Background
Since Hippocrates’ times, patients and clinicians have been meeting on a one-to-one basis. It is unclear, however, whether one-to-one appointments are the most effective and efficient way of informing patients about their health status and improving their ability to manage their own health and illness. Group medical appointments (GMAs) could be a valid alternative in outpatient care, leading to improved health status and well-being for patients with a primary physical illness (chronic or non-chronic). At the same time GMAs could help to make better use of one of the most precious resources in health care: time. In recent decades, GMAs have been offered to patients in various healthcare organisations in the US and other western countries. This protocol describes our methods for systematically analysing the effects of GMAs in outpatient care settings. For the purpose of this review, the term 'outpatient care' is used to cover a range of ambulatory care modes and includes care delivered in primary care, specialty clinics and hospital outpatient settings.
Description of the condition
GMAs are currently being offered to several patient groups with a primary physical illness, in outpatient care. Patient groups range from children and adults with diabetes, to patients recovering after bone marrow transplantation (Sadur 1999; Meehan 2006; Edelman 2010; Rijswijk 2010). Most of the patients who attend GMAs have a chronic condition needing continuous management, although GMAs are also delivered to patients with a non-chronic physical illness, for example a total hip or knee replacement. The focus of this review will be on patients with a primary physical illness, both chronic and non-chronic. Patients with a physical illness can have mental health issues as well. Most of the time mental health issues will be on the agenda during the GMA, particularly when they influence the course or management of the physical disease. However studies focusing solely on mental illness will not be included in this review.
Description of the intervention
A GMA is a series of one-to-one patient-clinician contacts, in the presence of a group of at least two voluntary attending patients. Usually the clinician is supported by a group facilitator. A GMA generally takes 1 to 2 hours and is a substitute for a clinician’s individual appointments with the attending patients at a primary care clinic, specialty clinic or hospital outpatient setting. The same items the clinician attends to in a one-to-one appointment are attended to during the GMA. Patients can ask questions of their fellow patients, and patients and clinicians can learn from the other attending patients and their carers. In this review, carers can be spouses, partners, parents, children or other family members or friends who are closely involved with the patient's life. In a GMA the clinician may have more time to give information compared to a one-to-one clinician contact by not having to repeat information which is similar for all patients. This time can be redirected to more time for the patient’s medical needs, psychosocial needs, patient education, and patient empowerment.
Distinction between GMAs and other group meetings
GMAs are not to be confused with meetings for a group of patients, such as group therapy, group education or peer support groups. As opposed to a GMA, the focus of these group meetings is not primarily medical issues, although the working mechanisms can be similar. The goal of a GMA is to substitute for a whole consultation with the clinician, whereas the other types of group meetings are often intended to substitute for one part of the consultation such as education, support or therapy (Noffsinger 2009; Zantinge 2009; Edelman 2010). The difference between GMAs and group therapy or a peer support group is that the GMA focuses primarily on management of the physical illness and secondarily on the additional psychosocial aspects, while group therapy or peer support groups primary focus on emotional, psychological or social matters. The difference between a GMA and group education relates to the agenda setting which is led by patients' individual questions during a GMA, compared with being pre-specified and clinician-led during group education.
Conceptual framework
There is large diversity in the design of GMAs, as well as the types of patients and clinicians involved in them. These issues pose key challenges for this review. We have devised a conceptual framework in order to provide a consistent approach to describe and assess the different types of GMAs. Our conceptual framework describes three key domains as shown below:
Conceptual framework for GMAs
| Design | Patient Group | Team |
| Number of GMAs offered | Continuity versus non-continuity | Type of clinician |
| Time between successive GMAs | Heterogenous versus homogenous | Presence of group facilitator |
| Duration of GMA | Chronic versus non-chronic | Training of team |
| Number of patients per GMA | Children, adults, elderly |
Design
The design of the GMA has four components: number of GMAs offered (typically around 8 with a broad range from 1 to 36), time between successive GMAs (from every month to every 3 months), number of patients per GMA (6 to 10 patients in most cases) and duration of the GMA (typically 2 hours with a range of 1 to 3.5 hours). Differences in these components of the GMA could hypothetically be supposed to account for differences in effects on outcomes.
The effects on patients attending GMAs with a longer duration, or attending multiple GMAs, may be reinforced due to receiving repeated information. Participants attending multiple GMAs could feel more comfortable by becoming accustomed to the GMA care model and to other patients, which could improve satisfaction. Second, the number of patients who attend the GMA could influence outcome measures. Edelman 2010 suggested an ideal group size of 5 to 10 patients. Fewer patients endanger the interaction and information exchange, while more patients could make attention to individual needs more challenging . Time between successive GMAs might also influence outcomes. It is conceivable, for instance, that a long period between the GMAs (for example six months or longer) may reduce their effectiveness, compared with two GMAs in a short interval (for example one to three months). After a year patients have to make a new start in the group, and may forgotten information provided earlier.
Types of patient groups
Types of patient groups can be divided into continuity GMAs and non-continuity GMAs, heterogeneous or homogeneous patient groups, patients with chronic or acute illness and patients of different ages.
