No Easy Answers in Bioethics Podcast

Activating and Empowering Patients: Hart-Davidson, Kelly-Blake, and Olomu – Episode 15

May 30, 2019 Bill Hart-Davidson photoKaren Kelly-BlakeAde Olomu photo

How can shared decision-making tools and evidence-based guidelines be used to ensure that every patient receives the best care possible? How can patients be activated and equipped to interact with their provider and manage their health condition? In this episode, three Michigan State University researchers—Dr. Bill Hart-Davidson, Professor in the Department of Writing, Rhetoric, and American Cultures, Dr. Karen Kelly-Blake, Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine, and Dr. Ade Olomu, Professor of Medicine in the Department of Medicine—discuss a shared decision-making tool they developed called Office-GAP, Office-Guidelines Applied to Practice. Together they discuss the origins of the project, and the results so far in improving outcomes for patients managing chronic illness by using a simple checklist to get patients and providers on the same page.

This episode was produced and edited by Liz McDaniel in the Center for Ethics. Music: "While We Walk (2004)" by Antony Raijekov via Free Music Archive, licensed under a Attribution-NonCommercial-ShareAlike License.

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Episode Transcript

Liz McDaniel: Hello and welcome to another episode of No Easy Answers in Bioethics, the podcast from the Center for Ethics and Humanities in the Life Sciences at the Michigan State University College of Human Medicine. Today we are joined by three Michigan State University researchers, Bill Hart-Davidson, Karen Kelly-Blake, Ade Olomu, who have developed and implemented a shared decision-making tool called Office-GAP, or Office-Guidelines Applied to Practice. Together they discuss the origins of the project, and the results so far in improving outcomes for patients managing chronic illness by using a simple checklist to get patients and providers on the same page.
With this episode we wrap up this season of No Easy Answers in Bioethics, and we’ll be back with new episodes after the summer. On behalf of the Center for Ethics, we thank you so much for listening! Now, on to the episode...

Bill Hart-Davidson: Why don't we begin by we'll each say our name, and just describe our role and position here at MSU. So, Ade, do you want to start?

Ade Olomu: Yes, my name is Ade Olomu. I am faculty in the Department of Medicine, Professor of Internal Medicine, and the Vice Chair for Research in the Department of Medicine, College of Human Medicine. And also I'm the Faculty Excellence Advocate for the College of Human Medicine.

BHD: And Karen?

Karen Kelly-Blake: I am Karen Kelly-Blake. I'm an Assistant Professor in the Center for Ethics and Humanities in the Life Sciences and the Department of Medicine here in the College of Human Medicine at Michigan State.

BHD: And I am Bill Hart-Davidson, and I'm a Professor in the Department of Writing, Rhetoric, and American Cultures which is in the College of Arts and Letters, and in addition to that I'm also the Associate Dean for Research in Graduate Education in the college. So, today we're here to talk a little bit about our collaborative research around shared decision-making, and maybe that's a place to begin for all of us. So I wonder, Ade, would you talk about how did you first become interested in the topic of shared decision-making as part of your medicine practice?

AO: Okay, thank you for that question. When I joined MSU as a faculty in 2000, I met with my mentor Dr. Holmes-Rovner, a health services researcher and one of the leaders in shared decision-making. She's well known nationally and internationally for shared decision-making, and she got me kind of very interested in the field. I got interested in the concept of using shared decision-making to improve prevention of heart disease for patients with cardiovascular disease. I thought that if you apply shared decision-making in clinical practice, get the patient engaged, and the patient to discuss their condition, which has been shown that it improves outcomes. Okay, and my research proposal was to look at how we can breach the disparity gap in the care of patient with cardiovascular disease. So this population, low-income population, minority population, they are not typically known to be engaged in shared decision-making. So I think if we improve shared decision-making for this population, we are likely to improve their outcome, get them activated and engaged in their care. So using the model of shared decision-making, we can get our patients, is an important strategy that we can use to improve outcomes for all patients, actually, not just minority and low-income populations.

BHD: And Karen, how about you, when did, when and where in your professional life did shared decision-making become an interest?

