Are group visits for patients with Parkinson disease (PD) in your practice's future? Should they be? Are they practical? And what benefits might they provide that are missing from conventional one-on-one care?
DR. E. RAY DORSEY Th...Image Tools
Perhaps only the individual neurologist can answer the first two questions, but the answers to the last two are a little clearer after the first pilot study assessing the feasibility of delivering PD care in a group setting. The results, which were published first in the online edition of Neurology, show that group visits are not only practical but may also offer PD patients some unique benefits.
“The way we have been delivering care for Parkinson disease and other chronic conditions has remained largely unchanged in the past 50 years,” E. Ray Dorsey, MD, associate professor of neurology at Johns Hopkins University in Baltimore, told Neurology Today in a telephone interview. “Yet there is limited evidence that the way we provide care really addresses all the needs of patients.”
High among those needs is education about their condition and strategies for coping with it. In other chronic conditions, such as diabetes and coronary artery disease, group visits have offered a valuable forum for that kind of education and have demonstrated clinical benefits, the study investigators noted. For example, a 2001 study in the Journal of Family Practice reported that group office visits helped change dietary habits of patients with coronary artery disease; another 2001 study on group visits in Diabetes Care reported improvements in metabolic control in patients with type 2 diabetes. And most recently, a March 14 study in the Archives of Internal Medicine reported that patients participating in primary care-based diabetes mellitus group clinics that included “structured goal-setting approaches to self-management” had significant improvements in their glycosylated hemoglobin levels, which were maintained one year later.
“As physicians, we can provide evidence and recommendations about exercise, for instance, but we don't know what it is like to exercise with PD. In a group, other members can provide that perspective, about what has worked and what hasn't, and the benefits they've experienced, providing a much richer context than we can offer.”
To test the feasibility of group patient visits in PD, Dr. Dorsey and colleagues at the Movement Disorders Clinic at the University of Rochester, where Dr. Dorsey was employed at the time of the study, conducted a 12-month trial comparing group visits to standard one-on-one care. They enrolled 30 patient volunteers along with their caregivers, and randomized them to one or the other treatment.
Group visits occurred every three months. Each visit lasted 90 minutes, and consisted of brief introductions, 10 minutes of patient updates, and a 40-minute educational session, whose subject was chosen by the group beforehand. For example, educational topics included drug and non-drug therapies for PD, disease progression and prognosis, and deep brain stimulation. Following a brief break, the educational session was completed, questions were answered, research opportunities were discussed, and the topic of the next meeting was decided. Patients signed agreements not to disclose confidential health information discussed by other patients. Such agreements are standard in group-visit practices for other conditions.
Either before or after each session, each patient had the option of meeting with their neurologist for 10 minutes to discuss individual concerns, including drug dose adjustments. Individuals in the group arm could also schedule a one-on-one visit between group visits if necessary.
Patients in the one-on-one arm met with their physician every three to six months for approximately 30 minutes. Individuals in both groups could also phone their physician's office for emergent concerns. Patients were not billed for participation in either arm of the study.
The primary outcome for the study was simply whether it was feasible to conduct group visits, and the results indicated it was. Ninety percent of participants completed the study. Two patients in the group setting opted to return to one-on-one care after a single visit. Three patients in the one-on-one arm required unscheduled visits, versus none in the group arm. There were no significant differences between the groups in quality of life, patient satisfaction, or caregiver burden, nor in PD-related symptoms, depression, or cognition.
Not all patients receiving group care would sign up again. Five of 14 in the group arm said they preferred one-on-one visits. On the other hand, five of those in the one-on-one arm said they would prefer to try group care.
“Group visits are not an unmitigated success, and no one model is best for every patient,” Dr. Dorsey said. “The standard model of care may meet the needs of large numbers of patients, but probably doesn't meet the needs of a large proportion as well. Group visits might be anathema to some patients who are more private, and that's fine. We were trying to see if this model of care could be of value to a large segment of the PD population, and based on our limited experience in this study, I think the answer to that question is yes.”
There was no rigorous tracking of total physician time spent in the two settings, Dr. Dorsey said. “It is probably a wash, at least at the outset. Because it is new and different, it obviously takes a lot more effort.”
A key benefit for the physician, he said, is the opportunity to observe patients for longer periods, and engaged in different activities, than would be otherwise possible. “Sleepiness means a whole lot more when you observe it occurring than when the patient simply reports it to you. The more you experience what a patient experiences, the more you can put yourself in their position, the more you will be motivated to do things that will hopefully be of benefit to the patient.”
How would neurologists bill for group visits? Neurology Today checked with several billing experts who were not clear on the code to use. But Dr. Dorsey offered this response from Medicare received by the American Academy of Family Physicians (AAFP), which has led the way in developing the group visit model. “Under existing CPT codes and Medicare rules, a physician could furnish a medically necessary face-to-face [evaluation and management] visit (CPT code 99213 or similar code depending on level of complexity) to a patient that is observed by other patients. From a payment perspective, there is no prohibition on group members observing while a physician provides a service to another beneficiary.” Private insurers may prefer different reimbursement codes, and the AAFP recommends contacting them before initial billing.
Dr. Dorsey also identified some logistical challenges in setting up group visits — everything from the time and effort involved in finding a room large enough to fit the group to changing the scheduling software to allow multiple simultaneous appointments. “But the primary issue for adoption [of group visits] in neurology is changing the orientation of one's practice to accommodate it,” he said. “You have to be willing to change the way you've been delivering care. That's the limiting step.”
Commenting on the idea for group visits, Charles Adler, MD, PhD, who heads the Parkinson's Disease and Movement Disorders Center at the Mayo Clinic in Scottsdale, AZ, said: “I think that it is certainly something that may have its place. We know that many PD patients like to attend support group meetings, and enjoy the camaraderie of being in the presence of other patients. Group visits are an extension of this in many ways. Patients also like to be educated. So this is something worth further investigation.”
“I think at this point, as the authors state, it is very much a pilot study,” Dr. Adler added. “They didn't have the power to look at differences between the groups. I would have liked to see a study looking at the actual difference between the treatment groups, to see if there is a benefit” from this alternative way of delivering care. Dr. Adler recommended that outcomes for future studies should include how well the education component works in the group setting versus the individual setting, cost, and physician time.
Dorsey ER, Deuel LM, Biglan KM, et al. Group patient visits for Parkinson disease: A randomized, feasibility trial. Neurology 2011; E-pub 2011 April 27.
Trento M, Passera P, Tomalino M, et al. Group visits improve metabolic control in type 2 diabetes: A 2-year follow-up. Diabetes Care 2011;24:995–1000.
Masley S, Phillips S, Copeland JR. Group office visits change dietary habits of patients with coronary artery disease: The Dietary Intervention and Evaluation Trial (DIET). J Fam Pract 2001:50-235–239.
Naik AD, Palmer N, Haidet P, et al. Comparative effectiveness of goal setting in diabetes mellitus group clinics: Randomized Clinical Trial. Arch Intern Med 2011;171(5)-453–459.