Non-continuity GMAs are free-standing and so different groups of patients may attend the appointments, although they usually comprise a homogenous group of patients with the same diagnosis. Non-continuity groups can be divided into drop-in groups where no scheduling is necessary in advance (the so-called Drop In Group Medical Appointments (DIGMAs)), and GMAs for which scheduling is necessary. GMAs, with the exception of DIGMAs, are usually diagnosis- or population-specific.
Depending on the design DIGMAs can consist of homogeneous or heterogenous patient groups with a different group of patients from appointment to appointment who 'drop in' to the appointment in the same day or week as their specific medical need arises (Pennachio 2003; Noffsinger 2003).
During continuity GMAs, patients are offered multiple appointments with the same cohort of patients during a given period of time (Pennachio 2003; Trilling 1999). The same group of patients attending every appointment may create a safe atmosphere in which patients feel free to ask their questions. In heterogenous groups with different diagnoses, patients might learn less from each other than patients in homogeneous groups with the same diagnoses. It is conceivable that GMAs in groups of patients with chronic illnesses show different effects compared to groups of patients with non-chronic illnesses. On the one hand, characteristics of a chronic disease (unexpected relapses and recoveries) may imply a higher need for peer support, and therefore reinforce the effect of peer support through a GMA. On the other hand peer support in non-chronic diseases may be less organised through patient advocacy groups. Consequently the effect of peer support through GMAs may have a bigger effect in people with non-chronic than in chronic diseases.
Patients of different ages may be offered GMAs; we consider the following different age groups: children (< 18 years), adults (18 to 65 years) and elderly people (over 65 years). Depending on the preferences of the organisation, carers of the patients may be invited to attend the GMA. The attendance of carers may reinforce the positive effects of GMAs, for example by remembering more new information.
Team
The third key domain features the team of care providers conducting the GMA. We identify the profession of clinician, the presence of a group facilitator and the training of the GMA team as key features. The team usually consists of a clinician, a group facilitator and sometimes an administrator (Noffsinger 2009). The clinician is defined as a health professional whose consultations with the patient are substituted by the GMA. This can be a physician, physician assistant, specialised nurse, nurse practitioner or paramedical professional. Usually one clinician is present, but more than one may attend. The group mentor is a facilitator of the group process, who fosters interaction between fellow patients, and between patients and health professionals, and is responsible for time management. Consequently the attendance of a group facilitator may reinforce the effects of a GMA. This role can be occupied by different professionals, for example a psychologist, a behaviourist or a specialised nurse who is acquainted with group processes. Some GMAs are designed without an attending group mentor. The education or training of the GMA team can differ, from targeted training to 'learning by doing' and also depends on the background of the team members. A team trained in conducting GMAs, for example by learning extra interview techniques or managing group processes, may enhance the effects of GMAs.
Description of control intervention
The effects of GMAs will be compared to usual care defined as one-to-one patient-clinician appointments. Studies that include additional care such as telephone follow up or home visits alongside GMAs will not be included in this review.
How the intervention might work
Interest in GMAs derives from motivation on the part of consumers and healthcare providers to continuously search for the most effective and efficient way for care to be delivered. The effects of GMAs might be found on three different levels: patients and carers, clinicians and costs.
Patients and carers
In the literature, GMAs have been reported to result in fewer hospitalisations and emergency visits, increased patient satisfaction and increased self-efficacy as compared to usual one-to-one outpatient appointments in chronically-ill older patients (> 60 years) and improved self-efficacy and general health status in patients with diabetes (Sadur 1999; Wagner 2001; Scott 2004). In the latter group, a randomised controlled trial demonstrated more frequent preventive procedures among patients attending GMAs, resulting in better general health status (Scott 2004). Sadur 1999 found greater satisfaction with diabetes care, greater self-efficacy, better glycaemic control, and lower service utilisation among diabetic patients who were randomly allocated to GMAs as compared to their counterparts receiving usual care.
Evidence demonstrates that GMAs can have substantial added value, deriving not only from sharing a healthcare professional’s time, but also from sharing mutual experiences, particularly for patients with a chronic disease (Sadur 1999; Wagner 2001; Scott 2004; Edelman 2010). GMAs could contribute to improving self-management and quality of life by influencing patients' self-efficacy. The quality of life of chronically-ill patients is influenced strongly by self-management. Optimal self-management involves people taking responsibility for their own health and well-being, as well as learning to manage any long-term illnesses (Lorig 2003). One way to measure the self-management abilities of patients is to measure self-efficacy, defined as whether a patient feels confident to successfully perform a specific health-related task or behaviour (Bandura 1997). Self-efficacy can be facilitated by increased knowledge, social support and successful earlier experiences, either by oneself or by others to whom one can relate (Bandura 1997; Bodenheimer 2002; Bandura 2004; Sol 2005). These attributes are more readily available during a GMA than during one-to-one appointments. Therefore the positive effects of GMAs may be mediated by improved self-efficacy through increasing social support and learning about successful earlier experiences from others.
