A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic

Shared medical appointments for patients with diabetes mellitus: a systematic review

OBJECTIVES

Shared medical appointments (SMAs) are an increasingly used system-redesign strategy for improving access to and quality of chronic illness care. We conducted a systematic review of the existing literature on SMA interventions for patients with diabetes in order to understand their impact on outcomes.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, PsycINFO, and Web of Science from January 1996 through April 2012. PubMed search updated June 2013.

STUDY SELECTION

English-language peer-reviewed publications of randomized controlled trials (RCTs), nonrandomized cluster controlled trials, controlled before-and-after studies, or interrupted time-series designs conducted among adult patients with diabetes. Two independent reviewers used prespecified criteria to screen titles and abstracts for full text review.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two different reviewers abstracted data and rated study quality and strength of evidence. When possible, we used random-effects models to synthesize the effects quantitatively, reporting by a weighted difference of the means when the same scale was used across studies, and a standardized mean difference when the scales differed. We measured heterogeneity in study effects using Forest Plots, Cochran's Q, and I(2), and explored heterogeneity by using subgroup analyses for categorical variables and meta-regression analyses for continuous or discrete variables. Outcomes not suitable to meta-analysis were summarized qualitatively.

RESULTS

Twenty-five articles representing 17 unique studies compared SMA interventions with usual care. Among patients with diabetes, SMAs improved hemoglobin A1c (∆ = -0.55 percentage points [95 % CI, -0.11 to -0.99]); improved systolic blood pressure (∆ = -5.2 mmHg [95 % CI, -3.0 to -7.4]); and did not improve LDL cholesterol (∆ = -6.6 mg/dl [95 % CI, 2.8 to -16.1]). Nonbiophysical outcomes, including economic outcomes, were reported too infrequently to meta-analyze, or to draw conclusions from. The A1c result had significant heterogeneity among studies, likely secondary to the heterogeneity among included SMA interventions.

LIMITATION

Heterogeneity among the components of diabetes SMAs leads to uncertainty about what makes a particular SMA successful.

CONCLUSION

SMA interventions improve biophysical outcomes among patients with diabetes. There was inadequate literature to determine SMA effects on patient experience, utilization, and costs.

Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis

Background

A critical part of future service delivery will involve improving the degree to which people become engaged in ‘self-management’. Providing better support for self-management has the potential to make a significant contribution to NHS efficiency, as well as providing benefits in patient health and quality of care.

Objective

To determine which models of self-management support are associated with significant reductions in health services utilisation (including hospital use) without compromising outcomes, among patients with long-term conditions.

Data sources

Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health, EconLit (the American Economic Association’s electronic bibliography), EMBASE, Health Economics Evaluations Database, MEDLINE (the US National Library of Medicine’s database), MEDLINE In-Process & Other Non-Indexed Citations, NHS Economic Evaluation Database (NHS EED) and PsycINFO (the behavioural science and mental health database), as well as the reference lists of published reviews of self-management support.

Methods

We included patients with long-term conditions in all health-care settings and self-management support interventions with varying levels of additional professional support and input from multidisciplinary teams. Main outcome measures were quantitative measures of service utilisation (including hospital use) and quality of life (QoL). We presented the results for each condition group using a permutation plot, plotting the effect of interventions on utilisation and outcomes simultaneously and placing them in quadrants of the cost-effectiveness plane depending on the pattern of outcomes. We also conducted conventional meta-analyses of outcomes.

Results

We found 184 studies that met the inclusion criteria and provided data for analysis. The most common categories of long-term conditions included in the studies were cardiovascular (29%), respiratory (24%) and mental health (16%). Of the interventions, 5% were categorised as ‘pure self-management’ (without additional professional support), 20% as ‘supported self-management’ (< 2 hours’ support), 47% as ‘intensive self-management’ (> 2 hours’ support) and 28% as ‘case management’ (> 2 hours’ support including input from a multidisciplinary team). We analysed data across categories of long-term conditions and also analysed comparing self-management support (pure, supported, intense) with case management. Only a minority of self-management support studies reported reductions in health-care utilisation in association with decrements in health. Self-management support was associated with small but significant improvements in QoL. Evidence for significant reductions in utilisation following self-management support interventions were strongest for interventions in respiratory and cardiovascular disorders. Caution should be exercised in the interpretation of the results, as we found evidence that studies at higher risk of bias were more likely to report benefits on some outcomes. Data on hospital use outcomes were also consistent with the possibility of small-study bias.

Limitations

Self-management support is a complex area in which to undertake literature searches. Our analyses were limited by poor reporting of outcomes in the included studies, especially concerning health-care utilisation and costs.

Conclusions

Very few self-management support interventions achieve reductions in utilisation while compromising patient outcomes. Evidence for significant reductions in utilisation were strongest for respiratory disorders and cardiac disorders. Research priorities relate to better reporting of the content of self-management support, exploration of the impact of multimorbidity and assessment of factors influencing the wider implementation of self-management support.

Study registration

This study is registered as PROSPERO CRD42012002694.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis

BACKGROUND

Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group.

METHODS

We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted.

RESULTS

We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89).

INTERPRETATION

We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).

Medical group visits: a feasibility study to manage patients with chronic pain in an underserved urban clinic

BACKGROUND

Chronic pain affects millions of racially diverse Americans. Evidence suggests that group medical visits are effective for treating chronic pain; similarly, a number of studies demonstrate the effectiveness of certain evidence-based complementary therapies in managing pain.

OBJECTIVES

The primary goal of this study is to evaluate the feasibility of the integrative medical group visit (IMGV) care model in an inner-city racially diverse outpatient clinic. IMGV combines patient-centered, non-pharmacologic strategies and principles of mindfulness-based stress-reduction with a group medical visit to reduce pain and associated symptoms.

METHODS

We surveyed patients pre and post an 8-session IMGV program to evaluate changes in pain in the last week (0-10 point scale) and comorbid symptoms including depression (Patient Health Questionaire-8 [PHQ-8]), perceived stress, and sleep quality. We also recorded referrals to the program, patients screened for eligibility, total enrollment, loss to follow-up, and attendance.

RESULTS

Seventy patients joined IMGV, and of these, 65 (93%) enrolled in the study. Over the course of 12 months, 7 groups met (median 9 patients/group; range 8-13 participants). Mean difference in pain level for all patients between baseline and 8 weeks was 0.7 (SD=2.0, P=.005). Mean difference in PHQ-8 depression score for patients with baseline score ≥5 was 2.6 (SD=4.6, P<.001). Statistically significant improvements were also seen in sleep quality and perceived stress.

CONCLUSION

A group visits program combining conventional and integrative medicine for predominantly racially diverse patients is feasible.

