Shared Medical Appointments Group Research Articles

Reducing Opioid Reliance in Veterans Using a Whole Health Education and Shared Medical Appointment Care Model

ABSTRACT Background Reducing opioid reliance in chronic pain treatment may best be accomplished with interdisciplinary teams. Shared Medical Appointments (SMAs) are one format whereby an interdisciplinary team partners with groups of patients to provide health education and clinical care. The Whole Health (WH) model is an emerging framework whereby the care team partners with the patient to reach shared goals with emphasis on self-care and healing modalities. Purpose Assess the impact of a WH Education intervention in patients with chronic pain and long-term opioid use within the framework of Shared Medical Appointment (SMA). Results Retrospective chart review of 86 participants indicated significant opioid reduction at 12 and 24 months. The rate of opioid reduction in the SMA group surpassed the rate of decline of the host or national VA cohorts. Overall pain perception did not increase while patient satisfaction and safety indices improved. Discussion Results of the intervention suggest that a WH education model in a SMA is one approach to help patients reduce long-term opioid reliance. Translation to Health Education Practice: Trained Whole Health Coaches/Education Specialists are key personnel in the implementation of the WHSMA model of care and facilitators of behavioral change that results in improved wellness outcomes. A AJHE Self-Study quiz is online for this article via the SHAPE America Online Institute (SAOI) http://portal.shapeamerica.org/trn-Webinars

Qualitative exploration of the psychological dimensions of telehealth shared medical appointments (SMAs) for buprenorphine prescribing

Background: Shared medical appointments (SMAs) for buprenorphine prescribing are clinical encounters in which multiple patients with opioid problems receive treatment from providers in a group setting. Telehealth, the provision of clinical services remotely using telecommunications technology, is an essential modality for improving access to healthcare when combined with SMAs, especially since the COVID pandemic. Objectives: The current study specifically examined psychological components of telehealth SMAs for buprenorphine prescribing to learn about the benefits and drawbacks of this treatment model. Methods: Data was collected through qualitative interviews with patients (N=10) in a psychiatry addiction medicine clinic. Narrative synthesis using grounded theory was conducted to identify salient themes from the interviews. Results: Findings highlighted the advantages and downsides of telehealth SMA to treat addictive disorders in a digital age: (1) Shared group identity; (2) Decreased stigma around buprenorphine; (3) Benefits of telehealth; (4) Discomfort with group SMA format; (5) Strategies for managing medication side effects; and (6) Enhanced empathy for providers. Several themes corresponded to therapeutic factors identified in group therapy (i.e., installation of hope, universality, imparting information, altruism) and mechanisms theorized in previous SMA research (e.g., combating isolation, disease self-management, feeling inspired by others). Conclusion: Telehealth SMAs for buprenorphine prescribing may be a unique opportunity for patients to receive both ongoing medication management and psychosocial benefits that promote recovery and reduce stigma. The SMA group had shortcomings for some patients, including privacy concerns, fear of judgment from other patients and limited time to discuss individual concerns with providers.

Abstract #1185212: Obesity Management via Telemedicine Shared Medical Appointments

Obesity as a chronic disease has reached pandemic proportions. The prevalence of obesity between 2017-2018 was 42.4%, and the national healthcare cost on obesity amounts to $149.4 billion annually. Current strategies for weight management are limited to lifestyle changes, anti-obesity medications (AOM), and bariatric surgeries. However all of these treatment options are grossly underutilized with weight loss counseling occurring in fewer than 5.8% of primary care visits and only 0.8% of eligible patients receive AOM’s. Shared medical appointments (SMA) have emerged as a potential option to address the obesity pandemic, allowing patients to convene with a team of multidisciplinary providers in a group setting. There are few studies on the use of SMA’s in obesity management and even fewer studies assessing the efficacy of telemedicine SMA’s. Here we present a study examining the weight loss impact of telemedicine SMA’s through Program for Reducing Obesity (PRO), our institutional weight management clinic. Patients age ≥18 years with body mass index (BMI) ≥30 kg/m2 were referred from the community to PRO at the UCLA Thousand Oaks clinic. In addition to individual clinic visits, patients participated in weekly SMA group classes for counseling and education via video conference led by an obesity medicine board certified endocrinologist and a registered dietician. Enrollment period spanned from May 2020 to May 2021. Primary outcomes were change in body weight and percent body fat at 3 months and 6 months. Secondary outcome includes percentage of patients who achieved 5% weight loss. Thirty-two patients (mean age 62.1 years, 78% women, mean weight 97.6kg, mean BMI 35.6 kg kg/m2) were analyzed, with 27 patients completing at least 4 SMA sessions. Patients achieved on average a weight loss of 3.5% at 3 months and 4.9% at 6 months. By 6 months, 34.4% of the patients reached weight loss of ≥5%. Patients also achieved on average a 0.7% decrease in body fat at 3 months and 2.8% at 6 months. Overall 18.8% of participants were taking AOM by 6 months. Our study demonstrates that telemedicine SMA’s can be an efficient and effective approach to obesity management.

