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Roth I, Tiedt M, Brintz C, Thompson-Lastad A, Ferguson G, Agha E, Holcomb J, Gardiner P, Leeman J. Determinants of implementation for group medical visits for patients with chronic pain: a systematic review. Implement Sci Commun 2024; 5:59. [PMID: 38783388 PMCID: PMC11112917 DOI: 10.1186/s43058-024-00595-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Despite the critical need for comprehensive and effective chronic pain care, delivery of such care remains challenging. Group medical visits (GMVs) offer an innovative and efficient model for providing comprehensive care for patients with chronic pain. The purpose of this systematic review was to identify barriers and facilitators (determinants) to implementing GMVs for adult patients with chronic pain. METHODS The review included peer-reviewed studies reporting findings on implementation of GMVs for chronic pain, inclusive of all study designs. Pubmed, EMBASE, Web of Science, and Cochrane Library were searched. Studies of individual appointments or group therapy were excluded. The Mixed Methods Appraisal Tool was used to determine risk of bias. Data related to implementation determinants were extracted independently by two reviewers. Data synthesis was guided by the updated Consolidated Framework for Implementation Research. RESULTS Thirty-three articles reporting on 25 studies met criteria for inclusion and included qualitative observational (n = 8), randomized controlled trial (n = 6), quantitative non-randomized (n = 9), quantitative descriptive (n = 3), and mixed methods designs (n = 7). The studies included in this review included a total of 2364 participants. Quality ratings were mixed, with qualitative articles receiving the highest quality ratings. Common multi-level determinants included the relative advantage of GMVs for chronic pain over other available models, the capability and motivation of clinicians, the cost of GMVs to patients and the health system, the need and opportunity of patients, the availability of resources and relational connections supporting recruitment and referral to GMVs within the clinic setting, and financing and policies within the outer setting. CONCLUSIONS Multi-level factors determine the implementation of GMVs for chronic pain. Future research is needed to investigate these determinants more thoroughly and to develop and test implementation strategies addressing these determinants to promote the scale-up of GMVs for patients with chronic pain. TRIAL REGISTRATION This systematic review was registered with PROSPERO 2021 CRD42021231310 .
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Affiliation(s)
- Isabel Roth
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
| | - Malik Tiedt
- Department of Physical Medicine and Rehabilitation, Program on Integrative Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
- Department of Health Studies and Applied Educational Psychology, Program in Nutrition, Teachers College, Columbia University, New York, NY, USA
| | - Carrie Brintz
- Department of Anesthesiology, Division of Pain Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Osher Center for Integrative Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ariana Thompson-Lastad
- Department of Family and Community Medicine, Osher Center for Integrative Health, University of California San Francisco, San Francisco, CA, USA
| | - Gayla Ferguson
- Department of Management, Policy, and Community Health, University of Texas Health Science Center at Houston School of Public Health, Houston, TX, USA
| | - Erum Agha
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | | | - Paula Gardiner
- Department of Family Medicine, Cambridge Health Alliance, University of Massachusetts Medical School, Boston, MA, USA
| | - Jennifer Leeman
- University of North Carolina at Chapel Hill School of Nursing, Chapel Hill, NC, USA
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Ordaz OH, Croff RL, Robinson LD, Shea SA, Bowles NP. Belonging, endurance, and resistance: Black placemaking theory in primary care. Soc Sci Med 2024; 342:116509. [PMID: 38184964 PMCID: PMC10903339 DOI: 10.1016/j.socscimed.2023.116509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/04/2023] [Accepted: 12/10/2023] [Indexed: 01/09/2024]
Abstract
Black-Americans continue to experience pervasive health disparities. Factors contributing to increased disease risk include a general mistrust of biomedical institutions among Black Americans. The purpose of this focus group study was to identify, among Black patients who regularly seek care from a primary provider, salient themes regarding barriers to 1) receiving quality primary care; and 2) adhering to medical recommendations. We examined transcripts of eight focus groups held remotely with 29 Black patients (aged 30-60 years) who had established primary care providers. Using grounded theory and an inductive thematic analysis of the transcripts, we identified three themes (belonging, endurance, and resistance) consistent with Black placemaking theory. Our findings suggest that reducing health disparities for Black Americans will require clinical initiatives that emphasize: 1) attention to social influences on health behavior and to features of medical institutions that mark them as White spaces (belonging); 2) recognition of, as well as sensitivity to, community awareness of the systemic and interpersonal barriers to health and safety that many Black adults endure; and 3) reframing avoidant (resistant) behaviors as protective strategies among Black patients. Examining primary care in this way-through the lens of Black placemaking theory-reveals how culturally meaningful approaches to harnessing the specialized knowledge and resilience that clearly exists among many Black communities can improve health care delivery.
