Shared Medical Appointments Research Articles

Abstract: A Longitudinal Study of Patient-Reported Outcomes in Adolescent Breast Reduction

INTRODUCTION: To use a validated patient-reported outcomes measure to assess the satisfaction and well-being of adolescent patients before and after surgical treatment for macromastia. METHODS: This longitudinal study included adolescent females who were managed in clinic for macromastia and received both pre- and postoperative surveys. All patients who attended shared medical appointments during the study period were administered the preoperative BREAST-Q1 as a condition-specific measure of satisfaction and wellbeing. Patients who received surgical treatment were also administered the postoperative BREAST-Q at least 3 months after surgery. BREAST-Q scores range from 0–100 for each tested domain, with 100 corresponding to highest well-being or satisfaction. In addition, we recorded grams of breast tissue removed during surgery and postoperative complications. EXPERIENCE: During the study period, 22 patients who attended shared medical appointments were scheduled for reduction mammoplasty. Six surgeries were cancelled due to inability to obtain insurance coverage. The remaining 16 patients received surgery, eight of whom have taken follow-up surveys and were thus included in this analysis. RESULTS: For BREAST-Q domains that were measured pre- and postoperatively, the average scores significantly increased after surgery as follows: satisfaction with breasts increased from 21.8 to 76.0 (p=0.01), psychosocial well-being increased from 40.1 to 85.3 (p=0.04), and physical wellbeing increased from 24.6 to 83.6 (p=0.01). There was not a significant increase for sexual well-being, though average score increased from 35.8 to 72.8 (p=0.68). Postoperatively, patients also reported an average score of 92.6 for satisfaction with outcome, 81.3 for satisfaction with information, 82.4 for satisfaction with nipples, 100 for satisfaction with surgeon, 100 for satisfaction with medical staff, and 100 for satisfaction with office staff. The average weight of breast tissue removed was 802.0 grams per side. CONCLUSION: This is the first report of adolescent satisfaction and well-being before and after breast reduction surgery using the BREAST-Q. Given that we saw a significant increase in patient well-being and satisfaction after surgical treatment, the BREAST-Q should continue to be validated in the adolescent population so plastic surgeons can further demonstrate the functional and psychosocial benefits of adolescent reduction mammoplasties to third-party payors. Reference Citations: 1. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient reported outcome measure for breast surgery: the BREAST-Q. Plastic and Reconstructive Surgery 2009;124(2):345–53

A Shared Medical Appointment on the Benefits and Risks of Opioids in Chronic Pain Management: Evaluation of a Pilot Program in an Ambulatory Setting

A Shared Medical Appointment on the Benefits and Risks of Opioids in Chronic Pain Management: Evaluation of a Pilot Program in an Ambulatory Setting

A Description of Patient and Provider Experience and Clinical Outcomes After Heart Failure Shared Medical Appointment.

Background:Shared medical appointments (SMAs) are clinical visits in which several patients meet with 1 or more providers at the same time.Objective:To describe the outcomes of an interdisciplinary SMA for veterans recently discharged for heart failure (HF).Methods:A retrospective chart review for patients’ readmission rates, survival, medication adherence, and medication-related problems. For qualitative outcomes, we performed semistructured interviews on 12 patients who had undergone HF SMAs and their respective caregivers focusing on care satisfaction, HF knowledge, disease self-care, medication reconciliation, and peer support.Results:The cohort comprised 70 patients—49% had left ventricular function <40% and 50% were prescribed >10 medications. Medication-related problems occurred in 60% of patients. Interviews revealed overall satisfaction with HF-SMA, but patients felt overwhelmed with HF instructions, perceived lack of peer support and self-efficacy, and feelings of hopelessness related to HF.Conclusion:Shared medical appointments are well-perceived. Medication problems and need for medication management are prevalent along with patient’s lack of self-efficacy in HF care. Multiple HF-SMA visits may be needed to reinforce concepts, reduce confusion, and garner peer support.

Impact of a Shared Medical Appointment on Hypertension Clinical Outcomes and Medication Adherence in a Veterans Affairs Health Care System.