Can team-based care improve patient satisfaction? A systematic review of randomized controlled trials

Background

Team-based approaches to patient care are a relatively recent innovation in health care delivery. The effectiveness of these approaches on patient outcomes has not been well documented. This paper reports a systematic review of the relationship between team-based care and patient satisfaction.

Methods

We searched MEDLINE, EMBASE, Cochrane Library, CINAHL, and PSYCHOINFO for eligible studies dating from inception to October 8, 2012. Eligible studies reported (1) a randomized controlled trial, (2) interventions including both team-based care and non-team-based care (or usual care), and (3) outcomes including an assessment of patient satisfaction. Articles with different settings between intervention and control were excluded, as were trial protocols. The reference lists of retrieved papers were also evaluated for inclusion.

Results

The literature search yielded 319 citations, of which 77 were screened for further full-text evaluation. Of these, 27 articles were included in the systematic review. The 26 trials with a total of 15,526 participants were included in this systematic review. The pooling result of dichotomous data (number of studies: 10) showed that team-based care had a positive effect on patient satisfaction compared with usual care (odds ratio, 2.09; 95% confidence interval, 1.54 to 2.84); however, combined continuous data (number of studies: 7) demonstrated that there was no significant difference in patient satisfaction between team-based care and usual care (standardized mean difference, −0.02; 95% confidence interval, −0.40 to 0.36).

Conclusions

Some evidence showed that team-based care is better than usual care in improving patient satisfaction. However, considering the pooling result of continuous data, along with the suboptimal quality of included trials, further large-scale and high-quality randomized controlled trials comparing team-based care and usual care are needed.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

The effectiveness of interventions to increase the uptake of influenza vaccination in people aged 60 and older is uncertain.

OBJECTIVES

To assess access, provider, system and societal interventions to increase the uptake of influenza vaccination in people aged 60 years and older in the community.

SEARCH METHODS

We searched CENTRAL (2014, Issue 5), MEDLINE (January 1950 to May week 3 2014), EMBASE (1980 to June 2014), AgeLine (1978 to 4 June 2014), ERIC (1965 to June 2014) and CINAHL (1982 to June 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase influenza vaccination uptake in people aged 60 and older.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted influenza vaccine uptake data.

MAIN RESULTS

This update identified 13 new RCTs; the review now includes a total of 57 RCTs with 896,531 participants. The trials included community-dwelling seniors in high-income countries. Heterogeneity limited meta-analysis. The percentage of trials with low risk of bias for each domain was as follows: randomisation (33%); allocation concealment (11%); blinding (44%); missing data (49%) and selective reporting (100%). Increasing community demand (32 trials, 10 strategies)The interventions with a statistically significant result were: three trials (n = 64,200) of letter plus leaflet/postcard compared to letter (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.15); two trials (n = 614) of nurses/pharmacists educating plus vaccinating patients (OR 3.29, 95% CI 1.91 to 5.66); single trials of a phone call from a senior (n = 193) (OR 3.33, 95% CI 1.79 to 6.22), a telephone invitation versus clinic drop-in (n = 243) (OR 2.72, 95% CI 1.55 to 4.76), a free groceries lottery (n = 291) (OR 1.04, 95% CI 0.62 to 1.76) and nurses educating and vaccinating patients (n = 485) (OR 152.95, 95% CI 9.39 to 2490.67).We did not pool the following trials due to considerable heterogeneity: postcard/letter/pamphlets (16 trials, n = 592,165); tailored communications (16 trials, n = 388,164); customised letter/phone-call (four trials, n = 82,465) and client-based appraisals (three trials, n = 4016), although several trials showed the interventions were effective. Enhancing vaccination access (10 trials, six strategies)The interventions with a statistically significant result were: two trials (n = 2112) of home visits compared to clinic invitation (OR 1.30, 95% CI 1.05 to 1.61); two trials (n = 2251) of free vaccine (OR 2.36, 95% CI 1.98 to 2.82) and one trial (n = 321) of patient group visits (OR 24.85, 95% CI 1.45 to 425.32). One trial (n = 350) of a home visit plus vaccine encouragement compared to a home visit plus safety advice was non-significant.We did not pool the following trials due to considerable heterogeneity: nurse home visits (two trials, n = 2069) and free vaccine compared to no intervention (two trials, n = 2250). Provider- or system-based interventions (17 trials, 11 strategies)The interventions with a statistically significant result were: two trials (n = 2815) of paying physicians (OR 2.22, 95% CI 1.77 to 2.77); one trial (n = 316) of reminding physicians about all their patients (OR 2.47, 95% CI 1.53 to 3.99); one trial (n = 8376) of posters plus postcards (OR 2.03, 95% CI 1.86 to 2.22); one trial (n = 1360) of chart review/feedback (OR 3.43, 95% CI 2.37 to 4.97) and one trial (n = 27,580) of educational outreach/feedback (OR 0.77, 95% CI 0.72 to 0.81).Trials of posters plus postcards versus posters (n = 5753), academic detailing (n = 1400) and increasing staff vaccination rates (n = 26,432) were non-significant.We did not pool the following trials due to considerable heterogeneity: reminding physicians (four trials, n = 202,264) and practice facilitators (three trials, n = 2183), although several trials showed the interventions were effective. Interventions at the societal level We identified no RCTs of interventions at the societal level.

AUTHORS' CONCLUSIONS

There are interventions that are effective for increasing community demand for vaccination, enhancing access and improving provider/system response. Heterogeneity limited pooling of trials.

Influence of shared medical appointments on patient satisfaction: a retrospective 3-year study

PURPOSE

Shared medical appointments (SMAs) are becoming popular, but little is known about their association with patient experience in primary care. We performed an exploratory analysis examining overall satisfaction and patient-centered care experiences across key domains of the patient-centered medical home among patients attending SMAs vs usual care appointments.

METHODS

We undertook a cross-sectional study using a mailed questionnaire measuring levels of patient satisfaction and other indicators of patient-centered care among 921 SMA and 921 usual care patients between 2008 and 2010. Propensity scores adjusted for potential case mix differences between the groups. Multivariate logistic regression assessed propensity-matched patients' ratings of care. Generalized estimating equations accounted for physician-level clustering.

RESULTS

A total of 40% of SMA patients and 31% of usual care patients responded. In adjusted analyses, SMA patients were more likely to rate their overall satisfaction with care as "very good" when compared with usual care counterparts (odds ratio=1.26; 95% CI, 1.05-1.52). In the analysis of patient-centered medical home elements, SMA patients rated their care as more accessible and more sensitive to their needs, whereas usual care patients reported greater satisfaction with physician communication and time spent during their appointment.