Effects of shared medical appointments compared to individual appointments in children with atopic dermatitis: A pragmatic randomized controlled trial

Atopic dermatitis (AD) needs intensive treatment and has a negative impact on quality of life. Shared medical appointments (SMAs) showed to be effective in clinical outcomes of chronic diseases, but little is known about the effects on children and families. To evaluate the effects of SMAs compared to individual appointments (IA) for children with AD and their parents on coping and clinical outcomes. In a pragmatic randomized controlled trial, new patients in UMC Utrecht with AD, younger than 18years, and their parents were assigned to the SMA group or the IA group using a covariate adaptive randomization method, controlled for age. Before the intervention, 2months (primary time-point) and 6months thereafter, we assessed parental emotional coping (primary outcome), quality of life, anxiety about corticosteroids and patient disease activity. Patients, parents and healthcare professionals could not be blinded to group assignment. Of 140 patients, enrolled in the trial, 69 patients were assigned to the SMA and 71 to the IA intervention of whom 114 completed the intervention (SMA: 49; IA: 65). After 2months, there were no differences between SMAs and IAs in effects on emotional coping: b 0.66, 95% CI -0.7 to 2.03; P=0.33 (mean difference: 0.30; 95% CI -1.56 to 2.16; N SMA: 11; IA: 24), quality of life, anxiety about corticosteroids and disease activity. From the initial appointment to long-term follow-up, both groups showed substantial improvements, but not significant in disease activity and significant reduction in anxiety about corticosteroids. This study is limited by a low response rate; therefore, linear mixed models and dropout analyses were performed. No serious adverse events were reported. For children with AD and their parents, there were no additional benefits of GMAs in parental emotional coping, anxiety about corticosteroids, quality of life and disease activity. www.ISRCTN.org, ISRCTN08506572.

329-OR: Shared Medical Appointments (SMA) with Weight Management vs. SMA Alone for Overweight or Obese Patients with Type 2 Diabetes

Background: Shared medical appointments (SMA) improve outcomes in diabetes. SMAs often address lifestyle but infrequently lead to weight loss. Because weight loss reduces glycemia and medication use, we hypothesized an SMA intervention with weight management (WM/SMA) would be non-inferior for glycemic control and superior for patient-centered outcomes versus SMA alone. Methods: In a 48-week, randomized trial with primary outcome of HbA1c (non-inferiority margin 0.5%), we recruited outpatients with uncontrolled T2DM and BMI ≥27 from two Veterans Health Administration sites. WM/SMA participants received baseline medication reduction and low-carbohydrate diet counseling with medication optimization every 2 weeks for 16 weeks, then an abbreviated SMA intervention every 8 weeks. SMA participants received group counseling on diabetes-related topics with medication optimization every 4 weeks for 16 weeks, then every 8 weeks. HbA1c, diabetes medication effect score (MES) and hypoglycemic events were analyzed using linear mixed models. Results: In 263 participants, baseline mean age was 61, HbA1c 9.1% and BMI 35.3; 10.6% were women and 54.4% were black. At 48 weeks, HbA1c decreased 0.9% for WM/SMA and 0.8% for SMA (mean difference -0.1%, 95% CI -0.5, 0.3; non-inferiority criterion met), and decreased more with WM/SMA than SMA alone at interim weeks 16 (-0.7%, 95% CI -1.0, -0.4) and 32 (-0.5%; 95% CI -0.8, -0.2). At 48 weeks, diabetes medication use was lower in the WM/SMA than SMA group (mean difference in MES -0.5, 95% CI -0.6, -0.3; p<0.0001). WM/SMA participants had 51% fewer hypoglycemic events than SMA participants over 48 weeks (Incident Rate Ratio=0.49; 95% CI 0.27, 0.71; p<0.001). Conclusion: Compared with conventional SMA-based medication management for patients with T2DM, SMA with intensive low-carbohydrate diet counseling yielded similar glycemic control while improving hypoglycemia and decreasing medication burden. Disclosure W.S. Yancy: None. C. Coffman: None. M. Crowley: None. M. Dar: None. A.S. Jeffreys: None. M.L. Maciejewski: Employee; Spouse/Partner; Amgen Inc. Stock/Shareholder; Spouse/Partner; Amgen Inc. C.I. Voils: None. A.E. Barton: None. D. Edelman: None. Funding U.S. Department of Veterans Affairs