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Affiliation(s)
- Omar H Ordaz
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA
| | - Raina L Croff
- School of Medicine Department of Neurology, Oregon Health & Science University, Portland, OR, USA
| | - LaTroy D Robinson
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA
| | - Steven A Shea
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA
| | - Nicole P Bowles
- Oregon Institute of Occupational Health Sciences, Oregon Health & Science University, Portland, OR, USA.
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Mishra KK, Leung IC, Chao MT, Thompson-Lastad A, Pollak C, Dhruva A, Hartogensis W, Lister M, Cheng SW, Atreya CE. Mindfulness-Based Group Medical Visits: Strategies to Improve Equitable Access and Inclusion for Diverse Patients in Cancer Treatment. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2024; 13:27536130241263486. [PMID: 38895040 PMCID: PMC11185011 DOI: 10.1177/27536130241263486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/22/2024] [Accepted: 06/02/2024] [Indexed: 06/21/2024]
Abstract
Background Mindfulness-based interventions (MBIs) are supported by clinical practice guidelines as effective non-pharmacologic interventions for common symptoms experienced by cancer patients, including anxiety, depression, and fatigue. However, the evidence predominately derives from White breast cancer survivors. Racial and ethnic minority patients have less access to integrative oncology care and worse cancer outcomes. To address these gaps, we designed and piloted a series of mindfulness-based group medical visits (MB-GMVs), embedded into comprehensive cancer care, for racially and ethnically diverse patients in cancer treatment. Methods As a quality improvement project, we launched a telehealth MB-GMV series for patients undergoing cancer treatment, delivered as four weekly 2-hour visits billable to insurance. Content was concordant with evidence-based guidelines and established MBIs and adapted to improve cultural relevance and fit (eg, access-centered, trauma-informed, with inclusive communication practices). Program structure was adapted to address barriers to participation, with ≥50% slots per series reserved for racial and ethnic minority patients. Intake surveys incorporated a demographic questionnaire and symptom assessments. Evaluations were sent following the visits. Results In our first ten cohorts (n = 78), 80% of referred patients enrolled. Participants were: 22% Asian, 14% Black, 17% Latino, 45% non-Latino White; 65% female; with a median age of 54 years (range 27-79); and 80% had metastatic cancer. Common baseline symptoms included lack of energy, difficulty sleeping, and worrying. Most patients (90%) attended ≥3 visits. On final evaluations, 87% patients rated the series as "excellent"; 81% "strongly agreed" that they liked the GMV format; and 92% would "definitely" recommend the series to others. Qualitative themes included empowerment and connectedness. Conclusion Telehealth GMVs are a feasible, acceptable, and financially sustainable model for increasing access to MBIs. Diverse patients in active cancer treatment were able to participate and reported high levels of satisfaction with this series that was tailored to center health equity and inclusion.