KKB: So my story begins with Dr. Holmes-Rovner as well. I began working with her as a graduate assistant, and at the time I was trying to figure out what I was going to do for my dissertation research. I was in the medical anthropology program here at MSU, and I was working with a project of Dr. Holmes-Rovner's that had to do with benign prostate disease. So I became interested in decision-making in men's health and how men were making decisions about treatments for benign prostate disease, and specifically how they were incorporating their thinking about their own masculinity and their sexuality, and how that impacted their decisions about treatment. So, that's where my interest began.

BHD: Yeah that's a very anthropological way of seeing it, right?

KKB: Yes.

BHD: So you had a kind of a disciplinary orientation to it in the same way that Ade did, but different. My story is the same. [Laughter from all] That is, I met Dr. Holmes-Rovner at a meeting, at, of the Michigan Fitness Foundation, and we were called together to talk about issues related to public health at that meeting. But we were quick to find some shared interests in this idea of allowing providers and patients to find common ground, and in particular around the treatment for chronic illness. So my own interest became entwined with that when I was talking with her, and she said, why don't you come and meet this fantastic research team and I have. And I guess the rest is history, right. We've, we've now been working together we realize almost 10 years.

KKB: Yes.

AO: Yes.

BHD: That's exciting.

KKB: It is.

AO: It is, it really is.

BHD: The big project that we have had, that I've had the privilege really of working on for a shorter amount of time with all of you, but has been the majority of time we've had together, has been called Office-GAP. And Ade, you're really the mastermind behind Office-GAP, do you wanna talk a little bit about what it, what that stands for and what the origins of that project were?

AO: Office-GAP stands for Office-Guidelines Applied to Practice. We want to ensure that evidence-based guideline is applied during office visits for every patient that sees the provider. So because if you provide evidence-based care for a patient, their outcome is likely to be better than if you give them what evidence has not shown that really works for patients. So but the difficulty has always been how do we apply, how do we implement programs that will enable physician and patient to receive care that is best for the patient. Based on evidence that we have at hand. So that is how we've coined "office guidelines applied to practice." And then if we say what is office guidelines applied to practice? It is a patient activation program. We want to activate patients. We bring patients together during a group visit. We tell them about their disease condition. We let them understand their medication and the side effects of their medication. We teach them how they can interact with their doctor during the regular office visit. Ask questions, participate, get engaged with your, with your provider on your clinical condition. Equip them with self-confidence and self-efficacy so that the patient can feel that I can really manage my condition by myself because I understand what my medications are meant to do. So we try to achieve that by communicating and training the patients. At the same time we also train the provider, get them ready for an activated patient. The provider is then have to set goals with the patient, how to ask questions with the patient, and then we'll provide a one-page checklist, and this checklist is evidence-based. It contains medications, nutrition, diet, and counseling that the patient need that will help them to improve their care. The population we are studying are patients that have diabetes or have heart disease. And what we want to really to do is to prevent cardiovascular disease because we know cardiovascular disease is number one killer or number one cause of the morbidity and mortality among diabetic patients. Rather than being the blood sugar really, it is the heart disease that really is number one leader cause of their mortality. So we want to make sure we prevent them from having cardiovascular disease in the Office-GAP program.

BHD: Yeah, the fascinating thing for lots of people, particularly if they haven't had a lot of experience with this kind of a patient activation and shared decision-making protocol, is we do really have to work with both sides. We have to, it involves a change in practice for the providers as well as a change in attitude with the patients. So Karen maybe you can talk about when we work with providers, what are the changes that tend to happen there? And what do you see Office-GAP doing for a clinical practice that helps this along?

KKB: Well I think for the providers, it's a way of letting them understand that although oftentimes in the research, time is the most often-cited barrier for engaging in shared decision-making. I think what Office-GAP does is it allows providers to see that it can still be done, and done well, and not take any more time than what's allowed for that office visit. I think the checklist itself is an amazing tool because it acts as a prompt for them, and for the patient, that there is an understanding that a shared decision has to occur here. And we're going to walk through it, and we're going to understand the reasons for it, and we're going to come up with a plan. So I think for the providers, as we engage with them, they can see the importance of shared decision-making, and I think they also see the value in it because they see that their patients are more adherent to the medications. And I think that is a key factor.