Shared Medical Appointments: An Innovative Model to Reduce Health Disparities Among Latinxs With Type-2 Diabetes.

In the United States, diabetes is epidemic. A study of Latinxs with diabetes evaluated a behavioral shared medical appointment (SMA) intervention. This quasi-experimental study included nonrandomized matched control group participants receiving usual care. The nonprobability convenience sample consisted of 90 participants (SMA = 30; control = 60) receiving primary care at an FQHC (Federally Qualified Health Center) clinic. At 6 months, the percentage of participants achieving target A1C goals was greater in the intervention group (59%) than in the control group (31%; χ2 = 4.462, p ≤ .05). In a multiple regression model, the SMA intervention group, compared to the control group had an A1C decline at 3 months of 0.55% (b = - 0.55, t = - 1.48, p=.14) and an A1C decline at 6 months of 0.83% (b= - 0.83, t= - 2.25, p = .03). Therefore, the results showed 3- and 6-month declines that were greater in the SMA group than in the control group. Underserved, underinsured Latinxs in the ALDEA program achieved significant A1C reductions; the program succeeded in empowering Latino patients and improving glycemic control.

Early experience with shared medical appointments for penile problems

We examined the use of shared medical appointments (SMA) for educating and counseling children with penile problems. Forty-eight families were seen over 4 months with 21 participating in the SMA group and 27 in the traditional group. Using a questionnaire to assess adequacy of education, there was no difference in the overall scores between groups with a mean of 6.64/7 in the SMA and 6.56/7 in the traditional setting. With the increasing demands on providers, an SMA offers a solution to caring for more patients with penile problems in an efficient manner without impacting family education and satisfaction.

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.

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.

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.

Cost-effectiveness of shared medical appointments for neuromuscular patients

To assess whether shared medical appointments (SMAs) for neuromuscular patients represent a way of using clinicians' time efficiently without compromising quality of care for patients. Patients with a chronic neuromuscular disease (NMD) (n = 272) were randomly allocated to either an SMA or a regular individual annual appointment and followed up for a period of 6 months. Data on resource utilization and quality of life (EQ-5D) were collected prospectively, using a health care perspective. Incremental costs and changes in quality-adjusted life-years (QALYs) were computed using a probabilistic decision model. Factors critical to the incremental cost-effectiveness of SMAs were explored in sensitivity analyses. No substantial differences between SMAs and individual visits in terms of costs per QALY were found (incremental cost-effectiveness ratio €-960.00; 95% confidence interval €-34,600.00, €+36,800.00). Sensitivity analyses showed that the cost-effectiveness ratio was particularly sensitive to SMA group size and proportion of patients seeing their treating neurologist. Cost-effectiveness of SMAs did not show a significant difference vs that of individual appointments based on data from our randomized controlled trial. On the other hand, we were able to show that a minimum of 6 patients per SMA and 75% of patients attending their treating neurologist are specific conditions under which SMAs qualify as a cost-effective alternative. This implies that SMAs may be a means to increase productivity of the physician without compromising quality of care. This study provides Class III evidence that SMAs are not significantly more cost-effective than individual appointments for patients with NMDs. The study lacks the precision to exclude important differences in cost-effectiveness between SMAs and individual appointments.

A Randomized Controlled Effectiveness Trial for PSA Screening Decision Support Interventions in Two Primary Care Settings.

