A Systematic Review: Shared Medical Appointments for Chronic Medical 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 healthcare state. SMAs usually involve both a person trained or skilled in delivering patient education or facilitating patient interaction, and a practitioner with prescribing privileges. Typically, SMA sessions 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. This uncertainty regarding the optimal design and impact of SMAs led VA to commission this evidence synthesis report.

Investigators with the VA Evidence-based Synthesis Program at the Durham VA Medical Center conducted a review of the literature from January 1996 to April 2012, in order to summarize the effects of SMA's on staff, patient, and economic outcomes -- and to evaluate whether the impact varied by clinical condition or specific intervention components. After applying eligibility criteria to more than 1,100 citations, 25 articles (representing 19 unique studies) were used to help answer the following key questions.

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) bio-physical markers
     (i.e., lab or physiological markers of health
     status such as HbA1c and blood pressure)?

»   Symptom severity and functional status?

»   Use of medical resources or healthcare costs?

Thirteen randomized trials evaluated the effects of SMAs on outcomes for patients with diabetes. Other chronic medical conditions were not the primary organizing reason for any of the SMA trials in the review. Results from these studies include the following findings:

• All studies reported effects on average hemoglobin A1c at the end of the intervention. SMAs were associated with lower A1c than usual care (mean difference = 0.5 percentage points) at 4 to 48 months follow-up. However, effects varied significantly across studies, and this was not explained by study quality or baseline A1c.
• Eight studies reported effects on either total or LDL cholesterol, showing small but statistically non-significant treatment effects that varied across studies.
• Five studies reported effects on systolic blood pressure, showing a consistent and statistically significant effect (mean difference = 7 mmHg).
• Five studies reported large improvements in health-related quality of life, but effects were greater when using a disease-specific measure.
• Only two trials described the effects on patient experience, and neither of those trials showed greater satisfaction among those in SMAs compared with usual care.
• The effects of SMAs on hospital admissions and emergency department visits were explored in five studies on patients with diabetes. In three of these, admission rates were lower with SMAs, but the result was statistically significant in only one study. Two studies found emergency department visits decreased significantly with SMAs.
• Four studies reported effects on total costs, but results were mixed. In one, total costs were significantly higher; in another, total costs were significantly lower; in a third, results did not differ significantly; and the fourth was conducted in Europe and so costs may not apply to the U.S. health system.

Investigators identified two randomized trials and one observational study that evaluated the effects of SMAs on older adults with high healthcare service utilization rates. Results of these studies include the following findings:

• All studies reported positive effects on patient experience with SMAs compared with usual care.
• Both trials reported effects on overall health status and functional status, but there was no difference compared with usual care for either of these measures.
• All three studies showed fewer hospital admissions in the SMA groups, and both trials reported a statistically significant decrease in emergency department visits with SMAs compared with usual care.
• Total costs also were lower for the SMA group in each study, but varied substantially across studies and did not reach statistical significance for any study.

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?

No studies included in this review explored the sub-groups of patients that would benefit most from an SMA intervention.

Question #3
Is the intensity of the intervention or the components used by SMAs associated with intervention effects?

No studies included in this review explored the specific components of an SMA intervention that were most potent. SMA interventions did, however, have certain common components, such as:

• SMAs were led by teams of 1 to 3 clinicians that included a physician (n=15), clinical pharmacist (n=9); the prescribing clinician (n=3), and a registered nurse.
• In most studies, the clinical team was multidisciplinary, and pharmacists and mental health professionals participated in almost half of the studies.
• Sessions were designed for closed panels of patients in all but three studies, and group size was 6 to 10 members for most studies.
• SMA visits were a median of 2 hours (range 1 to 3.5 hours), and at least 16 of 19 studies offered individual breakouts.

Investigators also devised an intervention robustness score to attempt to address Question 3 quantitatively, but it was not associated with treatment effects.

Overall Conclusions
This review shows that SMAs—typically using closed groups with individual breakouts and opportunity for medication management—improve intermediate clinical outcomes for type 2 diabetes. Fewer studies show positive effects on patient experience in older adults and the possibility of lower healthcare utilization. SMAs may be most effective for illnesses such as diabetes that have a phase in which the risk of complication is relatively high, while the disease is simultaneously asymptomatic, and in which medication titration and self-management are important. Until further studies are done that allow for comparisons across conditions, the targeting of SMA interventions for chronic conditions other than diabetes will remain speculative.

Future Research
There was insufficient evidence in the literature on the following:

• Elements of an SMA intervention that are most effective and efficient;
• Effects on patient and staff satisfaction;
• Physiological variables other than HbA1c;
• Effects on health system costs, with the exception of the elderly high users of the healthcare system; and
• Unintended consequences to other aspects of the healthcare system, if SMAs were implemented.

A Cyberseminar session on this ESP Report was held on January 7, 2013. To access the archived session, please go to the HSR&D Cyberseminar web page.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers -- and to disseminate these reports throughout VA.

Reference

Edelman D, McDuffie JR, Oddone E, Gierisch JM, Nagi A, Williams JW Jr.. Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review. VA-ESP Project #09-010;2012.

View the full report.

Please feel free to forward this information to others!

Read past HSR&D Management e-Briefs on the HSR&D website.

This Management eBrief is a product of the HSR&D Evidence Synthesis Program (ESP). ESP is currently soliciting review topics from the broader VA community. Nominations will be accepted electronically using the online Topic Submission Form. If your topic is selected for a synthesis, you will be contacted by an ESP Center to refine the questions and determine a timeline for the report.

This Management e-Brief is provided to inform you about recent HSR&D findings that may be of interest. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs. If you have any questions or comments about this Brief, please email CIDER. The Center for Information Dissemination and Education Resources (CIDER) is a VA HSR&D Resource Center charged with disseminating important HSR&D findings and information to policy makers, managers, clinicians, and researchers working to improve the health and care of Veterans.

This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

See all reports online.