Information from fellow patients can be just as, or even more, important as information provided by clinicians (Tattersall 2002). During a GMA, peers who have real life experience can be strong advocates and a living example of the impact and pros and cons of a treatment or lifestyle change. Patients and carers acting as experts on their own disease can be a valuable support for peers during GMAs. Finally, patients may have more time with their clinician and may receive more and different information about their disease and symptoms in a GMA setting (Zantinge 2009).
GMAs might also have adverse effects. The foremost challenge is in securing patients' privacy when medical care is offered in a group; a second is ensuring that patients are able to talk freely about their problems. To guarantee privacy and safety is very important. This can be done in several different ways, depending on the legislation of the specific country and the policy of the healthcare organisation. First, patients need to be informed correctly and in advance about what to expect; they will need to give permission for discussion of their medical information in the group; patients and their carers need to declare they will not share information about other patients with third parties; and participation in GMAs has to be voluntary, with attendance at a one-to one appointment with the clinician an option at all times. Patients may not feel free to raise all issues relevant to the management of their condition during a GMA, for example, those concerning requests for certain medication or related to sensitive information such as fertility. Patients might perceive less attention to individual needs. On the other hand, patients with the same complaints or disease often have the same questions and get their questions answered more in depth. The time investment of 1 to 2 hours could place a larger burden on patients' schedules than the 10 to 30 minutes a one-to-one appointment usually takes. One could imagine people having a full-time job being more reluctant to attend a GMA.
Clinicians
Several advantages for clinicians have been described. Clinicians state that GMAs allow them more time to provide information to patients and more time to address psychosocial aspects of the disease (Zantinge 2009; Rijswijk 2010). The time gained from not having to repeat the same information to all patients might be used instead to stimulate exchange of experiences between fellow patients and to elaborate on specific aspects of a disease. Clinicians report learning from their patients during a GMA; paying more attention to psychological and social aspects of the disease; having the opportunity to see a group of patients with the same disease at a time; and see their patients interact with other patients which can stimulate them to ask critical questions (Zantinge 2009). Clinicians who participated in GMAs have reported a high level of job satisfaction (Zantinge 2009; Blumenfeld 2003).
Offering GMAs is not suitable for all clinicians. The health professional has to have a basic interest in offering health care to a group of patients and will have to have or develop specific skills in order to be able to conduct a GMA. Usually, training to gain skills in group facilitation is necessary (Beck 1997; Blumenfeld 2003; Zantinge 2009).
Costs
Improving efficiency by implementing GMAs can be seen from two different perspectives:
patients might use fewer care resources after GMA participation; and
the cost price per outpatient visit could be reduced through GMAs.
Studies show that the effects of GMAs on costs vary considerably (Jaber 2006). Although there is some evidence of reduced resource use by patients after having attended a GMA, such as lower emergency department use, hospital admissions and visits to medical specialists (Sadur 1999; Coleman 2001; Clancy 2008), there is no consistent evidence of cost savings, and this can vary for the different reimbursement systems in use (Scott 2004; Trento 2008). The cost price of a GMA depends on the number of patients attending, the time scheduled for one-to-one appointments with the same patient group, the number of health professionals who are on the team, and the reimbursement system. If clinicians are able to see more patients in the same timeframe than they would with one-to-one appointments and the reimbursement system accounts for the participating patients, this can be a more efficient way of using valuable clinician time. However to train clinicians and group mentors to implement GMAs is a cost investment in time and training. Offering a series of GMAs to patients who would otherwise attend fewer one-to-one appointments could increase costs as well. Costs from a societal point of view can be higher when patients attend a GMA of 1 to 2 hours instead of a one-to-one appointment of 10 to 30 minutes' for example, patients might have less time to participate in other activities like employment.
Why it is important to do this review
GMAs may be an effective and efficient way of delivering health care to patients with a chronic or non-chronic physical illness. This review aims to assess the effects of group medical appointments systematically, and understand the overall effectiveness of group medical appointments as a tool for providing ongoing care for patients with a physical illness.
A number of Cochrane reviews contain management options for specific problems - for example interventions for improving medication adherence (Haynes 2008), or patients' trust in doctors (McKinstry 2008) - that include GMAs as one of the studied interventions. Other reviews focus on the effects of GMAs for a specific condition (Gagnon 2007; Homer 2012). Two other reviews summarise the effects of GMAs for various patient groups (Jaber 2006; Edelman 2012). Our review differs from the latter two reviews in the following ways: Jaber's review is a qualitative review with a search strategy limited to PubMed and MEDLINE; it included both observational and randomised studies and was executed seven years ago. Although Edelman et al recently conducted an extensive systematic review on GMAs, they limited their review to studies in the English language, patients aged over 18 years with chronic conditions, and evaluations of a series of at least two GMAs.
Our review aims to give information on effectiveness of the GMA model, irrespective of condition, age and number of appointments evaluated, which differentiates it from existing Cochrane and non-Cochrane reviews.