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Affiliation(s)
- Kavita K. Mishra
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Osher Center for Integrative Health, San Francisco, CA, USA
- UCSF Department of Radiation Oncology, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Ivan C. Leung
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Osher Center for Integrative Health, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- UCSF Department of Medicine, San Francisco, CA, USA
- Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Maria T. Chao
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Osher Center for Integrative Health, San Francisco, CA, USA
- UCSF Department of Medicine, San Francisco, CA, USA
- Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ariana Thompson-Lastad
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Osher Center for Integrative Health, San Francisco, CA, USA
- UCSF Department of Family and Community Medicine, San Francisco, CA, USA
| | - Christine Pollak
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Anand Dhruva
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Osher Center for Integrative Health, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- UCSF Department of Medicine, San Francisco, CA, USA
| | - Wendy Hartogensis
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Osher Center for Integrative Health, San Francisco, CA, USA
| | - Michael Lister
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
| | - Stephanie W. Cheng
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Osher Center for Integrative Health, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- UCSF Department of Medicine, San Francisco, CA, USA
| | - Chloe E. Atreya
- University of California, San Francisco (UCSF), San Francisco, CA, USA
- UCSF Osher Center for Integrative Health, San Francisco, CA, USA
- UCSF Helen Diller Family Comprehensive Cancer Center, San Francisco, CA, USA
- UCSF Department of Medicine, San Francisco, CA, USA
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Loy MH, Prisco L, Parikh C. Implementation of Virtual Integrative Oncology Shared Medical Appointment Series (VIOSMAS) Within Mixed Diagnosis Population. Integr Cancer Ther 2024; 23:15347354231223969. [PMID: 38243739 PMCID: PMC10799580 DOI: 10.1177/15347354231223969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 11/09/2023] [Accepted: 12/15/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND Integrative oncology [IO] is sought-after by patients, endorsed by clinical guidelines, and valued within National Cancer Institute Centers. Shared Medical Appointments [SMA] leverage health education and social connection to deliver enhanced patient experience, population health, cost-reduction, and clinician well-being. Integrative Oncology Shared Medical Appointments increase access to integrative medicine but delivering these services via telehealth have not been evaluated. OBJECTIVE We created, and pilot tested a Virtual Integrative Oncology Shared Medical Appointment Series (VIOSMAS) to assess its feasibility, acceptability, and efficacy at an urban academic teaching hospital. METHODS The 7-session hour-long Living Well with and after Cancer series included didactics, multi-disciplinary experiential sessions, and group discussion. Topics included (1) Introduction, (2) Herbs/Botanicals/Fungi, (3) Mindful Movement, (4) Acupuncture, (5) Narratives and Nature, (6) Diet and Culinary Medicine, and (7) Vitamins/Supplements. Virtual visits via telehealth were offered to enhance patient participation during the pandemic. Outcome measures included recruitment, retention, pre/post-series patient survey and qualitative clinician feedback. RESULTS Between 9/2021 and 4/2023, 72 unique patients were recruited to 5 cohorts and had a total of 332 VIOSMAS visits. A total of 50 patients (69%) attended 4 or more of the 7-session series; 60 (83% were women); patients ranged in age from 28 to 93 years (median 66); 36 (50%) lived outside the city center; the most common cancer diagnoses were breast, lymphoma, and lung cancer. Patients were from diverse demographics. Pre-program, patients reported desiring assistance in addressing diverse symptoms including fatigue, insomnia, pain, gastrointestinal (GI) symptoms, anxiety, and depression. Post-series, patients reported that the VIOSMAS addressed their goals and symptoms; they also reported incorporating recommended lifestyle changes in diet, exercise, sleep, and stress management; they were satisfied with the number of sessions and telehealth format. The participating clinicians reported high levels of satisfaction with VIOSMAS. Revenue to the institution from VIOSMAS exceeded the revenue potential of equivalent time spent for individual visits while supporting extended physician-patient contact. CONCLUSION VIOSMAS is feasible for patients and clinicians, addresses patients' symptoms and questions about lifestyle and complementary therapies, and generates more revenue than individual visits. Larger implementation trials with appropriate comparison groups are recommended.