CONCLUSIONS

Overall, SMA patients appear more satisfied with their care relative to patients receiving usual care. SMAs may also improve access to care and deliver care that patients find to be sensitive to their needs. Further research should focus on enhancing patient-clinician communication within an SMA as this model of care becomes more widely adopted.

Examining Dose of Diabetes Group Medical Visits and Characteristics of the Uninsured

Type 2 diabetes is a significant problem for the uninsured. Diabetes Group Medical Visits (DGMVs) have been reported to improve outcomes. However, it is not known if the increased workload of the health care team to treat and educate patients at multiple visits has an impact on patient functioning and well-being. The aim of this study was to explore the impact of dose of DGMVs on biophysical outcomes of care in uninsured persons with diabetes. No significant correlations were found between number of DGMVs attended and biophysical outcomes of care. However, the majority of patients attended two or less DGMVs in 1 year. Dose of DGMVs did not impact outcomes and may not be enough to assure attendance. Involving patients to construct patient-centered interventions may decrease the treatment burden faced by both patients and providers. In addition, such interventions should be aimed at understanding reasons for low attendance, particularly in rural impoverished adults.

The mood disorders association of british columbia psychiatric urgent care program: a preliminary evaluation of a suggested alternative model of outpatient psychiatric care

OBJECTIVE

To describe an alternative model of psychiatric outpatient care for patients with mood and anxiety disorders (the Mood Disorders Association of British Columbia Psychiatric Urgent Care Program or the MDA Program) using group medical visits (GMV) and (or) email communications in lieu of individual follow-up appointments.

METHOD

Annual costs of the MDA Program were compared with average costs of private psychiatrists offering outpatient care and patients being treated in a mental health centre. In addition, questionnaires as to patient satisfaction with the MDA Program intake, GMV experience, and family physician satisfaction with the MDA Program were administered.

RESULTS

The MDA Program model of care is significantly more cost effective than individual psychiatric outpatient care or health authority mental health centre care for patients with moderate or severe illness. Patients and family physicians were very satisfied with the model of care and GMVs offered.

CONCLUSIONS

The MDA Program model of care appears to be efficient and cost-effective, and patients and referring physicians appear satisfied with the care offered in this program.

Families United/Familias Unidas

Purpose

The purpose of the Families United/Familias Unidas study was to evaluate the feasibility and efficacy of group office visits on reducing diabetes risk in a multiethnic, primary care population.

Methods

Adults, ages 18 to 70 years, with any diabetes risk factor were recruited to attend 12 group office visits over 6 months. Each participant identified 1 support person, age 14 to 70 years, to accompany them. Data were collected at baseline, postintervention, 6 months, and 12 months. Primary outcome measures were reduction in the total number of predefined, modifiable risk factors (ie, body mass index ≥25 kg/m2; waist circumference ≥88 cm [women], ≥102 cm [men]; blood pressure ≥140/90 mm Hg; hemoglobin A1C ≥5.7%; fasting insulin ≥15 µU/mL; glycemic index ≥52.5% [women], ≥53.4% [men]; and physical activity <150 min/wk).

Results

Thirty-nine participants/supporters completed the intervention (mean age 47.8 ± 12.3 years, 69.2% female, 61.5% white, 35.9% Latino). Risk reduction analysis included only participants/supporters who remained paired at the intervention’s end (n = 36). At baseline, primary participants (n = 18) had an average of 4.8 ± 1.6 (standard error) predefined risk factors; supporters (n = 18), 4.1 ± 1.4. Primary participants’ risk factors decreased approximately 15% immediately after the 6-month intervention (absolute reduction of 1.1 risk factors) and increased to ~20% reduction 1 year postintervention (absolute reduction of 1.4 risk factors). Risk reduction was primarily due to decreases in dietary glycemic index and fasting insulin levels.

Conclusions

Group visits provide an innovative and potentially efficacious model of diabetes prevention in multiethnic patients with heterogeneous risk factors.

Do patients really prefer individual outpatient follow-up visits, compared with group medical visits?

OBJECTIVE

Access to outpatient psychiatric care remains problematic in Canada. We have been using group medical visits (GMV) to treat psychiatric outpatients with mood and anxiety disorders. Our study aimed to show that patients are similarly satisfied with GMV and individual psychiatric treatment, hence the concern that patients truly prefer individual treatment may be unfounded.

METHOD

Our study compared patient satisfaction in people who have had previous individual psychiatric care and are now receiving GMV to determine whether there is a treatment preference.

RESULTS

Questionnaire data were analyzed using repeated measures ANOVA. The ANOVAs showed no differences in patients' experiences with individual treatment, compared with GMV. In addition, we found when asked directly, most patients preferred GMV or had no treatment preference.

CONCLUSIONS

These findings indicate that patients' perspectives of individual psychiatric treatment and GMV are roughly equal. This suggests that the method of GMV deserves further study and comparison with other clinical models of psychiatric outpatient treatment.

Effectiveness of group medical visits for improving diabetes care: a systematic review and meta-analysis

BACKGROUND

Group medical visits, whereby health care professionals meet with groups of patients who have the same disease, have been introduced in primary care as a way to meet the increasing demand for health care delivery to patients with chronic diseases. We performed a systematic review and meta-analysis of the evidence on the effectiveness of such visits for patients with diabetes.

METHODS

We conducted a systematic review of all relevant studies published from 1947 to February 2012 identified in a search of electronic databases and grey literature. We included randomized controlled trials (RCTs) and observational studies published in English that included patients aged 16-80 years with type 1 or 2 diabetes and that had group medical visits as the intervention. These studies were assessed for methodologic quality. We included data only from the RCTs in the meta-analysis.

RESULTS

Of the 94 studies identified, we selected 26 that met our inclusion criteria, 13 of which were RCTs. Group medical visits had a positive effect on clinical and patient-reported outcomes, with significant reductions in glycated hemoglobin (HbA1c reduction -0.46%, 95% confidence interval -0.80% to -0.31%). We were unable to assess the effect of group medical visits on processes of care because of an insufficient number of RCTs that reported on this outcome.

INTERPRETATION

Group medical visits for patients with diabetes were found to be effective in terms of reducing HbA1c. The results of our meta-analysis suggest that wider implementation of group medical visits for patients with diabetes will have a positive effect on patient outcomes.

The promise of group medical visits

Innovative group medical visit programs have emerged in an effort to increase efficiency, improve service and quality of healthcare, and better manage high-risk patient populations. A case study program for cancer survivors, adapted from the Centering Healthcare Institute's model, demonstrates how nurse practitioners can lead the implementation and measurement outcomes of group visit models.