Background:Shared medical appointments (SMAs) are utilized across health care systems to improve access and quality of care, with limited evidence to support the use of SMAs to improve clinical outcomes and medication adherence among hypertensive patients. Objective: Improve access and quality of care provided within a Veterans Affairs health care system via implementation of a hypertension SMA to improve clinical outcomes and medication adherence. Methods: Veterans were eligible for enrollment in the SMA if they received care within the health care system, were aged ≥18 years, were receiving at least 2 antihypertensive medications, and had systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg. A pre/post cohort design was used to evaluate the improvement in antihypertensive medication adherence as well as the change in SBP and DBP for all Veterans who attended at least 2 SMAs. Results: Twenty-one Veterans participated in at least 2 SMAs and were included in the analysis; 76.2% had a reduction in SBP with an overall average decrease of -8.3 mm Hg (P = .02). The proportion of Veterans considered to have controlled blood pressure (BP; <140/90 mm Hg) increased from 14.3% at baseline to 42.9% during the SMA period (P = .03). There was no significant difference found for the proportion of Veterans considered adherent to their prescribed antihypertensive medications (95.2% vs 85.7%, respectively; P = .50). Conclusions: SBP significantly improved for patients enrolled in a pharmacist-led SMA at a VA health care system, and the proportion of patients considered to have controlled BP increased significantly.

The Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study: study protocol for a randomized trial

BackgroundDiabetes shared medical appointments (SMAs) and reciprocal peer support programs have been found in efficacy trials to help adults with diabetes improve their self-management and achieve short-term gains in clinical and patient-centered outcomes. In order to translate this evidence to system-level interventions, there is a need for large-scale, pragmatic trials that examine the effectiveness, implementation, and costs of SMAs and reciprocal peer support across diverse settings.MethodsThe Shared Health Appointments and Reciprocal Enhanced Support (SHARES) study is a multisite, cluster randomized trial that is evaluating the effectiveness and implementation of SMAs with and without an additional reciprocal Peer-to-Peer (P2P) support program, when compared to usual care. The P2P program comprises periodic peer support group sessions and telephone contact between SMA participant pairs to promote more effective diabetes self-management. We will examine outcomes across three different treatment groups: (1) SMAs, (2) SMAs plus P2P, and (3) usual care. We will collect and analyze data over a 2.5-year implementation period at five geographically diverse Veterans Affairs (VA) health systems. The primary outcome is the relative change in hemoglobin A1c over time. Secondary outcomes are changes in systolic blood pressure, antihypertensive medication use, statin use, and insulin initiation over the study period. The unit of analysis is the individual, adjusted by the individual’s SMA group (the cluster). We will use mixed methods to rigorously evaluate processes and costs of implementing these programs in each of the clinic settings.DiscussionWe hypothesize that patients will experience improved outcomes immediately following participation in SMAs and that augmenting SMAs with reciprocal peer support will help to maintain these gains over time. The results of this study will be among the first to examine the effects of diabetes SMAs alone and in conjunction with P2P in a range of real-life clinical settings. In addition, the study will provide important information on contextual factors associated with successful program implementation.Trial registrationClinicalTrials.gov, ID: NCT02132676. Registered on 21 August 2013.

A Shared Medical Appointment on the Benefits and Risks of Opioids Is Associated With Improved Patient Confidence in Managing Chronic Pain.

Objectives:To evaluate a shared medical appointment (SMA) on opioids in the treatment of chronic pain.Research design:This prospective study was conducted at an ambulatory clinic within a health-care delivery system. The SMA is a single 90-minute encounter, led by a physician. We included adult patients who attended the SMA and completed an immediate pre–post survey. Survey items were measured on a scale from 0 (worst) to 5 (best). Mean differences in pre–post responses were assessed by a paired t test.Results:A total of 130 patients were included in the analysis. Patients showed improvements in confidence in self-managing pain (+0.44; 95% confidence interval [CI]: 0.29-0.59; P < .001) and their providers’ ability to help manage pain (+0.28; 95% CI: 0.14-0.43; P < .001). Most patients (81%) were very/extremely satisfied with the SMA.Conclusions:An SMA on the benefits and risks of opioids was associated with prompt improvements in patients’ confidence in self-managing pain and in their health-care providers’ ability to help manage pain. Such confidence can lay the foundation for increased patient engagement and activation in pain management.

Models of Care for Adolescents and Young Adults with Type 1 Diabetes in Transition: Shared Medical Appointments and Telemedicine.