BHD: Yeah they really start to build confidence when they see it working.

KKB: Absolutely.

BHD: I want to come back and talk just a moment about that checklist, because after the group visit, that's the really interesting piece of Office-GAP that allows the process to work well. And the checklist is what it sounds like. It's a simple list, and it gives people prompts to talk about when they have a patient encounter, when they have their doctor visit, and each time they go in they use the checklist. So they are reminded, as Karen said, that these are the things to discuss. And it does something else, especially in the kind of clinics where we've especially been focused on, which is that it helps to standardize what happens in those visits so that everyone gets the same kind of care. So do you want to talk, Ade, about the other challenge you, you've pointed our team toward which is where we implement Office-GAP in the FQHCs.

AO: Yes, FQHC we know, Federally Qualified Healthcare Centers, provide care for minority and low-income populations. A population that really are not participating in shared decision-making. So one of the challenges is that they don't understand most of their medication, why they are taking it, why they should not taking it. In the checklist, the patient asks the provider, "Am I on aspirin?" The provider has to say yes or no, and if no, why. Because evidence have shown for example that aspirin can reduce your cardiovascular risk by up to 25 percent. And if a patient is diabetic or have cardiovascular disease, have had a myocardial infarction, he should be on aspirin. If he is not on aspirin there must be a reason. So the patients ask why am I not on it. The provider can say because you bleed, or oh, I forgot. Most time is because they just forgot among all the other things they have to take care of. So the, this checklist kind of bring it forward for the provider and the patient to discuss. Then are you on cholesterol reducing medication, are you on Lipitor or statin? The patient can say yes or no, and if no, say why. Then they both understand each other and just drop it out of the list. And then the providers says okay, I'm going to put it back in there. So using that checklist, every patient is brought in contact with evidence. And all the medications will be, and if they follow it, and both of them have to sign the checklist at the end of the visit, which means discussion has occurred between the two of them, and we have agreed that this is what we are going to do. And then we give the patient a copy to take home to serve as a reminder for them. So it's a reminder for the provider, a reminder for the patient, and both of them be on the same page.

BHD: I think a huge component of that is just making a care plan very clear and explicit.

AO: Yes.

BHD: But the other thing that's always been remarkable to me is that power component. That it shifts the power dynamic in the, in the conversation a little bit so that the patient does feel empowered to say, hmm how come I'm not doing something for this category? Why am I not taking aspirin? So, Office-GAP has origins and another project-

AO: Yes.

BHD: -That you were familiar with and that you got to work on.

AO: Mm-hmm.

BHD: Which was a guidelines applied in practice in the hospital.

AO: Yes. Yes, the Office-GAP actually was developed as an inpatient tool by American College of Cardiology project that was led by Dr. Kim Eagle of University of Michigan. Here he designed the GAP, guideline applied to practice, the GAP in hospital for patients with acute myocardial infarction. He also developed a checklist and made sure that everyone that come with acute myocardial infarction or a heart attack is based, is on this medication. Aspirin, beta blocker, Angiotensin-converting inhibitors, and the statins, all are listed on the one single page. And then there is a checklist that everybody saw it. And by using that tool, he was able to reduce mortality by up to 20 percent or more for Medicare patients in one year doing that project. So we saw that the use of a simple checklist of the Office-GAP program in hospital really improved mortality for patients that really use the guideline, compared to those that were not using the guideline. So, from there we thought that okay, why can't we adapt this to outpatient practice? We know outpatient care is different from hospital care, so we have come with ways in which we adapt it, and how we can implement it in such a way that both patients and provider would agree to use it and participate in it.

KKB: And if I might add, I think Dr. Olomu is not given herself as much credit as she should, because once she implemented Office-GAP program in outpatient practice, and in Federally Qualified Health Centers in her earlier work, you all got like a greater than 90 percent completion rate of that checklist.

AO: Yes.

KKB: Between the providers-

AO: 97 percent.

KKB: Amazing.

BHD: Yeah that, that is almost unheard of when you have a, a practice change like that. To see that kind of adherence.

AO: Yes.

