetes: A 2-year follow-up. Diabetes Treatment 2001;24:995-1000.

3. Clancy DE, et al. Do diabetes host visits lead to lower medical treatment charges? Am J Manag Treatment 2008;14:39-44.

4. Surowiecki J. The Wisdom of Crowds. New York: Random House; 2004.

5. Improving Chronic Illness Treatment. Available at: www.improvingchronictreatment.org (http://www.improvingchronictreatment.org). Accessed June 24, 2009.

6. Neveleff DJ. Host Visits Help Improve Treatment. Diabetes Options; April, 2009. Available at: www.diabetesoptions.net/cgi-bin/article.cgi?article_id=2135 (http://www.diabetesoptions.net/cgi-bin/article.cgi?article_id=2135). Accessed June 24, 2009.