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Affiliation(s)
- Michelle H. Loy
- Cornell University, New York, NY, USA
- Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
| | | | - Chiti Parikh
- Cornell University, New York, NY, USA
- Weill Cornell Medicine/New York Presbyterian Hospital, New York, NY, USA
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Taylor-Swanson L, Stoddard K, Fritz J, Anderson B(B, Cortez M, Conboy L, Sheng X, Flake N, Sanchez-Birkhead A, Stark LA, Farah L, Farah S, Lee D, Merkley H, Pacheco L, Tavake-Pasi F, Sanders W, Villalta J, Moreno C, Gardiner P. Midlife Women's Menopausal Transition Symptom Experience and Access to Medical and Integrative Health Care: Informing the Development of MENOGAP. GLOBAL ADVANCES IN INTEGRATIVE MEDICINE AND HEALTH 2024; 13:27536130241268355. [PMID: 39092447 PMCID: PMC11292722 DOI: 10.1177/27536130241268355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 06/14/2024] [Accepted: 07/03/2024] [Indexed: 08/04/2024]
Abstract
Background Individuals with a uterus experience menopause, the cessation of menses, on average at age 51 years in the United States. While menopause is a natural occurrence for most, over 85% of women experience multiple interfering symptoms. Menopausal women face health disparities, including a lack of access to high-quality healthcare and greater disparities are experienced by women who are black, indigenous, and people of color. Some women are turning away from hormone therapy, and some seek integrative health interventions. Objective Some menopausal women who seek healthcare do not receive it as they lack access to medical and integrative healthcare providers. A potential solution to this problem is a medical group visit (MGV), during which a provider sees multiple patients at once. The aims of this study were to gather women's opinions about the menopause, provider access, and conventional and integrative health interventions for later use to develop a menopause MGV. Methods We conducted a Community Engagement Session and a Return of Results (RoR) with midlife women to learn about their menopause experiences, barriers and facilitators to accessing health providers, and their interest in and suggestions for designing a future integrative MGV (IMGV). Thematic qualitative research methods were used to summarize session results. Results Nine women participated in the Session and six attended the RoR. Participants were well-educated and diverse in race and ethnicity. Themes included: an interest in this topic; unfamiliar medical terms; relevant social factors; desired whole person care; interest in integrative health; barriers and facilitators to accessing healthcare. The group expressed interest in ongoing participation in the future process of adapting an IMGV, naming it MENOGAP. Conclusion These findings highlight the importance of stakeholder engagement before designing and implementing MENOGAP and the great need among midlife women for education about the menopausal transition, integrative self-care, and healthcare.
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Affiliation(s)
| | - Kari Stoddard
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | - Julie Fritz
- College of Health, University of Utah, Salt Lake City, UT, USA
| | | | - Melissa Cortez
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Lisa Conboy
- Instructor in Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Xiaoming Sheng
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | - Naomi Flake
- Utah Clinical and Translational Science Institute, University of Utah, Salt Lake City, UT, USA
| | | | - Louisa A. Stark
- Utah Clinical and Translational Science Institute, University of Utah, Salt Lake City, UT, USA
- Department of Human Genetics, University of Utah, Salt Lake City, UT, USA
| | - Luul Farah
- University of Utah, Salt Lake City, UT, USA
| | - Sara Farah
- University of Utah, Salt Lake City, UT, USA
| | | | - Heather Merkley
- College of Health Professions, Weber State University, Ogden, UT, USA
| | | | | | | | | | - Camille Moreno
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Paula Gardiner
- University of Massachusetts Medical School and Director of Primary Care Implementation Research, Cambridge Health Alliance, Cambridge, MA, USA
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Mitchell SE, Bragg A, De La Cruz BA, Winter MR, Reichert MJ, Laird L, Moldovan IA, Parker KN, Martin-Howard J, Gardiner P. Effectiveness of an immersive telemedicine platform for delivering diabetes medical group visits for African American/ Black and Hispanic/ Latina women with uncontrolled diabetes: The Women in Control 2.0 non-inferiority randomized clinical trial (Preprint). J Med Internet Res 2022; 25:e43669. [PMID: 37163341 DOI: 10.2196/43669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/12/2023] [Accepted: 03/10/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Medically underserved people with type 2 diabetes mellitus face limited access to group-based diabetes care, placing them at risk for poor disease control and complications. Immersive technology and telemedicine solutions could bridge this gap. OBJECTIVE The purpose of this study was to compare the effectiveness of diabetes medical group visits (DMGVs) delivered in an immersive telemedicine platform versus an in-person (IP) setting and establish the noninferiority of the technology-enabled approach for changes in hemoglobin A1c (HbA1c) and physical activity (measured in metabolic equivalent of task [MET]) at 6 months. METHODS This study is a noninferiority randomized controlled trial conducted from February 2017 to December 2019 at an urban safety net health system and community health center. We enrolled adult women (aged ≥18 years) who self-reported African American or Black race or Hispanic or Latina ethnicity and had type 2 diabetes mellitus and HbA1c ≥8%. Participants attended 8 weekly DMGVs, which included diabetes self-management education, peer support, and clinician counseling using a culturally adapted curriculum in English or Spanish. In-person participants convened in clinical settings, while virtual world (VW) participants met remotely via an avatar-driven, 3D VW linked to video teleconferencing. Follow-up occurred 6 months post enrollment. Primary outcomes were mean changes in HbA1c and physical activity at 6 months, with noninferiority margins of 0.7% and 12 MET-hours, respectively. Secondary outcomes included changes in diabetes distress and depressive symptoms. RESULTS Of 309 female participants (mean age 55, SD 10.6 years; n=195, 63% African American or Black; n=105, 34% Hispanic or Latina; n=151 IP; and n=158 in VW), 207 (67%) met per-protocol criteria. In the intention-to-treat analysis, we confirmed noninferiority for primary outcomes. We found similar improvements in mean HbA1c by group at 6 months (IP: -0.8%, SD 1.9%; VW: -0.5%, SD 1.8%; mean difference 0.3, 97.5% CI -∞ to 0.3; P<.001). However, there were no detectable improvements in physical activity (IP: -6.5, SD 43.6; VW: -9.6, SD 44.8 MET-hours; mean difference -3.1, 97.5% CI -6.9 to ∞; P=.02). The proportion of participants with significant diabetes distress and depressive symptoms at 6 months decreased in both groups. CONCLUSIONS In this noninferiority randomized controlled trial, immersive telemedicine was a noninferior platform for delivering diabetes care, eliciting comparable glycemic control improvement, and enhancing patient engagement, compared to IP DMGVs. TRIAL REGISTRATION ClinicalTrials.gov NCT02726425; https://clinicaltrials.gov/ct2/show/NCT02726425.