End-of-life care in the treatment of advanced heart failure in the elderly

Heart failure presents its own unique challenges to the clinician who desires to make excellent and humane care near the end of life a tangible reality. Accurate prediction of mortality in the individual patient is complicated by both the frequent occurrence of sudden death, both with and without devices, and the frequently chronic course that is punctuated by recurrent and more prominent acute episodes. A significant literature demonstrates that healthcare providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, and it is clear from the prognostic uncertainty of advanced heart failure that this kind of communication, and discussions regarding palliative care, need to occur earlier rather than later. This article discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation, with concurrent discussion of the ethical ramifications and pitfalls of each. A recent scientific statement from the American Heart Association begins to address some of the methodological issues involved in the care of patients with advanced heart failure. Above all, clinicians who wish to provide the highest quality of care to the dying patient need to confront the existential reality of death in themselves, their loved ones, and their patients so as to best serve those remanded to their care.

Diabetes group visits: integrated medical care and behavioral support to improve diabetes care and outcomes from a primary care perspective

Of the many innovations in health care delivery proposed in the context of health reform for those with chronic diseases such as diabetes, the group visit model is relatively easy to implement and is effective for improving health outcomes and patient and provider satisfaction, with a neutral to positive effect on health care costs. This article describes the evolution of group visits for those with diabetes, the theory underlying group visits for patients with chronic medical conditions, and the existing evidence for the effectiveness of this model. It also addresses implementation of groups in practice, with an emphasis on the practical aspects of program implementation, integration of behavioral expertise into medical groups, individualization in various practice settings, and reimbursement issues.

Relationship between chronic conditions and patient satisfaction with managed care

The objective of this study was to compare the level of satisfaction among members with and without chronic health conditions (asthma, diabetes, hypertension, and elevated plasma lipoprotein) in a large California managed care organization. One year's worth of member satisfaction survey data was analyzed. Results showed that a high percentage of members were satisfied with the health plan and with their access to care. Members with chronic conditions were significantly more satisfied with their access to care than were members without such conditions.

Effectiveness of using group visit model to support diabetes patient self-management in rural communities of Shanghai: a randomized controlled trial

Background

Diabetes has become a major public health problem in China. Support of patient self-management is a key component of effective diabetes care and improved patient outcomes. A series of peer-led community-based disease-specific self-management programs including diabetes have been widely disseminated in urban communities of Shanghai since 1999. However, the strategy of using trained lay leaders to support patient self-management faces challenges in rural communities in Shanghai. This study developed a Chinese diabetes group visit program as an alternative approach to support patient self-management and examined its effectiveness on self-management behaviors, self-efficacy and health status for patients with type 2 diabetes in rural communities of Shanghai.

Methods

208 patients with type 2 diabetes aged 35–80 years were randomly assigned to the intervention group (n=119) of 12 monthly group visit sessions or to a control group (n=89) of usual care. The trial was undertaken in two rural communities in Shanghai, China. Randomization and allocation to study group were carried out by using a random number table. Analysis of covariance was used to compare changes in the 17 self-management behavior, self-efficacy and health status related variables in two groups at 12 months’ follow-up based on 176 patients (n=98; n=78).

Results

Compared with controls, the intervention patients, on average, increased their duration of aerobic exercise by more than 40 minutes per week (p=0.001); had significant increase of 0.71 in mean score on self-efficacy to manage diabetes (p=0.02); and had significant improvements in measures of illness intrusiveness and systolic blood pressure. The intervention patients attended an average of 10.1 of the 12 program sessions with 75.6% of them attended 10 and more sessions.

Conclusion

The Chinese diabetes group visit model is a feasible, acceptable and effective alternative for supporting diabetes patient self-management in Chinese rural communities. The model requires larger studies to determine its effect on blood glucose control and health care utilization.

Trial registration

ISRCTN87909028

Group versus conventional antenatal care for women

BACKGROUND

Antenatal care is one of the key preventive health services used around the world. In most Western countries, antenatal care traditionally involves a schedule of one-to-one visits with a care provider. A different way of providing antenatal care is through a group model.

OBJECTIVES

The first objective was to compare the effects of group antenatal care versus one-to-one care on outcomes for women and their babies. The primary outcomes were preterm birth (birth occurring before 37 completed gestational weeks), low birthweight (less than 2500 g), small-for-gestational age (less than the tenth percentile for gestation and gender) and perinatal mortality. Secondary outcomes included psychological measures and satisfaction as well as labour and birth and postnatal outcomes.The second objective was to compare the effects of group care versus one-to-one care on care provider satisfaction.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 March 2012), contacted experts in the field and reviewed the reference lists of retrieved studies.

SELECTION CRITERIA

All identified published, unpublished and ongoing randomised and quasi-randomised controlled trials comparing group antenatal care with conventional antenatal care were included. Cluster-randomised trials were eligible for inclusion but none were identified. Cross-over trials were not eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and evaluated trial quality. Two authors extracted data. Data were checked for accuracy.

MAIN RESULTS

We included two studies (1369 women). There were no statistically significant differences between women who received group antenatal care compared with standard one-to-one care in relation to the primary outcomes. In particular, there was no difference in the rate of preterm birth rate between the two groups (risk ratio (RR) 0.87; 95% confidence interval (CI) 0.47 to 1.60; two trials; N = 1315) and the proportion of low birthweight (less than 2500 g) babies was similar between the groups (RR 1.03; 95% CI 0.73 to 1.46; two trials; N = 1315).Satisfaction was rated highly in women who were allocated to group antenatal care but only measured in one trial. In this trial, the mean satisfaction with care in group antenatal care was almost five times higher compared with those allocated to standard care (N = 993). A number of outcomes related to stress, distress and depression were reported in one trial. There were no differences between the groups in any of these outcomes.There were no data available on the effects of group antenatal care on care provider satisfaction.

AUTHORS' CONCLUSIONS

The available evidence suggests that group antenatal care is positively viewed by women with no adverse outcomes for themselves or their babies. This review is limited owing to the small number of studies/women and the majority of the analyses are based on a single study. More research is required to determine if group antenatal care is associated with significant benefits.

Families United/Familias Unidas: development and implementation of a family-based group office visit model for the primary prevention of type 2 diabetes

PURPOSE

The purpose of this study is to describe the development and implementation of a new diabetes prevention intervention that combines the benefits of family support with the group office model. Intensive lifestyle modification can effectively delay the onset of type 2 diabetes, yet health providers are challenged in translating these results to their patients. The group outpatient visit model can provide a means to address prevention issues in a financially sustainable manner.