Decision support interventions (DESIs) provide a mechanism to translate comparative effectiveness research results into clinical care so that patients are able to make informed decisions. Patient decision support interventions for prostate-specific antigen (PSA) have been shown to promote informed decision making and reduce PSA testing in efficacy trials, but their impact in real world settings is not clear. We performed an effectiveness trial of PSA decision support interventions in primary care. A randomized controlled trial of three distribution strategies was compared to a control. Participants included 2,550 men eligible for PSA testing (76.6 % of the eligible population) and 2001 survey respondents (60.1 % survey response rate). The intervention groups were: 1) mailed the DESI in DVD format, 2) offered a shared medical appointment (SMA) to view the DESI with other men and discuss, and 3) both options. We measured PSA testing identified via electronic medical record at 12 months and DESI use by self-report 4 months after the intervention mailing. We found no differences in PSA testing across the three distribution strategies over a year-long follow-up period: 21 %, 24 %, 22 % in the DESI, SMA, and combined group respectively, compared to 21 % in the control group (p = 0.51). Self-reported DESI use was low across all strategies at 4 months: 16 % in the mailed DESI group, 6 % in the SMA group, and 15 % in the combined group (p = < 0.0001). Mailing PSA decision support interventions or inviting men to shared medical appointments unrelated to a primary care office visit do not appear to promote informed decision making, or change PSA testing behavior.

Effectiveness of Prediabetes Nutrition Shared Medical Appointments

The purpose of this study is to evaluate the effectiveness of a nutrition-based shared medical appointment (SMA) intervention in the treatment of prediabetes compared to the individualized counseling standard of care. A randomized controlled trial design comparing health outcomes in patients with prediabetes attending either an individualized counseling (control group) or three 90-minute nutrition SMA (intervention group) sessions. Demographic, anthropometric (weight and body mass index), clinical (blood pressure), and biochemical (lipid profile, fasting blood sugar, glycated hemoglobin, albumin-to-creatinine ratio) measures were obtained from all participants at baseline, at 3 months, and at 1 year. Ninety-four participants were randomized into the 2 study groups with a 69% completion rate at 1 year (n = 34 SMA, n = 31 control). The average participant was Caucasian (64%), male (54%), 58.3 ± 9.6 years, had a BMI of 30.8 ± 4.9 kg/m(2) (obese), and fasting blood glucose of 109 ± 9.5 mg/dL. The SMA and control participants lost a mean of 6.6 pounds and 3.6 pound, respectively; neither group met the 5% modest weight loss expected. The SMA and control group experienced a mean drop in fasting blood glucose of 6 mg/dL. As demands on health care providers continue to rise, finding innovative ways to manage the patient load while providing quality health care is increasingly important. SMA health outcomes were equivalent to individual counseling outcomes, while increasing the provider's productivity by treating 6 to 8 people with prediabetes in 90 minutes compared to 1 patient in 60 minutes.

Shared medical appointments: new concept for high-volume follow-up for bariatric patients

Background Shared medical appointments (SMAs) are a new model in patient care. This model was designed to improve patients’ access to their physicians and improve physician productivity. The aim of this study was to evaluate patient satisfaction with SMAs after bariatric surgery. Methods The medical records of consecutive patients who were followed up after bariatric surgery were retrospectively reviewed. The type of bariatric surgery and type of medical appointment were recorded, as were the patients’ replies to the evaluation questionnaires in the SMA group. Results From April 2004 to December 2004, 277 individual visits were conducted; 242 visits for patients who underwent Roux-en- Y gastric bypass and 35 visits for patients who underwent laparoscopic gastric banding. Thirty-three SMAs occurred during that period—28 SMAs for patients who underwent Roux-en- Y gastric bypass and 5 SMAs for patients who underwent laparoscopic gastric banding. Of the patients who initially participated in an SMA, 91% scheduled a subsequent SMA, and 96% indicated that they would recommend SMAs to others. On a scale of 1 to 5 (1, poor and 5, excellent), patients graded their overall experience with SMAs as 4.5. Other parameters in the questionnaire all ranked between 4 and 5. The average waiting period for an appointment before the implementation of SMAs was 57.7 days (range 50–65) for new patients and 50 days (range 20–72) for former patients. After the implementation of SMAs, the average waiting period was 25 days (range 8–42) for new patients ( P = 0.0046) and 20.3 days (range 0–42) for former patients ( P = 0.06). Conclusion The SMA offers the patient prompt access to medical care, enables high-volume follow-up, with high satisfaction rates.