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Bharmal N. Social Determinants and Health Equity in Functional Medicine. Phys Med Rehabil Clin N Am 2022; 33:665-678. [DOI: 10.1016/j.pmr.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Bharmal N, Beidelschies M, Alejandro-Rodriguez M, Alejandro K, Guo N, Jones T, Bradley E. A nutrition and lifestyle-focused shared medical appointment in a resource-challenged community setting: a mixed-methods study. BMC Public Health 2022; 22:447. [PMID: 35255887 PMCID: PMC8900391 DOI: 10.1186/s12889-022-12833-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In order to address disparities in preventable chronic diseases, we adapted a nutrition and lifestyle-focused shared medical appointment (SMA) program to be delivered in an underserved community setting. The objective was to evaluate a community-based nutrition and lifestyle-focused SMA as it relates to acceptability and health and behavior-related outcomes. METHODS A mixed-methods study was performed to evaluate pre-post changes in wellness indices, biometrics, self-efficacy, and trust in medical researchers as part of a community-based SMA. To understand program acceptability including barriers and facilitators for implementation and scalability, we conducted two participant focus groups and five stakeholder interviews and used content analysis to determine major themes. RESULTS Fifteen participants attended 10 weekly sessions. The majority were older adult, African American women. There were pre-post improvements in mean [SD] systolic (-10.5 [7.7] mmHg, p = 0.0001) and diastolic (-4.7 [6.7] mmHg, p = 0.17) blood pressures and weight (-5.7 [6.3] pounds, p = 0.003) at 3 months though these were not significant at 6 months. More individuals reported improvements in health status, daily fruit and vegetable intake, and sleep than at baseline. There were no significant pre-post changes in other wellness indices, self-efficacy, trust in medical researchers, hemoglobin A1c, insulin, or LDL cholesterol. Participants discussed positive health changes as a result of the SMA program, program preferences, and facilitators and barriers to continuing program recommendations in focus groups. SMA implementation was facilitated by clinical staff who adjusted content to a low health literacy group and partnership with a trusted community partner. Sustainability barriers include heavy personnel time and in-kind resources to deliver the program. CONCLUSIONS Nutrition and lifestyle-focused SMAs in a resource-challenged community setting may be an acceptable intervention for underserved patients.
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Affiliation(s)
- Nazleen Bharmal
- Community Health & Partnerships, Cleveland Clinic Community Care, Cleveland Clinic, Ohio, Cleveland, USA.
| | | | | | - Kayla Alejandro
- Center for Functional Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ning Guo
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Tawny Jones
- Center for Functional Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Elizabeth Bradley
- Center for Functional Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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Aysola J, Rewley J, Xu C, Schapira M, Hubbard RA. Primary Care Patient Social Networks and Tobacco Use: An Observational Study. J Prim Care Community Health 2022; 13:21501327211037894. [PMID: 35120417 PMCID: PMC8819821 DOI: 10.1177/21501327211037894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Importance: Tobacco use remains the leading cause of preventable deaths and is
susceptible to social influence. Yet, we know little about the
characteristics of primary care social networks and how they influence
tobacco use. Objective: To determine what primary care patient social network characteristics are
associated with individual smoking behavior. Design: Cross-sectional. Setting: Two primary care practices in West Philadelphia, Pennsylvania (PA), USA. Participants: A random sample of 53 primary care patients and 155 of their nominated social
ties. Main Outcome and Measures: We examined the association between social network characteristics (degree,
communicated weighted social ties, and presence of social reinforcement) and
tobacco use history (never smoker, successful quitter, or current smoker).