BHD: But it is a combination of, there's, there's almost a convenience factor for the providers.

AO: Yes.

BHD: Because it's all written down in one place.

KKB: Yes.

AO: Yes.

BHD: And then there's this confidence that comes when they see that it gets results.

AO: Yes.

BHD: So you got really, you got really good results. You first tried this in a health center in Ingham County, is that right?

AO: Yes, yeah.

BHD: Do you want to talk about that first trial, the first time you implemented it and what happened?

AO: Yeah the first time we tried it, cause that was the first thing we tried to do. The first question was can we implement in outpatient. If we can, does it make any impact, does it improve outcome or change anything for patients. Those were the first two questions that we wanted to answer. And then so what we did, we find so far, we demonstrated the feasibility of Office-GAP in clinical practice. That it can do it because 97 percent, as we said before, of patients at intervention center use the GAP tool during their visit with their provider. The Office-GAP was found to improve secondary prevention of heart disease. One, it improved their medication use, the rate of use in using aspirin, beta blocker, aspirin, and ACE inhibitor increased. And then we also demonstrated that blood pressure control was more if patient used the Office-GAP intervention. So all these have, all these outcomes have been published in peer-reviewed journals. So Office-GAP has improved patient satisfaction and also led to increased communication and confidence in their decision making with their provider. So patients that really participate in Office-GAP really want to continue, because they really are finding benefit. They are equipped, they are empowered to be able to participate in their care during the office visit.

BHD: So, Karen I know you've also had a chance to talk about Office-GAP in conjunction with other sorts of shared decision-making tools. Maybe you would like to talk a little bit about what Office-GAP is, or how it's been received in share decision-making, how does it compare to other shared decision-making projects that you've worked on?

KKB: How does it compare... to other shared decision-making projects. That's a very difficult question for me.

BHD: Yeah?

AO: Yeah.

KKB: And I'm not sure how to respond.

AO: But I can, I can help, but I can help you actually. What makes Office-GAP stand out as, among shared decision-making. The use of the brief patient and physician training in shared decision-making. It's a 90-minute training for physicians. And then the patient come into a group visit about 90 minutes as well. Very brief, but very effective. It makes it stand out. Number two, the use of one-page checklist based on evidence in real time during office visit with their provider make it to be very unique. And the Office-GAP intervention getting the patient and provider on the same page is also a very unique.

KKB: Thank you, Dr. Olomu. [Laughter]

BHD: That was great.

KKB: Because I had no idea how to respond to that question.

BHD: Well I know you built some — so I wanna dig a little bit.

KKB: [Laughs]

BHD: Because, you're, now you're the one selling yourself short. I mean you built some quite elaborate shared decision-making resources in some cases that are, you know, they're interactive. You fill out this and you go, they're an online thing. This is kind of just, you know, it's just a piece of paper.

KKB: Yeah.

BHD: So-

KKB: So yes. So I have been engaged in other SDM projects with my collaborators down at the University of Michigan, with Dr Masahito Jimbo in the Department of Family Medicine where we've been working on shared decision-making in colorectal cancer screening. Where we were using an interactive decision aid, and whether or not that had any role in how people were making their decisions. We found that an interactive decision is not necessarily what you need. As we know with Office-GAP that that little paper checklist works incredibly well. And yes, in the work that I continue to do with Dr. Holmes-Rover we developed decision aids having to do with stress testing.

BHD: Yeah.

KKB: And so that was a remarkable process to work through that, to develop it from the very beginning and get out a completed product. So, yes, I have been involved in those-

BHD: You have a lot of expertise.

KKB: -Processes, yes. But I guess I was just sort of thrown by the question, it didn't click.

BHD: Sure. [Laughter] Well, again I am, I'm always impressed that, because we have a technological component that we've now begun to add into Office-GAP and I'll talk about that in a minute. But, one of the things that we're always quick to caution people is to say, it's not about necessarily incorporating the latest or fanciest technology. The real, the real effective mechanism here is creating a kind of feedback loop between the doctor and the patient that doesn't exist without this. this process. And sometimes the process, all it needs is a little piece of paper.

AO: Yes.

