What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review

Development of a group-based behaviour change intervention for people with severe obesity informed by the social identity approach to health

INTRODUCTION

Interventions to support behaviour change in people living with chronic health conditions increasingly use patient groups as the mode of delivery, but these are often designed without consideration of the group processes that can shape intervention outcomes. This article outlines a new approach to designing group-based behaviour change interventions that prioritizes recipients' shared social identity as group members in facilitating the adoption of established behaviour change techniques (BCTs). The approach is illustrated through an example drawn from research focused on people living with severe obesity.

METHODS

A prioritization process was undertaken in collaboration with stakeholders, including behaviour change experts, clinicians, and a former patient to develop an evidence-based, group intervention informed by the social identity approach to health. Three phases of development are reported: (1) identification of the health problem; (2) delineation of intervention mechanisms and operationalization of BCTs for group delivery and (3) intervention manualization. The fourth phase, intervention testing and optimization, is reported elsewhere.

RESULTS

A group-based behaviour change intervention was developed, consisting of 12 group sessions and 3 one-to-one consultations. The intervention aimed to support the development of shared social identity among recipients, alongside the delivery of evidence-based BCTs, to improve the likelihood of successful intervention and health outcomes among people living with severe obesity.

CONCLUSIONS

A manualized intervention, informed by the social identity approach to health, was systematically designed with input from stakeholders. The development approach employed can inform the design of behavioural interventions in other health contexts where group-based delivery is planned.

Determinants of implementation for group medical visits for patients with chronic pain: a systematic review

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 .

Lessons learned and recommendations in conducting solutions-driven environmental and public health research

Solutions-driven research is a transdisciplinary approach that incorporates diverse forms of expertise to identify solutions to stakeholder-identified environmental problems. This qualitative evaluation of early solutions-driven research projects provides transferable recommendations to improve researcher and stakeholder experiences and outcomes in transdisciplinary environmental research projects. Researchers with the U.S. Environmental Protection Agency (EPA) Office of Research and Development recently piloted a solutions-driven research approach in two parallel projects; one addressing nutrient management related to coastal waters and another studying wildland fire smoke impacts on indoor air quality. Studying the experiences of those involved with these pilots can enhance the integration of researcher and experiential expertise, improving solutions-driven research outcomes. Data collection included semi-structured interviews with 17 EPA researchers and 12 other stakeholders and reflective case narratives from the authors. We used conventional content analysis to qualitatively analyze perspectives on implementing innovative engagement and research approaches in a solutions-driven process. Findings that reflect common perspectives include the importance of continuous engagement, the challenges of differing timelines and priorities for researchers and stakeholders, and the need to define consistent markers of success across researchers and stakeholders. Key lessons to improve transdisciplinary research identified from the analysis are (1) improving clarity of roles and responsibilities; (2) planning to provide sufficient, continuous project funding over multiple years; (3) expecting research needs and plans to adapt to evolving circumstances; and (4) clearly defining the end of the project.

Feasibility and efficacy of implementing group visits for women's health conditions: a systematic review

BACKGROUND

Shared medical appointments, also known as group visits, are a feasible and well-accepted approach for women receiving antenatal care, yet the feasibility and efficacy of this approach for female-specific reproductive conditions is uncertain.

OBJECTIVE

The aim of this systematic review was to (a) determine the feasibility of group visits in adults with any female-specific reproductive condition, and (b) identify whether delivering group care for these conditions impacts clinical outcomes.

METHOD

Six databases and two clinical trials registries were searched from inception through to 26 January 2022 for original research examining group medical visits or group consultation interventions for adults with female reproductive conditions or pathologic conditions specific to the female reproductive system.

RESULTS

The search yielded 2584 studies, of which four met the inclusion criteria. Included studies sampled women with breast cancer, chronic pelvic pain, polycystic ovary syndrome and gynaecological cancers. Studies reported high levels of patient satisfaction, with participants indicating their expectations had been met or exceeded. The impact of group visits on clinical outcomes was inconclusive however.

