Group Medical Care: A Systematic Review of Health Service Performance

Self-Monitoring With Coping Skills and Lifestyle Education for Hypertension Control in Primary Care

Self-monitoring with support, lifestyle modifications, and emotion management improves blood pressure (BP). Patients with hypertension need continual support to modify behaviors, but time pressures limit lifestyle education in primary care settings. Using mixed methods, we aimed to study the feasibility and acceptability of an innovative 6-week program that combined self-monitoring with coping skills and lifestyle education for patients with uncontrolled hypertension. Patients with uncontrolled hypertension interested in lifestyle modifications before intensifying medications were enrolled from primary care clinics. Patients self-monitored emotions, behaviors, and BPs and received education from medical providers and mind-body therapists through shared medical appointments (SMAs) with an option of weekly printed materials. Over 6 months, 31 eligible participants completed the program with higher uptake (21/41) from physician referrals (74.2% women, 41.9% Black, median household income $100 000). Fourteen participants opted for weekly educational materials due to upcoming SMA sessions being fully booked or personal schedules. Pre- to post-intervention paired t-test showed improvement in systolic BP of 11.6 mmHg (95% CI, 6.6-16.6, p < 0.0001), and hypertension control rate improved by 36% (11/31) post-intervention. Higher baseline systolic BP was associated with higher BP reduction (p < 0.001). Thematic analysis showed the perceived benefit of self-awareness, education, and peer support, whereas time constraints were perceived as challenges. Self-monitoring with education on coping skills and lifestyle modification is feasible and improved BP and hypertension control across diverse primary care patients interested in lifestyle modifications; however, few low-income patients enrolled. Less burdensome and community-based interventions may improve participation in low-income patients.

Cost-effectiveness of group medical visits and microfinance interventions versus usual care to manage hypertension in Kenya: a secondary modelling analysis of data from the Bridging Income Generation with Group Integrated Care (BIGPIC) trial

BACKGROUND

The Bridging Income Generation with Group Integrated Care (BIGPIC) trial in rural Kenya showed that integrating usual care with group medical visits or microfinance interventions reduced systolic blood pressure and cardiovascular risk in participants. We aimed to estimate the incremental cost-effectiveness of three BIGPIC interventions for a modelled cohort and by sex, as well as the cost of implementing these interventions.

METHODS

For this analysis, we used data collected during the BIGPIC trial, a four-group, cluster-randomised trial conducted in the western Kenyan catchment area of the Academic Model Providing Access to Healthcare. BIGPIC enrolled participants from 24 rural health facilities in rural western Kenya aged 35 years or older with either increased blood pressure or diabetes. Participants were assigned to receive either usual care, group medical visits, microfinance, or a combination of group medical visits and microfinance (GMV-MF). Our model estimated the incremental cost-effectiveness of the three BIGPIC interventions via seven health states (ie, a hypertensive state, five chronic cardiovascular-disease states, and a death state) by simulating transitions between health states for a hypothetical cohort of individuals with hypertension on the basis of QRISK3 scores. In every cycle, participants accrued costs and disability-adjusted life-years (DALYs) associated with their health state. Incremental cost-effectiveness ratios (ICERs) were calculated for the entire modelled cohort and by sex by dividing the incremental cost by the incremental effectiveness of the next most expensive intervention. The main outcome of this analysis was ICERs for each intervention evaluated. This analysis is registered at ClinicalTrials.gov (NCT02501746).