BHD: But one of the things I'll talk about that we've added recently to Office-GAP is a third component, and that is text messaging.

AO: Yes.

BHD: So the idea there is as Ade mentioned there's a, there's a group meeting at the beginning, and then there is a checklist at the doctor visit, but then it might be three months, sometimes six months between visits. And so one of the things we're interested in, in making sure is that the effects of these patient activation and, and shared decision-making with the care plan are maintained over time because these are chronic conditions-

AO: Yes, exactly.

BHD: -That people are, are dealing with. And so what we also have added to it is text messaging.

AO: Yes.

BHD: And the idea there is in between visits, patients will get a couple of different kinds of messages that act as reinforcement-

AO: Yes.

BHD: For what's happened prior.

AO: Yes.

BHD: They'll get some information, a little bit like an education component.

AO: Reminders.

BHD: Yeah, some reminders, either for medication or office visits. And sometimes they get questions or interactive prompts. And the idea is to keep them engaged and also to remind them of the, of the components of that care plan that they came to an agreement with.

AO: Good.

BHD: And so far, we have a, we have a clinical trial pilot that we've, that we've had. And our results have been pretty good with the with the phone. We have, similar to, to the shared decision-making protocol, one of the things we measured is whether people respond well. And, to see if it's feasible. And what we find is with simple text messages about one a day, it's very usable, and people actually like it. One of the more interesting findings has nothing to do with the outcomes but it is that text messaging is a preferred way that most of our participants wanted to interact with their doctor.

AO: Yes, yeah.

BHD: That was a surprise to me.

AO: But one thing we are find in our pilot study is that text messaging alone, combined with GAP, text messaging and GAP combined work better than text messages alone. So we find that if you combine GAP with text messaging, you have a better outcome compared when you add mobile health or text messaging alone. So we find that patients are more activated, they use their medication more, they have more self-efficacy if you combine them all. It is not really surprising because you'll find that the group visit aspect and interaction with their provider during office visits is really an important mover for patients. Rather than just text messages alone. That really does not really get them face-to-face engagement with their provider. So it's not surprising that even the AHRQ review studies have shown that multiple mobile ... test that really did not impact outcome so much as they expected. The reason being that, yes, you have to have the patient and physician on the same page interacting, and also activating your patients, equipping them, improving their self-efficacy before they can really participate more using the text messages. So, text messages combined with Office-GAP is really closed the loop, how our patients actually describe it.

KKB: And I think one of the things we've talked about before in our research meetings is that adding the text messaging to Office-GAP is a way of sort of extending that patient/provider being on the same page. It extends it in a way that either alone doesn't do. But together, as you said, Dr. Olomu, it sort of closes that feedback loop.

BHD: Yeah, and I'm particularly excited about this finding because it does, it does a couple of things for us. One is that it does reinforce the idea that the feedback loop is the thing that's causing the effect, and not just one form of message or another, and maybe not even the content of those messages. But the other thing is something that's much more tied to another issue that I know we want to talk about of medical disparities. And that is, mobile phone texting is often seen as an inexpensive option.

AO: Yes.

BHD: And so its attraction is because it's easy to send a message from a lot of these E.M.R. systems, people will just sign up their patients to get text messages. But what we're trying to send is a message of caution to say, that's not gonna do much.

AO: Yes.

BHD: Don't, don't just settle for the default low-cost option. Because just getting barraged with text messages by themselves is probably not going to move the needle.

KKB: And when you consider our particular patient population, FQHCs, you can't also make the assumption that there is no cost associated with receiving and sending text messaging. So that also lends to the caution.

BHD: Absolutely. So let's, let's talk a little bit about patient population and another goal that we have that really is a big motivator for our research, and that is we not only want to help people get healthier and treat chronic illness, but we also want to, to aim at a larger social problem of medical disparities. So, Ade, I know you have some facts about this, because you talk about this quite a lot. But what do we mean when we talk about medical disparities let's say related to heart disease and diabetes.