DISCUSSION/CONCLUSIONS

The studies in this review indicate delivery of female-specific healthcare via a group model maybe feasible and well-accepted. The review provides a solid basis for proposing larger and longer studies on group visits for female reproductive conditions.

TRIAL REGISTRATION

The review protocol was registered with PROSPERO (CRD42020196995).

Implementation and delivery of group consultations for young people with diabetes in socioeconomically deprived, ethnically diverse settings

BACKGROUND

Young people with diabetes experience poor clinical and psychosocial outcomes, and consider the health service ill-equipped in meeting their needs. Improvements, including alternative consulting approaches, are required to improve care quality and patient engagement. We examined how group-based, outpatient diabetes consultations might be delivered to support young people (16-25 years old) in socio-economically deprived, ethnically diverse settings.

METHODS

This multi-method, comparative study recruited a total of 135 young people with diabetes across two implementation and two comparison sites (2017-2019). Informed by a 'researcher-in-residence' approach and complexity theory, we used a combination of methods: (a) 31 qualitative interviews with young people and staff and ethnographic observation in group and individual clinics, (b) quantitative analysis of sociodemographic, clinical, service use, and patient enablement data, and (c) micro-costing analysis.

RESULTS

Implementation sites delivered 29 group consultations in total. Overall mean attendance per session was low, but a core group of young people attended repeatedly. They reported feeling better understood and supported, gaining new learning from peers and clinicians, and being better prepared to normalise diabetes self-care. Yet, there were also instances where peer comparison proved difficult to manage. Group consultations challenged deeply embedded ways of thinking about care provision and required staff to work flexibly to achieve local tailoring, sustain continuity, and safely manage complex interdependencies with other care processes. Set-up and delivery were time-consuming and required in-depth clinical and relational knowledge of patients. Facilitation by an experienced youth worker was instrumental. There was indication that economic value could derive from preventing at least one unscheduled consultation annually.

CONCLUSIONS

Group consulting can provide added value when tailored to meet local needs rather than following standardised approaches. This study illustrates the importance of adaptive capability and self-organisation when integrating new models of care, with young people as active partners in shaping service provision.

TRIAL REGISTRATION

ISRCTN reference 27989430.

A group-based behavioural intervention for weight management (PROGROUP) versus usual care in adults with severe obesity: a feasibility randomised controlled trial protocol

Background

Approximately 15 million people in the UK live with obesity, around 5 million of whom have severe obesity (body mass index (BMI) ≥35kg/m²). Having severe obesity markedly compromises health, well-being and quality of life, and substantially reduces life expectancy. These adverse outcomes are prevented or ameliorated by weight loss, for which sustained behavioural change is the cornerstone of treatment. Although NHS specialist ‘Tier 3’ Weight Management Services (T3WMS) support people with severe obesity, using individual and group-based treatment, the current evidence on optimal intervention design and outcomes is limited. Due to heterogeneity of severe obesity, there is a need to tailor treatment to address individual needs. Despite this heterogeneity, there are good reasons to suspect that a structured group-based behavioural intervention may be more effective and cost-effective for the treatment of severe obesity compared to usual care. The aims of this study are to test the feasibility of establishing and delivering a multi-centre randomised controlled clinical trial to compare a group-based behavioural intervention versus usual care in people with severe obesity.

Methods

This feasibility randomised controlled study is a partially clustered multi-centre trial of PROGROUP (a novel group-based behavioural intervention) versus usual care. Adults ≥18 years of age who have been newly referred to and accepted by NHS T3WMS will be eligible if they have a BMI ≥40, or ≥35 kg/m² with comorbidity, are suitable for group-based care and are willing to be randomised. Exclusion criteria are participation in another weight management study, planned bariatric surgery during the trial, and unwillingness or inability to attend group sessions. Outcome assessors will be blinded to treatment allocation and success of blinding will be evaluated. Clinical measures will be collected at baseline, 6 and 12 months post-randomisation. Secondary outcome measures will be self-reported and collected remotely. Process and economic evaluations will be conducted.