Other covariates included age, race/ethnicity, sex, education, income, and
employment status, self-efficacy, depression status, provider-patient
relationship. Results: Of those enrolled in our study (n = 208), 101 identified as never smokers, 59
as successfully quitters, and 48 as current smokers. Social reinforcements
from connected alter pairs that never-smoked (OR = 1.20, 95% CI: 1.08, 1.34)
was significantly associated with a participant being a never smoker.
Participants with stronger ties with successful quitters were significantly
more likely to identify as successfully quitting (OR = 1.37, 95% CI: 1.11,
1.69) and conversely had a negative association with stronger ties to
unsuccessful quitters (OR = 0.59, 95% CI: 0.44, 0.80) or current smokers who
had not tried to quit in the last year (OR = 0.82, 95% CI: 0.68, 0.98).
Social reinforcement from connected pairs of alters that were unsuccessful
quitters was significantly associated with the participant being a current
smoker (OR = 1.26, 95% CI: 1.10, 1.45). Conclusions: Our study suggests that smoking behaviors do not occur in isolation, nor
because of 1 or 2 prominent social network members. Rather, our findings
suggest that both strong ties and social reinforcement from clusters of
similarly-behaving persons influence smoking behavior. Primary care
practices have an opportunity to leverage these insights on patient networks
to improve cancer prevention.
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Affiliation(s)
- Jaya Aysola
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey Rewley
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chang Xu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marilyn Schapira
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Rebecca A Hubbard
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Graham F, Tang MY, Jackson K, Martin H, O'Donnell A, Ogunbayo O, Sniehotta FF, Kaner E. Barriers and facilitators to implementation of shared medical appointments in primary care for the management of long-term conditions: a systematic review and synthesis of qualitative studies. BMJ Open 2021; 11:e046842. [PMID: 34429309 PMCID: PMC8386233 DOI: 10.1136/bmjopen-2020-046842] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To synthesise the published literature on practitioner, patient and carer views and experiences of shared medical appointments (SMAs) for the management of long-term conditions in primary care. DESIGN Systematic review of qualitative primary studies. METHODS A systematic search was conducted using MEDLINE (Ovid), PsycINFO (Ovid), CINAHL (EBSCOhost), Web of Science, Social Science Premium Collection (Proquest) and Scopus (SciVerse) from database starting dates to June 2019. Practitioner, patient and carer perspectives were coded separately. Deductive coding using a framework approach was followed by thematic analysis and narrative synthesis. Quality assessment was conducted using the Critical Appraisal Skills Programme for qualitative studies. RESULTS We identified 18 unique studies that reported practitioner (n=11), patient (n=14) and/or carer perspectivs(n=3). Practitioners reported benefits of SMAs including scope for comprehensive patient-led care, peer support, less repetition and improved efficiency compared with 1:1 care. Barriers included administrative challenges and resistance from patients and colleagues, largely due to uncertainties and unclear expectations. Skilled facilitators, tailoring of SMAs to patient groups, leadership support and teamwork were reported to be important for successful delivery. Patients' reported experiences were largely positive with the SMAs considered a supportive environment in which to share and learn about self-care, though the need for good facilitation was recognised. Reports of carer experience were limited but included improved communication between carer and patient. CONCLUSION There is insufficient evidence to indicate whether views and experiences vary between staff, medical condition and/or patient characteristics. Participant experiences may be subject to reporting bias. Policies and guidance regarding best practice need to be developed with consideration given to resource requirements. Further research is needed to capture views about wider and co-occurring conditions, to hear from those without SMA experience and to understand which groups of patients and practitioners should be brought together in an SMA for best effect. PROSPERO REGISTRATION NUMBER CRD42019141893.