AO: Yeah, we, we so far we know that African-Americans are 30 percent more likely than whites to die prematurely from heart disease. And we also know that African-Americans are twice as likely than whites to die prematurely from stroke. So there's a, the morbidity and mortality from cardiovascular disease is really high among the minority and low-income population. And we also already know that cardiovascular disease morbidity and mortality is number one killer. One in three Americans die from cardiovascular disease. But this is more even so among the minority and low-income population. What our program can do is to leverage this, the care that everybody receives. If everybody receive the same care for the same condition, their outcome is likely to be the same. So we want to use our intervention to close the cardiovascular disparity gap in the care of patients with cardiovascular disease. That is what we're after, we want to close that gap. By giving everybody the same evidence-based care any time they visit their provider in the clinic.

BHD: Yeah, one of the, one of the things that Office-GAP aims at changing soonest is the adherence-

AO: Yes.

BHD: -Of patients to their medication. And I know that is in particular a factor here that is hypothesized as one driver of the gap.

AO: Yeah. One of our co-investigators in University of Michigan, Dr. Michele Heisler has also published that lower medication use or lower medication adherence among U.S. African-American contribute to the disparity in the blood glucose control. So the rate in which the blood glucose, the blood sugar is controlled for a diabetic has been linked to the rate in which they are adhering to their medication. There, so, if Office-GAP can help to improve the rates of compliance or medication adherence, it's going to help to improve the rate of their blood pressure control, their blood sugar control, and going to decrease the rate of morbidity and mortality, decrease the rate of heart disease or heart myocardial infarction, or having a stroke.

KKB: But I think what it also does is not only helps patients improve their medication adherence, it also helps patients understand why they need to take these particular medications. Because as you indicated earlier, often times they really don't understand why they need to take a particular medication.

AO: Yes.

KKB: So Office-GAP also then improves that communication that was previously lacking.

AO: Yes.

KKB: And communication errors are one of the prime drivers of medical errors.

AO: Yes.

KKB: So if we are successful with Office-GAP, that we can not only improve medication adherence but improve the communication around why it's important to adhere to these medications, then I think we are doing a potentially phenomenal job in helping improve health outcomes in these areas.

AO: Yes.

BHD: I agree I think one way I described especially the Office-GAP checklist, but really the whole program to somebody who's in the sort of elevator speech mode, is we kind of give people a user guide, a user manual for their medications. You take this for this.

AO: Yes.

BHD: This for this. And then every visit you say, okay, you're taking this for this, let's see how that went. Okay, is your blood pressure lower? Yes, that's good, that one's working. If it wasn't then we would have an opportunity to have a conversation and we would say, hmm, we don't see this number coming down like we had hoped for, and then the doctor might be able to ask a question like, are you taking it every day, are you taking it at the same time? And you often learn, don't you, Ade, in those, in that conversation you often learn, oh, the patient had a different idea. [Laughter]

AO: Yeah, about their medication. They think aspirin that they are taking is meant for headache. Instead of preventing their heart disease. So they don't take it every day, they only take it only when they have headache. Whereas if you are using it for the prevention of heart disease, it's a baby aspirin, it's a 1 milligram every day. Not only when you have headache. So all of this kind of misconception are corrected during the group visit in the Office-GAP program.

BHD: Yeah. And, and we get, we get a lot of that conversation that might account for non-adherence.

AO: Yes, yes.

BHD: So, one, another one that we hear a lot is, well I stopped taking my blood pressure medication because it made me get up and go to the bathroom too much.

AO: Yes.

BHD: But then, once a doctor knows that you can have an conversation about maybe a different option-

AO: Yes.

BHD: -That still brings the blood pressure down, but doesn't have that side effect.

AO: Exactly.

BHD: So when we talk about altering the patient and provider dynamic so they feel more, maybe more trust, and also more openness, those are the kind of conversations that result.

AO: Yes, yes, exactly. And also patient, with, in Office-GAP during the group visit we tell them their goal number. This is what your blood, if you're a diabetic patient, your blood pressure should be below 130 over 80. If you have diabetes, your A1C should be less than 7. We equip them with numbers. And so when they go to see their doctor, my blood pressure is 150 over 90, what are we going to do about it.

BHD: That's great.