Discussion

This randomised feasibility study has been designed to test all the required research procedures and additionally explore three key issues; the feasibility of implementing a complex trial at participating NHS T3WMS, training the multidisciplinary healthcare teams in a standard intervention, and the acceptability of a group intervention for these particularly complex patients.

Trial registration

ISRCTN number 22088800.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01167-0.

Implementing video group consultations in general practice during COVID-19: a qualitative study

Background

Group consultations have been gaining ground as a novel approach to service delivery. When in-person care was restricted owing to COVID-19, general practice staff began delivering group consultations remotely over video.

Aim

To examine how multiple interacting influences underpinned implementation and delivery of video group consultations (VGCs).

Design and setting

Qualitative study in general practice in England.

Method

a) 32 semi-structured interviews with patients, clinical, and non-clinical staff (from eight GP surgeries in total), NHS policymakers and programme managers, and other stakeholders; b) observation in relevant training and operational meetings; and c) three co-design workshops (21 participants). Thematic analysis was informed by the Planning and Evaluating Remote Consulting Services (PERCS) framework.

Results

In the first year of the pandemic, VGCs focused on supporting those with long-term conditions or other shared health and social needs. Most patients welcomed clinical and peer input, and the opportunity to access their practice remotely during lockdown. However, not everyone agreed to engage in group-based care or was able to access IT equipment. At practice level, significant work was needed to deliver VGCs, such as setting up the digital infrastructure, gaining team buy-in, developing new patient-facing online facilitation roles, managing background operational processes, protecting online confidentiality, and ensuring professional indemnity cover. Training provided nationally was seen as instrumental in capacity building for VGC implementation.

Conclusion

Small scale VGC implementation addressed unmet need during the pandemic. However, embedding VGCs in routine care requires rethinking of operational, infrastructural, and clinical processes. Additional research on costs and benefits at service and patient level is needed.

Barriers to losing weight for women attending group visits in primary care: A qualitative exploration using in-depth interviews

Background

Despite the accumulated evidence suggesting the positive aspects of using group visits in obesity, the number of qualitative studies that examine why and how the effects occur at an individual level is limited.

Objectives

This qualitative study aimed to explore the experiences and perspectives of women who participated in group visits and had different weight loss outcomes in the programme.

Method

Purposive maximum variation sampling was performed. Data collection and analysis were performed iteratively, and the data saturation method was used as a guideline for sample size. All participants who completed the group visits were approached, and finally, 20 individuals were included in the study. Semi-structured in-depth interviews were audio-recorded, transcribed verbatim, and analysed thematically using a phenomenological approach.

Results

The mean age of the individuals was 38.5 ± 9.8 years, the education level ranged from incomplete-high school to university degree, and the weight changes were between +4.1% and −17.1%. Two main themes emerged from the thematic analysis revealing barriers: weight stigma (two sub-themes: internal and external stigma) and traumatic life events (three sub-themes: ‘loss of relatives,’ ‘childhood traumas,’ and ‘conflicting intimate partner relationships’).

Conclusion

Considering the barriers to weight loss efforts in this study, these issues need to be explicitly investigated before and during the group visits in addition to weight loss practices and behavioural changes.

CLUSTER searching approach to inform evidence syntheses: A methodological review

BACKGROUND

The CLUSTER model of searching was proposed as a systematic method of searching for studies for reviews of complex interventions.

AIM

The method has not been evaluated before. This methodological review identified and evaluated a sample of evidence syntheses that have used CLUSTER.

METHODS

A forward citation search on the seed CLUSTER publication was conducted on Web of Science Core Collection using six journal citation indexes and Google Scholar in December 2020. Reviews which used the CLUSTER method were eligible for inclusion. A narrative synthesis was used to describe the types of evidence syntheses that used CLUSTER searching, the extent to which the CLUSTER approach has been operationalised within evidence syntheses and whether the value, benefits and limitations of CLUSTER were assessed by the reviewers.

