David Edelman, M.D.
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.
Avishek Nagi, M.S.
Liz Wing, M.A.
Evidence-based Synthesis Program (ESP) Center
Durham Veterans Affairs Healthcare System
Durham, NC; Department of Veterans Affairs; July 2012
The most successful health care systems offer ready access to high-quality primary careï¿½an
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
We addressed the following key questions:
Patient and staff experience?
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?