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Affiliation(s)
- Fiona Graham
- NIHR Policy Research Unit in Behavioural Science, Newcastle University, Newcastle upon Tyne, UK
| | - Mei Yee Tang
- NIHR Policy Research Unit in Behavioural Science, Newcastle University, Newcastle upon Tyne, UK
| | | | - Helen Martin
- Research and Evidence Team, NECS, Newcastle upon Tyne, UK
| | - Amy O'Donnell
- NIHR Policy Research Unit in Behavioural Science, Newcastle University, Newcastle upon Tyne, UK
| | - Oladapo Ogunbayo
- Population Health Science Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Falko F Sniehotta
- NIHR Policy Research Unit in Behavioural Science, Newcastle University, Newcastle upon Tyne, UK
- Faculty of Behavioural, Management and Social Sciences, University of Twente, Enschede, The Netherlands
| | - Eileen Kaner
- NIHR Policy Research Unit in Behavioural Science, Newcastle University, Newcastle upon Tyne, UK
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Thompson-Lastad A, Gardiner P. Group Medical Visits and Clinician Wellbeing. Glob Adv Health Med 2020; 9:2164956120973979. [PMID: 33282545 PMCID: PMC7683834 DOI: 10.1177/2164956120973979] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/01/2020] [Accepted: 10/12/2020] [Indexed: 11/17/2022] Open
Abstract
There is strong evidence for clinical benefits of group medical visits (GMVs) (also known as shared medical appointments) for prenatal care, diabetes, chronic pain, and a wide range of other conditions. GMVs can increase access to integrative care while providing additional benefits including increased clinician-patient contact time, cost savings, and support with prevention and self-management of chronic conditions. During the COVID-19 pandemic, many clinical sites are experimenting with new models of care delivery including virtual GMVs using telehealth. Little research has focused on which clinicians offer this type of care, how the GMV approach affects the ways they practice, and their job satisfaction. Workplace-based interventions have been shown to decrease burnout in individual physicians. We argue that more research is needed to understand if GMVs should be considered among these workplace-based interventions, given their potential benefits to clinician wellbeing. GMVs can benefit clinician wellbeing in multiple ways, including: (1) Extended time with patients; (2) Increased ability to provide team-based care; (3) Understanding patients' social context and addressing social determinants of health. GMVs can be implemented in a variety of settings in many different ways depending on institutional context, patient needs and clinician preferences. We suggest that GMV programs with adequate institutional support may be beneficial for preventing burnout and improving retention among clinicians and health care teams more broadly, including in integrative health care. Just as group support benefits patients struggling with loneliness and social isolation, GMVs can help address these and other concerns in overwhelmed clinicians.
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Affiliation(s)
- Ariana Thompson-Lastad
- Osher Center for Integrative Medicine, UC San Francisco School of Medicine, San Francisco, California
| | - Paula Gardiner
- Department of Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, Massachusetts
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12
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Tataryn A, Derbowka H, Shen X, Gage E, Kang E, Wlock J, Lieffers J. A Qualitative Evaluation of Patient Experiences With Group Medical and Individual Education Appointments for Type 2 Diabetes Management in Saskatchewan, Canada. DIABETES EDUCATOR 2020; 46:261-270. [PMID: 32228289 DOI: 10.1177/0145721720913278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The purpose of this study was to capture information on patient experiences and perspectives of group medical appointments (GMAs) and compare them to those attending individual appointments (IAs) with the diabetes education team (usual care) for managing type 2 diabetes. METHODS Adults (N = 18; 61% male; 83% 50-70 years old ) with type 2 diabetes (or prediabetes) living in rural Saskatchewan were recruited to complete a semistructured interview on their experiences with GMAs or IAs. To be eligible to participate, individuals must have attended at least 2 GMAs or 2 IAs. Transcripts were coded and analyzed using content analysis. RESULTS Overall, participants spoke highly of their respective appointment type. Results indicated that both appointment types positively influenced understanding of diabetes management, with the most notable difference being greater understanding of stress management in the GMAs. Participants identified several positive aspects of each appointment type, which included convenience, supportive and enjoyable, and informative for GMAs and time and tailored information for IAs. Participants provided some suggestions to improve diabetes related-care for their respective appointment type. CONCLUSIONS Participants of GMAs and IAs for type 2 diabetes each reported unique strengths to their respective care plan and reported benefiting from their care.