METHODS

Materials from the Diabetes Prevention Program and a previously developed group office visit program were combined to create the Families United/Familias Unidas curriculum. The session content utilized a multiculturally tailored approach designed to help participants decrease portion size, decrease carbohydrate intake, increase physical activity, and increase resiliency. Adults aged 18 to 70 were recruited who had any diabetes risk factors but did not have diabetes. Eligible participants enlisted a support person, aged 14 to 70, to join them in the 6-month group office visit intervention.

RESULTS

Twenty-nine pairs (n = 58) of primary participants plus support persons were recruited. Participants' average age was 45; 74% were female; 56.9% identified themselves as white and 37.9% as Hispanic/Latino. Over one-third had 4 or more diabetes risk factors. Twelve family group office visits were delivered over 6 months. The attendance rate for those who attended at least one session was 72%.

CONCLUSIONS

Group office visits can provide a new sustainable model for diabetes prevention and are a natural fit for primary care physicians in collaboration with other health care professionals, such as dieticians or diabetes educators.

Group prenatal care versus individual prenatal care: a systematic review and meta-analyses

OBJECTIVE

To compare the effects of group prenatal care (GPC) and individual prenatal care (IPC) on perinatal health outcomes, including our primary outcomes of preterm birth (PTB < 37 weeks) and low birth weight (< 2500 g).

DATA SOURCES

We searched Medline, Embase, CINAHL, and the references of selected articles.

STUDY SELECTION

Two reviewers independently performed each step of the systematic review. Of the 4178 non-duplicate titles and abstracts identified, 77 were selected for full-text review. An additional eight full-text articles were selected from reference lists. Overall, 85 full-text articles were reviewed. Studies included assessed maternal or infant health outcomes.

DATA EXTRACTION AND DATA SYNTHESIS

Two reviewers independently extracted data from eligible full-text articles. Statistical analyses were completed using Review Manager, version 5.0 (Copenhagen: The Nordic Cochrane Centre, Cochrane Collaboration, 2011), whereby dichotomous variables and continuous outcomes were analyzed using relative risk and mean difference, respectively. The random effects model was employed to pool data. Where available, adjusted data were used to assess the independent effect of GPC. Eight studies of mostly low quality (three randomized controlled trials and five cohort studies) were included, involving 3242 women, most at high risk. Women randomized to GPC had lower rates of PTB (RR 0.71; 95% CI 0.52 to 0.96), no difference in rates of LBW (RR 0.91; 95% CI 0.65 to 1.27) or IUGR (RR 0.85; 95% CI 0.61 to 1.19), fewer Caesarean sections (RR 0.80; 95% CI 0.67 to 0.93), and slightly higher rates of breastfeeding (RR 1.08; 95% CI 1.02 to 1.14).

CONCLUSION

Studies comparing GPC with IPC are mostly of low quality and in high-risk groups, although two randomized studies, one a secondary analysis, showed improvement in some outcomes, including rates of PTB in women participating in GPC. In order to determine generalizability, more high-quality studies of GPC are needed.

Self-management education and support in chronic disease management

With the changing health care environment, prevalence of chronic health conditions, and burgeoning challenges of health literacy, obesity, and homelessness, self-management support provides an opportunity for clinicians to enhance effectiveness and, at the same time, to engage patients to participate in managing their own personal care. This article reviews the differences between patient education and self-management and describes easy-to-use strategies that foster patient self-management and can be used by health care providers in the medical setting. It also highlights the importance of linking patients to nonmedical programs and services in the community.

The effectiveness of group visits for patients with heart failure on knowledge, quality of life, self-care, and readmissions: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to identify the effectiveness of group visits for patients with heart failure (HF) on knowledge, quality of life, self-care behaviors, and hospital readmissions.

RESEARCH QUESTIONS

BACKGROUND: Heart failure (HF) continues to be a major health burden throughout the world. There are currently over 5.7 million Americans, 15 million Europeans, and 277,800 Australians living with HF. These numbers are expected to double by 2040. Patients and caregivers perform the majority of HF care in the home. Patients with HF need to learn to be successful in self-managing their condition to lessen the burden of symptoms such as fatigue, dyspnea, and edema.Patient education is the primary process used to increase knowledge of self-care practices for patients with HF. Patients with HF need to follow a complex medical regimen while adhering to a low sodium diet and prescribed fluid restrictions. In addition patients monitor their physical condition daily for exacerbation of symptoms or signs of fluid overload. Education, behavior modification, and skill development are necessary for a patient with HF to be successful in self-managing their condition.Most HF education occurs during one-on-one visits between the patient and the health care provider in an examination room during a regular clinic visit. However, there is usually limited time to address all of the needed education topics in an in-depth, meaningful manner with information the patient can take home and utilize in their daily routines.Group visits provide an alternative venue to provide care for this complex patient population. A group visit is an interactive process between a health care provider and a small group of patients and their caregivers who usually share a common medical concern. The participants of group visits can benefit from the knowledge and experiences of the other participants while providing support and encouragement to each other as they learn to cope with living with a chronic condition.The process of the group visit was first developed in 1991 by Dr. John C. Scott at the Kaiser Permanente system in Colorado, United States. Dr. Scott and a nurse held monthly group visits lasting 60 minutes with a group of 15 to 20 patients to manage their complex medical conditions. The group visit model can vary across settings, including from 6-20 patients over a 1-2 hour period with varying times devoted to education and discussion of health concerns. The group visit typically incorporates a one-on-one physical examination with a physician or nurse practitioner in conjunction with a group discussion and medical management. Group visits have shown to be beneficial in improving patient outcomes for conditions such as diabetes, hypertension, and other chronic illness.The goal of group visits for patients with HF is to increase patient knowledge and self-care abilities, while improving self-efficacy. Self-care incorporates the decision making process a patient undergoes when deciding on a course of action to maintain stability as a result of a change in symptoms. Improved self-care can improve symptoms, which will likely result in an increase in quality of life and a reduction in hospitalizations related to decompensation. Quality of life (QOL) refers to a patient's perception of the impact of a health condition and treatment on the patient's health status and can be measured with valid and reliable tools such as the Minnesota Living with Heart Failure Questionnaire (MLHFQ) or the Kansas City Cardiomyopathy Questionnaire (KCCQ). Self-care abilities can be measured using an instrument such as the Self-Care Heart Failure Index (SCHFI). HF knowledge can be measured using an instrument such as the Atlanta Heart Failure Knowledge Test. Group visits can be used to continue to optimize medication therapy while providing a forum for knowledge acquisition and fostering support.A search of the Cochrane Library of Systematic Reviews, the Joanna Briggs Library of Systematic Reviews, MEDLINE, and CINAHL did not identify any previously conducted systematic reviews on the effectiveness of group visits on outcomes for patients with heart failure. Therefore, this review seeks to identify studies evaluating the effectiveness of group visits for patients with heart failure on patient knowledge, quality of life, self-care behaviors, and hospital readmissions.