FINDINGS

A total of 16 reviews were identified and eligible for synthesis. Six different review types that used CLUSTER were identified with realist reviews being the most prominent. The evaluation of complex interventions was the most common review topic area. The use of CLUSTER varied among reviews with the retrieval of sibling studies being the most common reason. 'Citations' and 'Lead authors' were the most followed elements of CLUSTER.

CONCLUSIONS

Evidence suggests that CLUSTER has been adopted for use in reviews of complex interventions. Its usage varied among the included reviews. It is imperative that future reviewers diligently report the elements and steps of CLUSTER that were utilised in order to provide a reproducible and transparent search strategy that can be reported with similar transparency to bibliographic database searches.

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

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.

A Multi-Domain Group-Based Intervention to Promote Physical Activity, Healthy Nutrition, and Psychological Wellbeing in Older People with Losses in Intrinsic Capacity: AMICOPE Development Study

The World Health Organization has developed the Integrated Care of Older People (ICOPE) strategy, a program based on the measurement of intrinsic capacity (IC) as "the composite of all physical and mental attributes on which an individual can draw". Multicomponent interventions appear to be the most effective approach to enhance IC and to prevent frailty and disability since adapted physical activity is the preventive intervention that has shown the most evidence in the treatment of frailty and risk of falls. Our paper describes the development of a multi-domain group-based intervention addressed to older people living in the community, aimed at improving and/or maintaining intrinsic capacity by means of promoting physical activity, healthy nutrition, and psychological wellbeing in older people. The process of intervention development is described following the Guidance for reporting intervention development studies in health research (GUIDED). The result of this study is the AMICOPE intervention (Aptitude Multi-domain group-based intervention to improve and/or maintain IC in Older PEople) built upon the ICOPE framework and described following the Template for Intervention Description and Replication (TIDieR) guidelines. The intervention consists of 12 face-to-face sessions held weekly for 2.5 h over three months and facilitated by a pair of health and social care professionals. This study represents the first stage of the UK Medical Research Council framework for developing and evaluating a complex intervention. The next step should be carrying out a feasibility study for the AMICOPE intervention and, at a later stage, assessing the effectiveness in a randomized controlled trial.

Experience of implementing and delivering group consultations in UK general practice: a qualitative study

Background

Group consultations are a relatively new concept in UK primary care and are a suggested solution to current workload pressures in general practice. Little is known about the experience of implementing and delivering this approach from staff and organisational perspectives.

Aim

To explore the experience of implementing and delivering group consultations in general practice.

Design and setting

Qualitative telephone interview study.

Method

Topic guides explored the perspectives and experiences of general practice staff on the implementation and delivery of group consultations. Data analysis adopted principles of the Framework Method underpinned by Normalisation Process Theory.

Results

Interviews were conducted with 8 GPs, 8 practice nurses, 1 nurse associate, 1 practice pharmacist, 1 deputy practice manager, and 1 healthcare assistant. Four themes were identified: sense making of group consultations; the work associated with initiating group consultations; the experiences of operationalising group consultations; and sustaining change. Group consultations made sense to participants as a mechanism to reduce burden on primary care, enhance multidisciplinary working, and provide patient-centred care. Implementation required strong leadership from a ‘champion’, and a facilitator had a pivotal role in operationalising the approach. The associated workload was often underestimated. Barriers to embedding change included achieving whole practice buy-in, competing practice priorities, and system-level flexibility.

Conclusion

General practice clinicians enjoyed group consultations, yet significant work is required to initiate and sustain the approach. An implementation plan considering leadership, roles and responsibilities, and wider organisational support is required at the outset. Further research or evaluation is needed to measure process outcomes.