Transitioning through adolescence and young adulthood is challenging, and even more so for patients living with a chronic disease such as type 1 diabetes. Patients in this age group encounter multiple obstacles to effectively managing their diabetes, experience suboptimal glycemic control, face higher rates of acute complications, and are often lost to medical follow-up. Comprehensive strategies and innovative clinical models are needed to engage this population in diabetes medical care, address barriers to ideal management, and improve outcomes. Telemedicine, shared medical appointments (SMA), or a combination of telemedicine and SMA are potential models to more successfully, efficiently, and satisfactorily address the urgent need for improved care in this high-risk population. This article reviews various clinical care models within these categories of telemedicine and SMA. [Pediatr Ann. 2017;46(5):e193-e197.].

Shared medical appointments help diabetes patients learn from one another

Shared medical appointments help diabetes patients learn from one another

Jump starting shared medical appointments for diabetes with weight management: Rationale and design of a randomized controlled trial

BackgroundRates of glycemic control remain suboptimal nationwide. Medication intensification for diabetes can have undesirable side effects (weight gain, hypoglycemia), which offset the benefits of glycemic control. A Shared Medical Appointment (SMA) intervention for diabetes that emphasizes weight management could improve glycemic outcomes and reduce weight while simultaneously lowering diabetes medication needs, resulting in less hypoglycemia and better quality of life. We describe the rationale and design for a study evaluating a novel SMA intervention for diabetes that primarily emphasizes low-carbohydrate diet-focused weight management. MethodsJump Starting Shared Medical Appointments for Diabetes with Weight Management (Jump Start) is a randomized, controlled trial that is allocating overweight Veterans (body mass index≥27kg/m2) with type 2 diabetes into two arms: 1) a traditional SMA group focusing on medication management and self-management counseling; or 2) an SMA group that combines low-carbohydrate diet-focused weight management (WM/SMA) with medication management. Hemoglobin A1c reduction at 48weeks is the primary outcome. Secondary outcomes include hypoglycemic events, diabetes medication use, weight, medication adherence, diabetes-related quality of life, and cost-effectiveness. We hypothesize that WM/SMA will be non-inferior to standard SMA for glycemic control, and will reduce hypoglycemia, diabetes medication use, and weight relative to standard SMA, while also improving quality of life and costs. ConclusionsJump Start targets two common problems that are closely related but infrequently managed together: diabetes and obesity. By focusing on diet and weight loss as the primary means to control diabetes, this intervention may improve several meaningful patient-centered outcomes related to diabetes.

The Art and Science of Group Visits in Lifestyle Medicine.

Lifestyle medicine group sessions present a promising approach to clinical care. Based on decades of work in shared medical appointments and group visits for diabetes and other chronic conditions, a lifestyle medicine group session has the potential to provide a fresh and rewarding way of interacting with patients that fuels the practitioner and feeds patients' needs to spend time with the lifestyle medicine practitioner, connect with him or her, connect with others, learn the latest recommendations regarding healthy habits, practice these behaviors, and discuss their obstacles, motivations, and strategies for healthy living. The lifestyle medicine group session discussed in this article is a combination of group coaching, education, and group support.

A realist review of shared medical appointments: How, for whom, and under what circumstances do they work?

BackgroundShared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances.MethodsRealist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations).ResultsNine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one’s ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others’ illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients’ needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust.ConclusionsNine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.

Shared Medical Appointments Role in the Opioid Epidemic Era: A Tool for Integration of Care

Medical visits encompass multiple medical issues, leaving little time to address substance use disorder issues, such as medication-assisted treatment (MAT) for opioid use disorders (OUD). This becomes a barrier to expanding Office-Based Opioid Treatment (OBOT), as many physicians express concern about treating high-risk patients under the current time constrained treatment model. Evidence shows that shared medical appointments (SMAs) are effective treatment models that increase health outcomes and are well received by patients. Research studies that come from primary care where large patient panels and limited access have necessitated the creation of innovative and efficient care delivery. Substance use disorders (SUDs) are chronic diseases comparable to diabetes and hypertension with similar treatment outcomes. Group therapy is well established as an effective, evidence-based treatment for SUDs. Using the SMA model with elements of group therapy to provide OBOT allows physicians to spend more time with their patients, albeit in a group setting. SMA for OBOT will allow these physicians more time with high-risk patients. When done with elements of group therapy, SMAs can provide quality and cost-effective treatment. This manuscript will provide an overview of the scope of the current opioid problem, current treatment practices and barriers to treatment as well as guidelines on how to implement SMA model in an integrated care setting.