Addressing obesity in pregnancy: the design and feasibility of an innovative intervention in NSW, Australia

OBJECTIVE

Obesity amongst women of child bearing age is increasing at an unprecedented, rate throughout the Western world. This paper describes the design of an innovative, collaborative, antenatal intervention that aims to assist women to manage their weight during pregnancy and, presents aspects of the programme evaluation.

DATA SOURCES/STUDY SETTING

The programme was introduced at two sites, one in South East Sydney and, the other on the Central North Coast of NSW. Data were drawn from both sites and pooled for analysis.

STUDY DESIGN

This evaluation used mixed methods drawing on qualitative and quantitative data.

DATA COLLECTION METHODS

Focus groups were held with staff in the antenatal clinic, who were, responsible for recruiting to the new service. Members of staff were also asked to record BMI for all women offered the service and using a simple questionnaire, record the reasons women gave for declining the new service.

PRINCIPLE FINDINGS

The recruitment rate to the new service was 35% though this result should be treated with caution. Those women with a BMI of >35 were twice as likely to elect to participate in the new service as women with a BMI of less than 35. Focus groups with midwives in the antenatal clinic responsible for recruitment identified three themes impacting on recruitment to the service; 'finding the words', 'acknowledging challenges' and 'midwives' knowledge'.

CONCLUSIONS

Antenatal clinic midwives were unprepared for talking to women about their weight. Increasing the confidence and skills of staff in offering service innovations to eligible women is a major challenge to be met if new models of care are to be successful in addressing overweight and obesity in pregnancy.

Group medical visits in the follow-up of women with a BRCA mutation: design of a randomized controlled trial

Background

BRCA mutation carriers have a 40-80% life-time risk of developing breast cancer. They may opt for yearly breast cancer surveillance or for prophylactic mastectomy. Both options show increased survival rates. It is a complex choice to be made between these two options. As a result most women experience high levels of distress and high needs for information. To fulfill the needs for psychosocial support and information we have introduced group medical consultations (GMCs). A GMC provides individual medical visits conducted within a group. This 90 minute group-visit with 8-12 patients gives patients the opportunity to spend more time with their clinician and a behavioral health professional and learn from other patients experiencing similar topics. However, it should be noted that group sessions may increase fear in some patients or influence their decision making.

Methods/design

In this randomized controlled trial, 160 BRCA mutation carriers diagnosed maximally 2 years ago are recruited from the Radboud University Nijmegen Medical Centre. Participants are randomized in a 1:1 ratio to either the GMC intervention group (onetime participation in a GMC instead of a standard individual visit) or to a usual care control group. Primary outcome measures are empowerment and psychological distress (SCL 90). Secondary outcome measures are fear of cancer, information needs before the consultation and the received information, self-examination of the breasts, patient satisfaction, quality of life and cost-effectiveness. Data are collected via self-reported questionnaires 1 week before the visit, and at 1 week and at 3 months follow-up. A pilot study was conducted to test all procedures and questionnaires.

Discussion

The possibility for interaction with other BRCA mutation carriers within a medical visit is unique. This study will assess the effectiveness of GMCs for BRCA mutation carriers to improve empowerment and decrease distress compared to individual visits. If GMCs prove to be effective and efficient, implementation of GMCs in regular care for BRCA mutation carriers will be recommended.

Trial registration

The study is registered at ClinicalTrials.gov (NCT01329068)

Effects of shared medical appointments on quality of life and cost-effectiveness for patients with a chronic neuromuscular disease. Study protocol of a randomized controlled trial

Background

Shared medical appointments are a series of one-to-one doctor-patient contacts, in presence of a group of 6-10 fellow patients. This group visits substitute the annual control visits of patients with the neurologist. The same items attended to in a one-to- one appointment are addressed. The possible advantages of a shared medical appointment could be an added value to the present management of neuromuscular patients. The currently problem-focused one-to-one out-patient visits often leave little time for the patient's psychosocial needs, patient education, and patient empowerment.

Methods/design

A randomized, prospective controlled study (RCT) with a follow up of 6 months will be conducted to evaluate the clinical and cost-effectiveness of shared medical appointments compared to usual care for 300 neuromuscular patients and their partners at the Radboud University Nijmegen Medical Center. Every included patient will be randomly allocated to one of the two study arms. This study has been reviewed and approved by the medical ethics committee of the region Arnhem-Nijmegen, the Netherlands. The primary outcome measure is quality of life as measured by the EQ-5D, SF-36 and the Individualized neuromuscular Quality of Life Questionnaire. The primary analysis will be an intention-to-treat analysis on the area under the curve of the quality of life scores. A linear mixed model will be used with random factor group and fixed factors treatment, baseline score and type of neuromuscular disease. For the economic evaluation an incremental cost-effectiveness analysis will be conducted from a societal perspective, relating differences in costs to difference in health outcome. Results are expected in 2012.

Discussion

This study will be the first randomized controlled trial which evaluates the effect of shared medical appointments versus usual care for neuromuscular patients. This will enable to determine if there is additional value of shared medical appointments to the current therapeutical spectrum. When this study shows that group visits produce the alleged benefits, this may help to increase the acceptance of this innovative and creative way of using one of the most precious resources in health care more efficiently: time.

Trial registration

DutchTrial Register http://www.trialregister.nlNTR1412

Group medical appointments: organization and implementation in the bone marrow transplantation clinic

Group medical appointments provide patients with prompt access to care, greater attention to their psychosocial needs, and increased time with their medical team. Care providers evaluate more patients with similar needs in a shorter period. Eligible patients (between 100 days and 3 years after autologous stem cell transplantation) were contacted to participate. The laboratory and radiographic results of each patient's completed reevaluation were entered into the electronic template office note before their visit. A group medical visit model, called a Physical Shared Medical Appointment (PSMA), was employed because this uses individual patient examinations followed by a group meeting. On the day of the visit, brief physical examinations were performed on each patient. A transplantation physician then met with the group of patients and answered questions. Patient satisfaction surveys were distributed upon completion of the group session. Each PSMA was limited to 10 patients to facilitate patient participation. Questions during the group meeting were general and applicable to all patients. At completion of the 2-hour visit, patient surveys indicated an extremely high level of satisfaction and the preference to attend a future PSMA. Issues discussed during the group meeting were pertinent to all transplant recipients, regardless of diagnosis. The PSMA model allows the patient to spend extended time with their care providers while providing the care providers an opportunity to discuss health issues with numerous patients during 1 appointment. The Dartmouth Transplant PSMA model is expanding to pretransplantation and postallogeneic transplant recipients.