FINDINGS

Between Feb 6, 2017, and Dec 29, 2019, 2890 people were recruited to the BIGPIC trial. 2020 (69·9%) of 2890 participants were female and 870 (30·1%) were male. At baseline, mean QRISK3 score was 11·5 (95% CI 11·1-11·9) for the trial population, 11·9 (11·5-12·2) for male participants, and 11·3 (11·0-11·6) for female participants. For the population of Kenya, group medical visits were estimated to cost US$7 more per individual than usual care and result in 0·005 more DALYs averted (ICER $1455 per DALY averted). Microfinance was estimated to cost $19 more than group medical visits but was only estimated to avert 0·001 more DALYs. Relative to group medical visits, GMV-MF was estimated to cost $29 more and avert 0·009 more DALYs ($3235 per DALY averted). Relative to usual care, GMV-MF was estimated to cost $37 more and avert 0·014 more DALYs ($2601 per DALY averted). In the first year of the intervention, usual care was estimated to be the least expensive intervention to implement ($87 per participant; $10 238 per health-facility catchment area [HFCA]), then group medical visits ($99 per participant; $12 268 per HFCA), then microfinance ($120 per participant; $14 172 per HFCA), with GMV-MF estimated to be the most expensive intervention to implement ($139 per participant; $16 913 per HFCA).

INTERPRETATION

Group medical visits and GMV-MF were estimated to be cost-effective strategies to improve blood-pressure control in rural Kenya. However, which intervention to pursue depends on resource availability. Policy makers should consider these factors, in addition to sex differences in programme effectiveness, when selecting optimal implementation strategies.

FUNDING

US National Institutes of Health.

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 .

Optimizing Diabetes Care Through Listening to Multiple Voices

This article is adapted from the address Dr. Caballero delivered as the recipient of the American Diabetes Association's Outstanding Educator in Diabetes Award for 2023. He delivered the address in June 2023 during the Association's 83rd Scientific Sessions in San Diego, CA. A webcast of this speech is available for viewing on the DiabetesPro website (https://events.diabetes.org/live/25/page/186).

Group medicare wellness visits: A pilot exploration of an approach to wellness and preventive medicine for older adults

Introduction

The Medicare annual wellness visit was designed to address health risks and encourage evidence-based preventive care in aging. However, it can be challenging for providers to dedicate time for comprehensive attention to wellness during these visits. Our project implements a group setting for Medicare wellness visits (GMWV) as an efficient method for delivering high value preventive care.

Methods

Three hundred patients from two primary care ambulatory clinics in Detroit, MI in need of their annual Medicare visit were invited to participate in the pilot GMWV. Fifty-eight patients agreed and completed their GMWV. The visit included collection of vitals, vision screening, and risk assessment during check-in, followed by educational wellness presentations led by an interdisciplinary team of six healthcare professionals. Patients completed a post visit-satisfaction survey and researchers calculated rates of completion of health maintenance gaps (HMG), i.e. immunizations and cancer screenings, among participants.

Results

The average age of participants (N female = 48) was 74 years old. Thirty-four participants had more than one HMG at baseline. On average, 8 % of immunization gaps and 12 % of screening gaps were completed at or within one-year post GMWV. Participant feedback reported that 82 % of patients felt that they learned something new from the presentation and 81 % of patients felt satisfied with the amount of time they spent with their physician.

Discussion

GMWV is a feasible approach to promoting wellness and healthy aging that patients find satisfying although, additional study is needed to compare the effectiveness of this model to standard care.

Physician-Chef-Dietitian Partnerships for Evidence-Based Dietary Approaches to Tackling Chronic Disease: The Case for Culinary Medicine in Teaching Kitchens

Since the middle of the 20th century, the American food environment has become increasingly ultra-processed. As a result, the prevalence of chronic, diet-related disease in the United States has skyrocketed. Meanwhile, physicians are still poorly trained in nutrition. A recent innovation that aims to address this is "culinary medicine" programming taught by teams of physicians, chefs, and registered dietitian nutritionists. Culinary medicine is an evidence-based, interprofessional field of medicine that combines culinary arts, nutrition science, and medical education to prevent and treat diet-related disease. It employs hands-on learning through healthy cooking and is typically taught in a teaching kitchen, either in-person or virtually. It can be dosed either as a patient care intervention or as experiential nutrition education for students, medical trainees, and healthcare professionals. Culinary medicine programs are effective, financially feasible, and well-received. As a result, healthcare systems and medical education programs are increasingly incorporating culinary medicine, teaching kitchens, and interprofessional nutrition education into their patient care and training models.

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).

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)

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 A_1c (HbA_1c) 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 HbA_1c ≥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 HbA_1c 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 HbA_1c 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.