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Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review

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Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review (July 2012)

Principal Investigator: David Edelman, M.D.
Co-Investigators: Jennifer R. McDuffie, Ph.D. Eugene Oddone, M.D., M.H.Sc. Jennifer M. Gierisch, Ph.D., M.P.H. John W. Williams Jr., M.D., M.H.Sc.
Research Associate: Avishek Nagi, M.S.
Medical Editor: Liz Wing, M.A.

Evidence-based Synthesis Program (ESP) Center
Durham Veterans Affairs Healthcare System

Durham, NC; Department of Veterans Affairs; July 2012

Download PDF: Complete Report, Executive Summary, Report, Appendices

Background

The most successful health care systems offer ready access to high-quality primary care�an approach that is embedded in the fundamental design of Veterans Affairs (VA) health care and which is consistent with the Institute of Medicine's definition of high-quality care. This definition emphasizes safe, effective, patient-centered, timely, efficient, and equitable health care. Group medical visits are a method to deliver health care that offers the promise of improving these aspects for patients with chronic conditions.

Group visits (or clinics) are a system redesign in which clinicians see multiple patients together in the same clinical setting. Shared medical appointments (SMAs) are a subset of such clinics and are defined by groups of patients meeting over time for comprehensive care for a defining chronic condition or health care state. SMAs usually involve both a person trained or skilled in delivering patient education or facilitating patient interaction and a practitioner with prescribing privileges. SMA sessions typically last 60 to 120 minutes, with time set aside for social integration, interactive education, and medication management, in an effort to achieve improved disease outcomes.

SMAs have been scientifically tested in an array of primary care settings over the last 10 to 15 years. However, there has been great variability among these studies in relation to setting; components included in the intervention; and measurement of clinical, cost, and utilization outcomes. For example, the patient group may stay constant, in an attempt to provide group bonding, or the patients may be allowed to choose sessions from a schedule at their convenience to promote attendance. Like patients, provider teams can be constant or vary over time. This uncertainty regarding the optimal design and impact of SMAs led the VA to commission this evidence synthesis report.

Our objective was to summarize the effects of SMA on staff, patient, and economic outcomes and to evaluate whether the impact varied by clinical condition or specific intervention components.

We addressed the following key questions:

Key Question #1. For adults with chronic medical conditions, do shared medical appointments (SMAs) compared with usual care improve the following:
  • Patient and staff experience?
  • Treatment adherence?
  • Quality measures such as (a) process of care measures utilized by VA, National Quality Forum, or National Committee for Quality Assurance and (b) biophysical markers (laboratory or physiological markers of health status such as HbA1c and blood pressure)?
  • Symptom severity and functional status?
  • Utilization of medical resources or health care costs?
Key Question #2. For adults with chronic medical conditions, do the effects of SMAs vary by patient characteristics such as specific chronic medical conditions and severity of disease? Key Question #3. Is the intensity of the intervention or the components used by SMAs associated with intervention effects?

See also