Group patient visits for Parkinson disease: a randomized feasibility trial

BACKGROUND

Group patient visits are medical appointments shared among patients with a common medical condition. This care delivery method has demonstrated benefits for individuals with chronic conditions but has not been evaluated for Parkinson disease (PD).

METHODS

We conducted a 12-month, randomized trial of group patient visits vs usual (one-on-one) care for patients with PD. Visits were led by one of 3 study physicians, included patients and caregivers, and lasted approximately 90 minutes. Those receiving group visits had 4 sessions over 12 months. The primary outcome measure was feasibility as measured by the ability to recruit participants and by the proportion of participants who completed the study. The primary efficacy outcome was quality of life as measured by the PD Questionnaire-39.

RESULTS

Thirty patients and 27 caregivers enrolled in the study. Thirteen of the 15 patients randomized to group patient visits and 14 of the 15 randomized to usual care completed the study. Quality of life measured 12 months after baseline between the 2 groups was not different (25.9 points for group patient visits vs 26.0 points for usual care; p = 0.99).

CONCLUSIONS

Group patient visits may be a feasible means of providing care to individuals with PD and may offer an alternative or complementary method of care delivery for some patients and physicians.

CLASSIFICATION OF EVIDENCE

This study provides Class II evidence that group patient visits did not improve quality of life for individuals with PD over a 1-year period.

The potential of cellular technology to mediate social networks for support of chronic disease self-management

Productive interactions among patients, friends/family, and health care providers, as outlined by the Chronic Care Model, are important for promoting adherence to recommended care and good health outcomes among adults with a chronic illness. Characteristics of these interactions--active participation, collaboration, and data sharing among constituents--are the same as those of social networks organized around Web 2.0 principles and technology. Thus, the Web 2.0 framework can be used to configure social networks without the inherent spatiotemporal constraints of face-to-face interactions that remain prevalent in health care delivery. In this article, the author outlines various design principles and decisions for a pilot study in which cellular technology was used to mediate interactions between adults with Type 2 diabetes and supporters (i.e., family members or friends selected by the patients who agree provide support) to motivate regular self-monitoring of blood glucose (among the diabetes participants). Participants generally found the network to be relatively easy to use. Some diabetes patients reported improved attention to self-monitoring; and, patient-selected supporters indicated improvements in emotional and instrumental support that should benefit diabetes patients' lifestyle and health.

Care Delivery Approaches and Seniors' Independence

Stimuler l'autonomie chez les gens de plus de 65 ans, dont plus de 80 pour cent éprouvent des troubles médicaux, constitue un défi de taille pour le personnel des politiques, les planificateurs de programme et les prestateurs de services, qui doivent prendre en considération les aspects physiques, sociaux et psychologiques de l'autonomie. Cet article présente une analyse bibliographique systématique et une synthèse rigoureuse de 65 rapports de recherche détaillés sélectionnés à partir de 238 études publicées sur les approches de soins favorisant la promotion de l'autonomie des personnes àgées. Cet article témoigne en faveur des programmes d'exercices et de promotion de la santé pour toutes les personnes âgées, ainsi que de la gestion à domicile des soins de santé et des programmes de prévention des chutes pour les aîné(e)s frêles. De plus, les conclusions soulignent l'importance d'accorder plus d'attention aux politiques sur les appareils accessoires fonctionnels et le besoin d'avoir plus de recherches sur l'efficacité des programmes de santé publique, sur les stratégies de promotion de soins médicaux préventifs et sur les facteurs psychosociaux qui influent sur l'auto-efficacité des personnes âgées.

Interventions to increase influenza vaccination rates of those 60 years and older in the community

BACKGROUND

Although the evidence to support influenza vaccination is poor, it is promoted by many health authorities. There is uncertainty about the effectiveness of interventions to increase influenza vaccination rates in those 60 years or older.

OBJECTIVES

To assess effects of interventions to increase influenza vaccination rates in those 60 or older.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, issue 3), containing the Cochrane Acute Respiratory Infections Group's Specialized Register, MEDLINE (January 1950 to July 2010), PubMed (January 1950 to July 2010), EMBASE (1980 to 2010 Week 28), AgeLine (1978 to July 2010), ERIC (1965 to July 2010) and CINAHL (1982 to July 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) to increase influenza vaccination rates in those aged 60 years and older, recording influenza vaccination status either through clinic records, billing data or local/national vaccination registers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data.

MAIN RESULTS

Forty-four RCTs were included. All included RCTs studied seniors in the community and in high-income countries. No RCTs of society-level interventions were included. Heterogeneity was marked and meta-analysis was limited. Only five RCTs were graded at low and six at moderate risk of bias. They included three of 13 personalized postcard interventions (all three with the 95% confidence interval (CI) above unity), two of the four home visit interventions (both with 95% CI above unity, but one a small study), three of the four reminder to physicians interventions (none with 95% CI above unity) and three of the four facilitator interventions (one with 95% CI above unity, and one P < 0.01). The other 33 RCTs were at high risk of bias and no recommendations for practice can be drawn.

AUTHORS' CONCLUSIONS

Personalized postcards or phone calls are effective, and home visits, and facilitators, may be effective. Reminders to physicians are not. There is insufficient good evidence for other interventions.

Group Visits and Chronic Disease Management in Adults: A Review

Chronic disease management using the traditional 15-minute appointment is exceptionally challenging and arguably inadequate to provide comprehensive, prospective, patient-centered primary care. A model of care designed to promote patient education, patient self-management, and improved access to their physicians and other health care providers is needed. Group visits have been identified as one model that allows physicians to deliver extensive patient education and self-management instruction while enhancing financial productivity. A thorough review of the literature on group visits was performed. Fairly consistent results from level I and II quality of evidence from a revised Strength of Recommendation Taxonomy (SORT) rating system indicate that patients who attended group visits demonstrated improved standards of care, improved quality of life, greater patient and physician satisfaction, lower rates of hospitalization and emergency department utilization, and reduced specialty costs. Discrepancies from the literature review include body mass index, hemoglobin A1C, blood pressure, and lipids. Overall, group visits appear to provide an effective and complementary strategy to traditional primary care in dealing with the complexities of providing chronic disease management in an increasing complex and aging population.

Different models to mobilize peer support to improve diabetes self-management and clinical outcomes: evidence, logistics, evaluation considerations and needs for future research

Much of diabetes care needs to be carried out by patients between office visits with their health care providers. Yet, many patients face difficulties carrying out these tasks. In addition, many adults with diabetes cannot count on effective support from their families and friends to help them with their self-management. Peer support programmes are a promising approach to enhance social and emotional support, assist patients in daily management and living with diabetes and promote linkages to clinical care. This background paper provides a brief overview of different approaches to mobilize peer support for diabetes self-management support, discusses evidence to date on the effectiveness of each of these models, highlights logistical and evaluation issues for each model and concludes with a discussion of directions for future research in this area.