Effectiveness of Shared Medical Appointments Targeting the Triple Aim Among Patients With Overweight, Obesity, or Diabetes.

Obesity and diabetes are epidemic in the United States, with many treatment options having limited long-term efficacy. A possible effective medical management tool is the shared medical appointment (SMA), which offers an efficient and cost-effective approach to behavior change and aligns with the Triple Aim (reduce costs, improve population health, and improve patient care experience) set forth by the Institute for Healthcare Improvement. To assess the effectiveness of SMAs to achieve the Triple Aim and to improve the management of overweight/obesity or diabetes. Peer-reviewed literature from PubMed was searched by the keywords shared medical appointments, group medical appointment, and group medical visit, with no date restrictions and limited to English publications with sample sizes greater than or equal to 20. Eight articles met inclusion criteria. The Triple Aim was not referenced in the studies, but most reported some combination of reduced costs, improved care, and improved outcomes or patient satisfaction. Potential benefits of SMAs include improved patient outcomes and satisfaction. Osteopathic and, in particular, primary care medicine could likely benefit from moving toward greater adoption of SMAs; however, more randomized controlled trials are needed to assess their effectiveness with regard to the Triple Aim.

Patients Attending Shared Medical Appointments for Metabolic Stone Prevention Have Decreased Stone Risk Factors.

Shared medical appointments (SMAs) have decreased patients' wait time to initial stone clinic appointment, standardized education, and increased exposure to nutrition therapy. We assessed the effectiveness of SMAs in reducing patients' urinary stone risk factors. Patients who established care in our stone clinic in an SMA between March 2012 and August 2015 were sequentially identified. After eliminating those without follow-up urine collections or whose urinary creatinine excretion between the two collections varied by >40%, 113 patients were included (M:F 63:50; 54 ± 15 years; body mass index [BMI] 30.6 ± 6.7). Results from before and after the SMA were compared with those from a similar cohort of patients who attended individual patient appointments (IPAs) for their first stone clinic visit (n = 63; M:F 37:26; 54 ± 14 years; BMI 30.1 ± 8.2). All patients received individualized medical therapy for stone prevention. After medical and nutritional therapy, SMA patients with elevated risk(s) at baseline achieved significant reductions in uric acid, calcium, and sodium; p ≤ 0.001 for all. Those with low urine magnesium, low urine volume, low urine pH, and/or low urine citrate at baseline achieved increases; p ≤ 0.0008 for all. IPA patients with elevated baseline risk factors achieved reductions in oxalate and uric acid (p ≤ 0.004 for both) but neither calcium nor sodium and an increase in citrate (p = 0.003) but not magnesium. Patients from SMAs reduced their stone recurrence risk and compared favorably with patients from IPAs. Contributing factors may include shorter time from stone event to appointment and more standardized education for patients attending SMAs.

Shared medical appointments for vasectomy consultation: prospective assessment of patient satisfaction and counseling effectiveness

Shared medical appointments for vasectomy consultation: prospective assessment of patient satisfaction and counseling effectiveness

Effectiveness of Shared Medical Appointments Versus Traditional Clinic Visits for Adolescents With Type 1 Diabetes.

Shared medical appointments began in the United States in 1996 to advance quality of care and enhance patients' ability to self-manage. Group visits gather patients with the same diagnosis for individual examinations followed by group education sessions taught by the provider. This leads to the opportunity to learn from the experiences of others. The Cleveland Clinic Department of Pediatric Endocrinology offers a shared medical appointment group for pediatric patients with type 1 diabetes called the ESCALAIT clinic (Enrichment Services and Care for Adolescents Living with Autoimmune Insulin Dependent Type 1 Diabetes). The objective of this study was to compare the effectiveness of traditional clinic visits with shared medical appointments for adolescents with type 1 diabetes in terms of hemoglobin A1c (HbA1c) improvement. Eighty ESCALAIT patients, aged 11 to 19 years were compared with 516 clinic controls of the same age. Visits were approximately 3 months apart for both patient groups. Changes in HbA1c between groups were calculated from the first to fourth visits. There was a statistically significant difference between the ESCALAIT clinic patients and the control patients. Our results revealed that the group visit patients had less improvement in HbA1c values at the last visit approximately 1 year later, but we would argue that the difference is not clinically significant. However, there were many benefits to shared medical appointment visits including increased access to care as well as peer support. Shared medical appointments are therefore a valid alternative to traditional clinic visits in this patient population.