Young People Who Display Harmful Sexual Behaviors and Their Families: A Qualitative Systematic Review of Their Experiences of Professional Interventions

It is estimated that 30-50% of all childhood sexual abuse involves other young people as perpetrators. The treatment of harmful sexual behavior (HSB) in young people has evolved from interventions developed for use with adult perpetrators of sexual offenses. Increasingly, these approaches were not seen as appropriate for use with young people. The purpose of this qualitative systematic review was to establish what intervention components are viewed as acceptable or useful by young people and their families in order to inform the development of interventions for young people with HSB. We conducted searches across 14 electronic databases as well as contacting experts to identify relevant studies. Thirteen qualitative studies were included in the analysis, reporting findings from intervention studies from the United Kingdom, United States, New Zealand, Australia, and Ireland. Thematic analysis was used to combine findings from the studies of young people and parent/carers views. Five key themes were identified as critical components of successful interventions for young people with HSB. These included the key role of the relationship between the young person and practitioner, the significance of the role of parents and carers, the importance of considering the wider context in which the abuse has occurred, the role of disclosure in interventions, and the need to equip young people with skills as well as knowledge. The evidence was limited by the small number of studies that were mainly from the perspectives of adolescent males.

Making connections: Social identification with new treatment groups for lifestyle management of severe obesity

Groups are regularly used to deliver healthcare services, including the management of obesity, and there is growing evidence that patients' experiences of such groups fundamentally shape treatment effects. This study investigated factors related to patients' shared social identity formed within the context of a treatment group for the management of severe obesity. A cross-sectional survey was administered to patients registered with a UK medical obesity service and enrolled on a group-based education and support programme. Patients (N = 78; M_BMI = 48 on entry to the service) completed measures of group demographics (e.g., group membership continuity) and psychosocial variables (e.g., past experiences of weight discrimination) and reported their social identification with the treatment group. The results showed that patients identified with the treatment group to the extent that there was continuity in membership across the programme and they perceived themselves more centrally in terms of their weight status. Weight centrality was negatively associated with external social support and positively associated with experiences of weight discrimination. Group continuity was positively correlated with session attendance frequency. Patients presenting to clinical treatment services with severe obesity often do so after sustained weight loss failure and exposure to negative societal experiences. This study highlights that providing a treatment environment wherein these experiences can be shared with other patients may provide common ground for development of a new, positive social identity that can structure programme engagement and progression.

Mixed methods study of a new model of care for chronic disease: co-design and sustainable implementation of group consultations into clinical practice

Objectives

Group consultations are used for chronic conditions, such as inflammatory arthritis, but evidence of efficacy for treatment to target or achieving tight control is lacking. Our aim was to establish whether group consultation is a sustainable, co-designed routine care option and to explore factors supporting spread.

Methods

The study used mixed methods, observational process/outcome data, plus qualitative exploration of enabling themes. It was set in two community hospitals, in 2008–19, with a third hospital from 2016, and was triangulated with primary care qualitative data. There was a total of 3363 arthritis patient attendances at 183 clinics during 2008–19. The early arthritis cohort comprised 46 patients, followed monthly until the treatment target was achieved, during 2016–19. Focus groups included 15 arthritis and 11 osteoporosis group attendees. Intervention was a 2 h group consultation, attended monthly for early/active disease and annually for stable disease. Measurements included attendance, DAS, satisfaction and enabling themes.

Results

There was a mean number of 18.4 patients per clinic (n = 16, 2010–15; n = 18, 2016; n = 20, 2017; n = 23, 2018–19). Forty per cent (1161/2874) of patients with DAS data reached low disease activity (DAS < 3.2) or remission (DAS < 2.6). Forty-six early arthritis patients followed monthly until they achieved remission responded even better: 50% remission; and 89% low disease activity/remission by 6 months. Qualitative analysis derived five main enabling themes (efficiency, empathy, education, engagement and empowerment) and five promotors to translate these themes into practice (prioritization, personalization, participation, personality and pedagogy). Limitations included the prospectively collected observational data and pragmatic design susceptible to bias.

Conclusion

Co-designed group consultations can be sustainable, clinically effective and efficient for monthly review of early active disease and annual review of stable disease. Promoting factors may support effective training for chronic disease group consultations.

How Group-Based Interventions Can Improve Services for People with Severe Obesity

PURPOSE OF REVIEW

Rising demand for specialised "Tier 3" weight management services in England is exceeding capacity, leading many services to offer group-based care programmes. This review considers the organisation of current provision, exploring how group programmes may enhance services and how these could be scaled up for wider implementation.