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Affiliation(s)
- Anna Tataryn
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Hannah Derbowka
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Xinyu Shen
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Emily Gage
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Ester Kang
- Nutrition and Food Services, Saskatchewan Health Authority, Saskatoon, Saskatchewan, Canada
| | - Jillian Wlock
- Sunrise Health and Wellness Centre, Saskatchewan Health Authority, Yorkton, Saskatchewan, Canada
| | - Jessica Lieffers
- College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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13
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Roth I, Thompson-Lastad A, Thomas AU. The Quadruple Aim as a Framework for Integrative Group Medical Visits. J Altern Complement Med 2020; 26:261-264. [PMID: 31971813 PMCID: PMC7153643 DOI: 10.1089/acm.2019.0425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Isabel Roth
- Program on Integrative Medicine, Department of Physical Medicine and Rehabilitation, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Ariana Thompson-Lastad
- Osher Center for Integrative Medicine, University of California San Francisco, San Francisco, CA
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14
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Meyer HM, Mocarski R, Holt NR, Hope DA, King RE, Woodruff N. Unmet Expectations in Health Care Settings: Experiences of Transgender and Gender Diverse Adults in the Central Great Plains. QUALITATIVE HEALTH RESEARCH 2020; 30:409-422. [PMID: 31328642 DOI: 10.1177/1049732319860265] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Transgender and gender diverse (TGD) individuals face a long-term, multifaceted process if they choose to begin a gender affirmation journey. Decisions to go on hormone therapy and/or have a surgical procedure necessitate the TGD individual to set up an appointment with a health care provider. However, when TGD patients interact with health care practitioners, problems can arise. This article documents and categorizes the types of unmet expectations that are common in the TGD patient-health care provider social dynamic in the Central Great Plains of the United States. Utilizing a community-based participatory research model, qualitative in-depth interviews were conducted with 27 TGD individuals about their health care experiences. From this, the researchers identified four main themes of unmet expectations: probing, gatekeeping, stigmatizing stance, and misgendering/deadnaming. Steps that can be taken by both the health care provider and the TGD individual to have a more successful encounter are discussed.
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Affiliation(s)
| | | | | | - Debra A Hope
- University of Nebraska-Lincoln, Lincoln, Nebraska, USA
| | - Robyn E King
- University of Nebraska at Kearney, Kearney, Nebraska, USA
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16
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Geller JS. Group Medical Visits: Introducing the "Group Inclusion Effect" and Key Principles for Maximization. J Altern Complement Med 2019; 25:673-674. [PMID: 31314563 DOI: 10.1089/acm.2019.0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Jeffrey S Geller
- Integrative Medicine and Group Medical Visits-Kronos Health, Integrated Center for Group Medical Visits, Lawrence, MA
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17
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Thompson-Lastad A, Gardiner P, Chao MT. Integrative Group Medical Visits: A National Scoping Survey of Safety-Net Clinics. Health Equity 2019; 3:1-8. [PMID: 30706043 PMCID: PMC6352502 DOI: 10.1089/heq.2018.0081] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose: Integrative group medical visits (IGMVs) aim to increase access to complementary and integrative health care, which is particularly relevant for low-income people. We sought to describe IGMV programs in US safety-net clinics through a survey of providers. Methods: An online and paper survey was conducted to collect data on the use of complementary health approaches and characteristics of IGMV programs. We recruited a purposive sample of safety-net clinicians via national meetings and listservs. Results: Fifty-seven clinicians reported on group medical visits. Forty percent worked in federally qualified health centers, 57% in safety-net or teaching hospitals, 23% in other settings such as free clinics. Thirty-seven respondents in 11 states provided care in IGMVs, most commonly for chronic pain and diabetes. Nutrition (70%), mindfulness/meditation/breathing (59%), and tai chi/yoga/other movement practices (51%) were the most common treatment approaches in IGMVs. Conclusion: Safety-net institutions in 11 states offered IGMVs to treat a range of chronic conditions. IGMVs are an innovative model to improve access to non-pharmacologic approaches to chronic illness care and health promotion. They may advance health equity by serving patients negatively impacted by health and health care disparities.
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Affiliation(s)
| | - Paula Gardiner
- Department of Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Maria T. Chao
- Division of General Internal Medicine and Osher Center for Integrative Medicine, UC San Francisco, San Francisco, California
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