Shared medical appointments as a new model for carpal tunnel surgery consultation: A randomized clinical trial

Background In chronic disease management, shared medical appointments have been shown to improve clinic access, productivity and patient education. However, adoption of this model in surgical consultation is limited, and its effect on surgical patients' satisfaction, comfort and surgical risk recall is unknown. Objective To determine whether shared medical appointments could be applied to carpal tunnel surgery consultation while being equally effective as individual consultation for risk recall, patient comfort and satisfaction. Methods A prospective randomized trial involving 80 patients referred for carpal tunnel release consultation, in which patients were assigned to an educational discussion individually or as part of a shared appointment, was conducted. In a blinded fashion, patients were contacted preoperatively to assess their risk recall and postoperatively to rate their overall satisfaction, comfort and satisfaction with the surgeon. Results Patient demographics were equal. Surgical risk recall was equivalent between shared and individual consults (2.06±1.15 versus 1.64±1.04; P=0.11). More participants in the shared appointments condition remembered the specific risks of infection (61.1% versus 33.3%; P=0.020) and bleeding (30.6% versus 10.3%; P=0.028). There was no difference in overall satisfaction (8.70 versus 8.88; P=0.75), satisfaction with the surgeon (8.05 versus 8.13; P=0.92) or overall comfort (8.80 versus 8.31; P=0.46). Discussion Shared medical appointments for carpal tunnel surgery consultation were equivalent to individual consultation in terms of surgical risk recall, patient satisfaction and comfort. Conclusion These results support the use of shared appointments for large-volume, low-variation surgery.

Combined Cascade Screening And Patient Education For Familial Hypercholesterolemia: Genetic Results From A Family Shared Medical Appointment Pilot Study

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INCREASED COST-EFFECTIVENESS AND EFFICIENCY UTILIZING SHARED MEDICAL APPOINTMENTS FOR CARDIAC REHABILITATION PROGRAM PATIENT ENROLLMENT

Cardiac rehabilitation programs positively impact survival and quality of life in persons who have experienced a cardiac event. However, the traditional enrollment process is lengthy, costly and utilizes significant resources and personnel. The Shared Medical Appointment (SMA) concept more

Abstract 104: Group Medical Visits versus Usual Care in Heart Failure: Clinical Trial Design &amp; Rationale

Objective: The literature has demonstrated that patient self-care behaviors in heart failure (HF) and health system factors play an important role in patients’ health status and hospitalization risk. Utilizing the Chronic Care Model, shared medical appointments (SMA) are a type of care delivery redesign that provides patient self-management and peer support in addition to clinician-led disease management. In this model, the SMA team consists of a nutritionist, cardiology nurse, health psychologist, and a non-physician prescribing provider. The session begins with an assessment of patient needs followed by pre-assigned theme-based education and individualized medication management. Methods and Expected Results: At two VA medical centers, we will randomize 375 patients within 6 weeks of discharge from a HF hospitalization to receive either SMA intervention (4 sessions over 8 weeks) versus usual care (individual provider appointments) for HF. Inclusion criteria are: not enrolled in other programs for HF care, &lt;2 hospitalizations last 6 months, left ventricular ejection fraction &lt;40%. We will use stratified block randomization with block sizes of 4 at each site to ensure balance of the stratified variables. At 180 days, we will determine whether HF patients who participate in HF-SMA, as compared to patients who receive usual care: 1) Experience better cardiac health status measured by Kansas City Cardiomyopathy Questionnaire (primary outcome), and overall health status (EQ5D, secondary outcome); 2) Have fewer hospitalization or death and 3) Experience improvement in intermediate outcomes: a) increase in HF Self-Care Index, and b) decrease in plasma BNP levels. For patients who underwent HF-SMA, we will also determine perceived benefits, areas in need of improvement, potential obstacles of implementation, and fidelity of the intervention across sites, by conducting (a) face-to-face interviews with patients and (b) telephone interviews with physicians and administrators. Using VA cost data, we will perform a cost-effectiveness analysis to inform future VA resource allocation. Conclusions: This trial will generate critical knowledge regarding the clinical and cost-effectiveness of SMA in HF patients to provide patient-centered care, improve health status, and reduce readmission for patients with HF. Further, the results of the formative evaluation will support future implementation of this novel intervention into routine clinical practice.