RECENT FINDINGS

Existing group-based programmes mainly focus on providing patients with information and education about their condition. Evidence suggests that groups themselves offer therapeutic benefits beyond this, by underpinning patients' engagement with programme materials and contributing to wider health and well-being. To maximise these benefits, there is a need to attend to the group processes that emerge in treatment groups which, left unchecked, may limit or even adversely impact programme outcomes. Group-based interventions may be of benefit to patients in Tier 3 specialist weight management services, although their format is complex and reliant on facilitators' expertise.

Shared medical appointments and patient-centered experience: a mixed-methods systematic review

Background

Shared medical appointments (SMAs), or group visits, are a healthcare delivery method with the potential to improve chronic disease management and preventive care. In this review, we sought to better understand opportunities, barriers, and limitations to SMAs based on patient experience in the primary care context.

Methods

An experienced biomedical librarian conducted literature searches of PubMed, Cochrane Library, PsycINFO, CINAHL, Web of Science, ClinicalTrials.gov, and SSRN for peer-reviewed publications published 1997 or after. We searched grey literature, nonempirical reports, social science publications, and citations from published systematic reviews. The search yielded 1359 papers, including qualitative, quantitative, and mixed method studies. Categorization of the extracted data informed a thematic synthesis. We did not perform a formal meta-analysis.

Results

Screening and quality assessment yielded 13 quantitative controlled trials, 11 qualitative papers, and two mixed methods studies that met inclusion criteria. We identified three consistent models of care: cooperative health care clinic (five articles), shared medical appointment / group visit (10 articles) and group prenatal care / CenteringPregnancy® (11 articles).

Conclusions

SMAs in a variety of formats are increasingly employed in primary care settings, with no singular gold standard. Accepting and implementing this nontraditional approach by both patients and clinicians can yield measurable improvements in patient trust, patient perception of quality of care and quality of life, and relevant biophysical measurements of clinical parameters. Further refinement of this healthcare delivery model will be best driven by standardizing measures of patient satisfaction and clinical outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12875-019-0972-1) contains supplementary material, which is available to authorized users.

Promises and Perils of Group Clinics for Young People Living With Diabetes: A Realist Review

Group clinics are becoming popular as a new care model in diabetes care. This evidence synthesis, using realist review methodology, examined the role of group clinics in meeting the complex needs of young people living with diabetes. Following Realist And Meta-narrative Evidence Synthesis-Evolving Standards (RAMESES) quality standards, we conducted a systematic search across 10 databases. A total of 131 articles met inclusion criteria and were analyzed to develop theoretically informed explanations of how and why group clinics could work (or not) for young people with diabetes. Models of group-based care in the literature varied significantly and incorporated different degrees of clinical and educational content. Our analysis identified four overarching principles that can be applied in different contexts to drive sustained engagement of young people in group clinics: 1) emphasizing self-management as practical knowledge; 2) developing a sense of affinity between patients; 3) providing safe, developmentally appropriate care; and 4) balancing group and individual needs. Implementation of group clinics was not always straightforward; numerous adjustments to operational and clinical processes were required to establish and deliver high-quality care. Group clinics for young people with diabetes offer the potential to complement individualized care but are not a panacea and may generate as well as solve problems.

PROCESS AND SYSTEMS: A systems approach to embedding group consultations in the NHS

Group consultations are an important care option that is -starting to gain traction in the USA and Australia. This review summarises the likely benefits accruing from a systems -approach to implementing group consultations widely in the NHS and other socialised healthcare systems. Existing evidence is mapped to five distinct systems approaches: (1) development; (2) different age groups; (3) patient-centred pathway of care; (4) NHS system changes; and (5) education. Implications are discussed for patients and staff, who both benefit from group consultations once embedded; ranging from improved access and efficiency to more enjoyable multidisciplinary team working, improved resource management, and maintained/better outcomes. Moreover, even patients who don't attend group consultations can benefit from system effects of long-term implementation. Changing behaviour and health systems is challenging, but change requires systematic experimentation and documentation of evidence. We conclude that group consultations have unique potential for delivering system-wide benefits across the NHS.

