Group Visits Focusing on Education for the Management of Chronic Conditions in Adults: A Systematic Review

VA has prioritized group visit implementation as part of a new primary care model that focuses on patient centeredness — the Patient Aligned Care Team (PACT). Group visits differ from shared medical appointments in that multiple patients are seen together by non-prescribing health professionals or lay facilitators, who do not make individual treatment decisions. The goal of group visits that focus on education is to communicate information and provide training to improve self-management skills for the large numbers of patients coping with chronic illness. Although the group visit delivery model has been widely used, there are vast differences in program structure, content, length of intervention, and follow-up time points. Moreover, there is little consensus as to whether, and for whom, group visits are an effective tool.

Investigators with the VA Evidence-based Synthesis Program at the Portland VA Medical Center conducted a review of the literature from database inception to February 2012, in order to:

• Summarize the characteristics of group visit interventions that have been tested in controlled trials of patients with chronic illness;
• Assess the effects of these interventions on quality of life, self-efficacy, healthcare utilization, and other health outcomes;
• Understand whether there are certain patient characteristics associated with intervention effectiveness; and
• Examine which components of group visit intervention structure and delivery may be associated with intervention effects.

After applying eligibility criteria to more than 2,400 citations, investigators identified 87 publications (reporting on 81 group visit intervention studies) that could be used to answer the three questions below. The interventions focused on education for the management of arthritis/falls prevention (n=22), asthma/COPD (n=10), hypertension/congestive heart failure (n=12), diabetes mellitus (n=29), multiple co-occurring chronic disease (n=4), and chronic pain (n=4).

Question #1
In adults with chronic medical conditions, how do group visits compared to usual care affect the following?

• Medication adherence, biophysical markers ( e.g., HbA1c, blood pressure);
• Symptom status, functional status, mortality, patient satisfaction;
• Use of medical resources and healthcare costs; and
• Adverse outcomes (e.g., patient confidentiality, participation/missed appointments).

In general, group visit interventions in most clinical areas were associated with short- and medium-term improvements in self-efficacy; few studies examined longer-term outcomes. However, there was little evidence that interventions improved quality of life, functional status, or utilization outcomes.

Meta-analyses of 17 studies of group visit interventions for patients with diabetes were associated with modest short-term improvements in HbA1c, but the strength of this evidence was low because of inconsistent results across studies and methodological concerns in the studies finding the greatest benefit.

Question #2
For adults with chronic medical conditions, do the effects of group visits vary by patient characteristics? Characteristics of interest include medical diagnosis, severity of disease, and comorbidities.

Relatively few studies (16) specifically examined how patient characteristics modified intervention effects. Overall, studies found little difference in group visit effectiveness according to patient demographic and socioeconomic characteristics. However, among studies of arthritis and history of falls, two studies found that obese patients tended to respond to aerobic exercise group visits more than participants with lower BMI on self-reported disability and falls.

Several studies found some indications of a dose-response with group session attendance, with those participants attending the greatest number of sessions benefitting the most from the group visit intervention. Among the diabetes mellitus studies, many found larger beneficial group visit intervention effects for patients with higher initial levels of HbA1c.

Among hypertension and heart failure studies, one study found patients with more years of education and better cognitive status showed greater short-term improvements in cardiac-specific quality of life.

One chronic pain study noted that group visit effectiveness was modified by agency-orientation, with high agency-oriented participants experiencing improvements in pain and pain coping resulting from group visit sessions.

Various authors note that small sample sizes limit the power to detect differences in subgroup analyses. In addition, findings of group visit benefit in subgroup analyses are tempered by fair and poor quality ratings for many of these studies.

Question #3
Depending on the size and comparability of elements identified in the literature, which components of group visits are associated with greater intervention effects?

In five studies, group visit interventions that focused on self-management educational strategies were more effective than sessions that were limited to didactic education. However, in four of these five studies, the intervention arms differed considerably from the comparators (e.g., having non-equivalent number of sessions), limiting the strength of this conclusion.

Studies that compared group visits to individual education visits found mixed results on a variety of outcomes, with no appreciable differences found in three studies, positive effects found with group visits in four other studies, and improvements with individual education in one study. Findings across studies could not be combined because of differences in study design.

Two studies compared the effects of in-person group self-management education and mailed or automated self-management programs, and found no differences in self-efficacy, pain, and functional status outcomes.

Conclusions
In general, many group visit interventions appear to be able to improve short- and medium-term patient self-efficacy, but there was little consistent, fair-to-good quality evidence that they improved quality of life, health outcomes, or health care utilization. Investigators found that diabetes group visit interventions were likely associated with small short-term improvements in glycemic control. The longer-term effects of group visit interventions are largely unknown since the vast majority of studies focused on short-term effects.

Whether group visit expenditures are warranted may depend on how highly patients and health systems value more proximate outcome measures, such as self-efficacy. On the other hand, peer-led, community-based self-management programs are a low-cost intervention that appears to improve self-efficacy and, in mixed groups of patients with various chronic illnesses, may improve health and utilization outcomes. Group visits may be as effective as individual education visits and may represent a reasonable alternative for educating patients with chronic illness, though the varied and sometimes low participation and retention rates suggest they should not be the sole alternative.

Although investigators did not find direct harms associated with group visits, the lack of robust findings that group visits improve long-term health outcomes invites caution around blanket recommendations for widespread and rapid group visit implementation. This is especially true for patient populations with specific health needs. Travel and participation time involved in group visits may preclude participation among patients with limited work schedule flexibility, and may be prohibitive for frail, older participants.

A Cyberseminar session on this ESP Report will be held on Monday, April 1, 2013 at 11:00am. Register here.

This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers — and to disseminate these reports throughout VA.

Reference

Quiñones AR, Richardson J, Freeman M, O'Neil M, Kansagara D. Group Visits Focusing on Education for the Management of Chronic Conditions in Adults: A Systematic Review. VA-ESP Project #05-225; 2012.

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http://vaww.hsrd.research.va.gov/publications/esp/group-visits.cfm

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This report is a product of the HSR&D Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers - and to disseminate these reports throughout VA.

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