AO: So the patient is now empowered to ask questions. Okay, my A1C is 9, what, are you going to increase my insulin or change my medication? Patients are taught during the group visit how to get engaged and how to ask questions. And because they now, they know their goal number, their target number. Many of them before they come to the Office-GAP don't know anything about their target goal. But when we equip them with their target goal number that is ideal that will improve their outcome, when they go to visit their doctor, that the first question they ask. One patient actually told me that before when he visited doctor in the office, she's always very quiet, never talk. Because he didn't know what to ask, doesn't want to appear stupid. But after the group visit with Office-GAP, said, when I visit my doctor I don't stop talking more. [Laughter] He goes I talk like a parrot. [Laughter]

BHD: Yeah that's, those are great. And that's another thing I think that accounts for why the providers like it. Because it really changes the quality of the interaction that they have too. There's nothing better I'm sure as you, you'll notice when you're talking with patients then when they take responsibility for their own-

AO: Yes.

BHD: -For their own care.

AO: Definitely.

BHD: So, the exciting thing is we have some things in the works coming up. We'll talk a little bit maybe about what's around the corner for us. We have a grant that we've submitted to expand our clinical trial, if that's successful we'll, we'll have the process in six clinics across the state. But we also have some other people using Office-GAP.

AO: Okay.

BHD: Do you want to mention who else has contacted you?

AO: Oh yeah, we, University of North Carolina and Duke University. They have contacted us that they want, they read about it in the literature, what we have done and the outcome, and the success of the program. So they are trying to use the Office-GAP to control blood pressure in their Federally Qualified Healthcare Center. As far as that in Duke University and North Carolina, Federally Qualified Healthcare Centers are also using it. So we are excited about this because if in our randomized control trial, we can prove the effectiveness that we want to determine, how effective is the impact of our program, and to want to determine cost effectiveness, what is the cost of implementing it, that's what we want to do in the grant that we have applied for. So can determine the effectiveness and the cost, then this can be spread widespread. The good thing about Office-GAP is that it can be used actually as a model for any chronic condition. It doesn't have to be cardiovascular disease alone. It can be, the program can be used for patients with asthma, chronic kidney disease, blood pressure control, any chronic condition, Office-GAP intervention is applicable.

BHD: Yeah it's really a very lightweight process in that it's a little bit of training-

AO: Yes.

BHD: -A bit of an investment in time for the initial group visit, and then a checklist each time, which often can be part of a care plan that's in the E.M.R.

AO: Yes.

BHD: So it doesn't really ask a lot of the practices to implement. And that was by design.

AO: Yes, that was the design. We wanted to design it to be very simple intervention, not interfere very much with the workflow of the provider, and yet very highly impactful.

BHD: It's, it is one of the big questions that we get. Maybe from a policy standpoint, is if we do this, will it save money. The fear as Karen mentioned that it will take too much time to implement shared decision-making that will cost money. But we really think there's some possibility here that with improved care, and certainly with improved outcomes, and in a large system it can save quite a lot because most of the cost in those kinds of scenarios comes from adverse events from untreated chronic illness. Karen, do you wanna talk a little bit about where folks can read more about Office-GAP? Do you want to mention something that we've, some things that we've done?

KKB: So we have published in several different journals, and I think we will be providing links to those references with this podcast as it goes online. But of course for those people who want more information and would like to perhaps consider using this model and implementing it in their own research, they should contact Dr. Olomu here at Michigan State University. And I believe we should be providing her contact information, but I guess, are you okay with me divulging your e-mail? So also you can contact Dr. Olomu at Olomu, O L O M U A, as an apple, at MSU dot edu. So she will be happy to respond to any inquiries that you may have about our project and our future work.

BHD: Yeah we really are excited if you are interested in implementing it in your own setting and evaluating it. We'd love to see that.

AO: Mm-hmm, very good.

BHD: Thank you!

AO: Thank you very much.

KKB: Thank you very much.

LM: Thank you for joining us today on No Easy Answers in Bioethics. Please visit us online at for full episode transcripts and other resources related to this episode. A special thank you to H-Net: Humanities and Social Sciences Online for hosting this series. This episode of No Easy Answers in Bioethics was produced and edited by Liz McDaniel in the Center for Ethics. Music is by Antony Raijekov via Free Music Archive.