Rehabilitation technologies and interventions for individuals with spinal cord injury: translational potential of current trends

In the past, neurorehabilitation for individuals with neurological damage, such as spinal cord injury (SCI), was focused on learning compensatory movements to regain function. Presently, the focus of neurorehabilitation has shifted to functional neurorecovery, or the restoration of function through repetitive movement training of the affected limbs. Technologies, such as robotic devices and electrical stimulation, are being developed to facilitate repetitive motor training; however, their implementation into mainstream clinical practice has not been realized. In this commentary, we examined how current SCI rehabilitation research aligns with the potential for clinical implementation. We completed an environmental scan of studies in progress that investigate a physical intervention promoting functional neurorecovery. We identified emerging interventions among the SCI population, and evaluated the strengths and gaps of the current direction of SCI rehabilitation research. Seventy-three study postings were retrieved through website and database searching. Study objectives, outcome measures, participant characteristics and the mode(s) of intervention being studied were extracted from the postings. The FAME (Feasibility, Appropriateness, Meaningfulness, Effectiveness, Economic Evidence) Framework was used to evaluate the strengths and gaps of the research with respect to likelihood of clinical implementation. Strengths included aspects of Feasibility, as the research was practical, aspects of Appropriateness as the research aligned with current scientific literature on motor learning, and Effectiveness, as all trials aimed to evaluate the effect of an intervention on a clinical outcome. Aspects of Feasibility were also identified as a gap; with two thirds of the studies examining emerging technologies, the likelihood of successful clinical implementation was questionable. As the interventions being studied may not align with the preferences of clinicians and priorities of patients, the Appropriateness of these interventions for the current health care environment was questioned. Meaningfulness and Economic Evidence were also identified as gaps since few studies included measures reflecting the perceptions of the participants or economic factors, respectively. The identified gaps will likely impede the clinical uptake of many of the interventions currently being studied. Future research may lessen these gaps through a staged approach to the consideration of the FAME elements as novel interventions and technologies are developed, evaluated and implemented.

Group clinics for young adults with diabetes in an ethnically diverse, socioeconomically deprived setting (TOGETHER study): protocol for a realist review, co-design and mixed methods, participatory evaluation of a new care model

INTRODUCTION

Young adults with diabetes often report dissatisfaction with care and have poor diabetes-related health outcomes. As diabetes prevalence continues to rise, group-based care could provide a sustainable alternative to traditional one-to-one consultations, by engaging young people through life stage-, context- and culturally-sensitive approaches. In this study, we will co-design and evaluate a group-based care model for young adults with diabetes and complex health and social needs in socioeconomically deprived areas.

METHODS AND ANALYSIS

This participatory study will include three phases. In phase 1, we will carry out a realist review to synthesise the literature on group-based care for young adults with diabetes. This theory-driven understanding will provide the basis for phase 2, where we will draw on experience-based co-design methodologies to develop a new, group-based care model for young adults (aged <25 years, under the care of adult diabetes services). In phase 3, we will use a researcher-in-residence approach to implement and evaluate the co-designed group clinic model and compare with traditional care. We will employ qualitative (observations in clinics, patient and staff interviews and document analysis) and quantitative methods (eg, biological markers, patient enablement instrument and diabetes distress scale), including a cost analysis.

ETHICS AND DISSEMINATION

National Health Service ethics approval has been granted (reference 17/NI/0019). The project will directly inform service redesign to better meet the needs of young adults with diabetes in socioeconomically deprived areas and may guide a possible cluster-randomised trial, powered to clinical and cost-effectiveness outcomes. Findings from this study may be transferable to other long-term conditions and/or age groups. Project outputs will include briefing statements, summaries and academic papers, tailored for different audiences, including people living with diabetes, clinicians, policy makers and strategic decision makers.

REGISTRATION DETAILS

PROSPERO (CRD42017058726).