Hospitalization as an opportunity to integrate palliative care in heart failure management

PURPOSE OF REVIEW

Hospitalization for heart failure is a critical event associated with high rates of readmissions, morbidity, and mortality. This review examines the role of hospitalization for heart failure as an opportunity to assess comprehensive patient needs including palliative care needs.

RECENT FINDINGS

Recent evidence demonstrates that institution of a comprehensive care plan at discharge reduces the high rates of readmissions and death seen in patients with heart failure. The chronic progressive nature of heart failure, with its concomitant limitations in functioning, significant psychosocial distress, and risk of death at all stages of illness creates a need for palliative care services that span the disease trajectory. These services include symptom management, psychosocial care, advance care planning, assistance in defining goals of care, and family/caregiver support and should be provided simultaneously with optimal medical management. Hospice is also underutilized.

SUMMARY

Hospitalization for heart failure should serve as an opportunity to assess, introduce, and provide comprehensive care that includes palliative care alongside optimal medical management. Palliative care services have the potential to positively impact the health and quality of life of patients with heart failure and should be integrated as an ongoing key component of their care.

Interventions to prevent disability in frail community-dwelling older persons: an overview

This narrative review was conducted to provide an overview of the variety of interventions aimed at disability prevention in community-dwelling frail older persons and to summarize promising elements. The search strategy and selection process found 48 papers that met the inclusion criteria. The 49 interventions described in these 48 papers were categorized into 'comprehensive geriatric assessment', 'physical exercise', 'nutrition', 'technology', and 'other interventions'. There is a large diversity within and between the groups of interventions in terms of content, disciplines involved, duration, intensity, and setting. For 18 of the 49 interventions, significant positive effects for disability were reported for the experimental group. Promising features of interventions seem to be: multidisciplinary and multifactorial, individualized assessment and intervention, case management, long-term follow-up, physical exercise component (for moderate physically frail older persons), and the use of technology. Future intervention studies could combine these elements and consider the addition of new elements.

Hearing aid effectiveness after aural rehabilitation - individual versus group (HEARING) trial: RCT design and baseline characteristics

BACKGROUND

Hearing impairment is the most common body system disability in veterans. In 2008, nearly 520,000 veterans had a disability for hearing loss through the Department of Veterans Affairs (VA). Changes in eligibility for hearing aid services, along with the aging population, contributed to a greater than 300% increase in the number of hearing aids dispensed from 1996 to 2006. In 2006, the VA committed to having no wait times for patient visits while providing quality clinically-appropriate care. One approach to achieving this goal is the use of group visits as an alternative to individual visits. We sought to determine: 1) if group hearing aid fitting and follow-up visits were at least as effective as individual visits, and 2) whether group visits lead to cost savings through the six month period after the hearing aid fitting. We describe the rationale, design, and characteristics of the baseline cohort of the first randomized clinical trial to study the impact of group versus individual hearing aid fitting and follow-up visits.

METHODS

Participants were recruited from the VA Puget Sound Health Care System Audiology Clinic. Eligible patients had no previous hearing aid use and monaural or binaural air-conduction hearing aids were ordered at the evaluation visit. Participants were randomized to receive the hearing aid fitting and the hearing aid follow-up in an individual or group visit. The primary outcomes were hearing-related function, measured with the first module of the Effectiveness of Aural Rehabilitation (Inner EAR), and hearing aid adherence. We tracked the total cost of planned and unplanned audiology visits over the 6-month interval after the hearing aid fitting.

DISCUSSION

A cohort of 659 participants was randomized to receive group or individual hearing aid fitting and follow-up visits. Baseline demographic and self-reported health status and hearing-related measures were evenly distributed across the treatment arms.Outcomes after the 6-month follow-up period are needed to determine if group visits were as least as good as those for individual visits and will be reported in subsequent publication.

TRIAL REGISTRATION

NCT00260663.

Implementing group medical visits for older adults at group health cooperative

In a pair of randomized controlled trials in the Kaiser Permanente delivery system in Colorado in the 1990s, group visits for older adults (monthly non-disease-specific group medical appointments for a cohort of patients led by primary care teams) were proven to reduce costs, decrease hospitalizations, and improve patient and provider satisfaction. As part of a translational effort, this group visit intervention was replicated in a delivery system in Seattle, Washington, and the log of total healthcare costs was measured in the first year of the intervention. Utilization and patient and physician satisfaction were secondary outcomes. For the cost and utilization analysis, a retrospective case-control design compared 221 case patients aged 65 and older with high outpatient usage in the previous 18 months with 1,015 control patients selected randomly from clinics not participating in the intervention. Controls were matched to cases on the number of primary care visits in the prior 18 months. Total costs were not statistically different for intervention patients and controls ($8,845 vs $10,288, P=.11), nor were there statistically significant differences in utilization, including hospital admissions and outpatient visits, but patient and provider satisfaction with the intervention was high. This translational effort did not demonstrate the cost savings of the original efficacy trials. Possible explanations for these divergent results may have to do with differences between those who participated and differences between the two delivery systems.

Models for integrating rehabilitation and primary care: a scoping study

OBJECTIVE

To describe the scope and breadth of knowledge currently available regarding the integration of rehabilitation and primary care services.

DATA SOURCES

Peer-reviewed journals were searched using CINAHL, MEDLINE, and EBM Reviews for the years 1995 through 2007. This process identified 172 items.

STUDY SELECTION

To be considered for the subsequent review, the article had to describe a service delivery program that offered primary care and rehabilitation, or services specifically designed for people with chronic conditions/disabilities. Further, it had to be available in English or French. No methodological limitations were applied to screen for levels of evidence.

DATA EXTRACTION

Based on these criteria, 38 articles remained that pertained to both primary care and rehabilitation. These were reviewed, sorted, and categorized to discover commonalities and differences among the approaches used to integrating rehabilitation into primary care.

DATA SYNTHESIS

In consultation with the team of investigators, it was determined that there were 6 different models for providing primary health care and rehabilitation services in an integrated approach: clinic, outreach, self-management, community-based rehabilitation, shared care, and case management. In addition, a number of themes were identified across models that may act as either supports or impediments to the integration of rehabilitation services into primary care settings: team approach, interprofessional trust, leadership, communication, compensation, accountability, referrals, and population-based approach.

CONCLUSIONS

Rehabilitation providers interested in working in the primary care sector may be assisted in conceptualizing the benefits that they bring to the setting by considering these models and issues.