ARTICLE IN BRIEF
Investigators randomized patients with neuromuscular disorders to individual one-on-one appointments with their physicians or to shared medical visits with five or eight patients and their partners. Among the primary outcomes, patients who did the shared visits reported better health-related quality of life than those who went for individual appointments.
Shared medical appointments for patients with chronic neuromuscular disorders — during which a physician sees multiple patients simultaneously, combining individualized medical patient care with peer-support and education on self-management — appear to result in better self-reported health-related quality of life outcomes.
So a team of Dutch investigators reported from a randomized controlled trial comparing group visits with individual one-on-one visits at the Radboud University Medical Centre in the Netherlands. The study was published in the June 18 online issue of Neurology.
“We started offering shared medical appointments in 2008 and the enthusiasm of patients, partners, and clinicians motivated us to evaluate scientifically whether attending a shared medical appointment would be more effective than an individual outpatient appointment,” said Femke Marie Seesing, MSc, the lead author of the study. “The quality of life of patients who attended a shared medical appointment improved on the subscales of general health and social functioning compared with patients who attended an individual appointment.”
Seesing noted that the neurologist actually spent less time per patient in the shared medical appointment group, but patients and their partners received a 90-minute to two-hour appointment, which enabled them to receive more information about living with their disease.
The study provides evidence that group visits can improve aspects of quality-of-life for patients with a chronic neuromuscular disorder and could offer an alternative to individual appointments, improving both effectiveness and efficiency, she said.
In the study, 272 patients and 149 partners were randomized to shared visits or 20- to 30-minute individual medical appointments. Patients were identified through the Computer Registry of All Myopathies and Polyneuropathies, a Dutch neuromuscular database.
During the group visit, one or two neurologists saw five to eight patients with the same diagnosis and their partners simultaneously, addressing the same topics that are commonly covered during an individual appointment. A group mentor was on hand to help the neurologist facilitate the group process by fostering interaction between patients and partners and by managing time.
Among their findings, the investigators reported that patients who participated in shared visits scored an average of third points on a measure of health-related quality of life as measured by the Short Form Health Survey (SF-36).
In secondary outcomes, patients who participated in group visits showed higher values for quality of life as measured by the Individualized Neuromuscular Quality of Life questionnaire fatigue scale relative to the control group. But they also reported they were less satisfied with the appointment than those who had individual appointments; and the social support scores were 1.1 points higher in the individual appointment group.
Seesing and colleagues suggest in their paper that the lower satisfaction scores in the group visit may be related to the fact that patients had only one shared visit; previous studies have looked at the effect of multiple shared visits. “...Attending multiple successive SMAs gives participants the opportunity to build a relationship with peers and to acquaint themselves with the new care model over time,” they wrote.
In comments to Neurology Today, she noted that maintaining a group size large enough to generate interactions between patients is critical. Although the “no-show” rate for group is not different from that for individual appointments, Seesing advised clinicians to “overbook” the shared appointments.
OTHER MODELS IN PLACE
Neurologists who have experimented with shared medical appointments also report benefits for patients, partners, and clinicians. Vascular neurologist Sharon Poisson, MD, told Neurology Today that she and Jennifer Simpson, MD, have been conducting a pilot project of a group stroke clinic at the University of Colorado since October 2013.
“We see three to six patients together in an initial post-hospitalization visit after ischemic or hemorrhagic stroke,” Dr. Poisson said. “Often these patients are from all walks of life, but appreciate their common ground with their experiences resulting from the stroke. We generally have a round-table group discussion about their experiences post-stroke then provide directed education about stroke symptoms, treatment, prevalence and prevention. Additionally we discuss medications and why they are used for stroke patients. We then see each patient separately for an exam and personalized issues.”
She added that both clinicians and patients enjoy the format. “We have collected feedback from all patients, with most commenting that they liked the group engagement and focused education,” Dr. Poisson said. “From a provider perspective, we have felt that we get the opportunity to focus more on education that most patients with stroke and their caregivers can benefit from.
“Initially, we thought that there would be very specific patients who would benefit, but what we've found is that it works for a much broader range of patients. Even some who are very disabled participate or have caregivers that participate,” she added. “I would say that patients who are particularly complicated — those we have never seen before in our system, or need more in depth evaluation or diagnostic workup and treatments — would be hard to see in this setting. I think the group format would work well in many different specialties when many patients have similar experiences and need similar education. One of the largest benefits to the patients is that they find out that this happens to many other people of all ages, and they are not the only one experiencing similar challenges.”
Regarding billing, Dr. Poisson said “because we see each patient both in the group and individually, we can bill at least a level 3 for all patients.”
Ray Dorsey, MD, professor of neurology and director of the Center for Human Experimental Therapeutics at the University of Rochester Medical Center, said he believes group visits can provide better, more efficient care. [In a 2011 paper in Neurology, he had previously reported on the benefits of group visits for Parkinson's disease.] But he added that in the United States, at least, a barrier to widespread adoption outside of research settings is how physicians are paid. “Reimbursement models are hindering the adoption of practices that are more efficient, safer and provide better care,” he said.
Other barriers may include having enough space to accommodate group visits, and adapting office software for scheduling group visits.
But Dr. Dorsey said shared appointments represent a marriage of the medical visit and the support group model. “Many patients with chronic conditions share similar concerns,” he said. “People are social beings and this provides an opportunity for patients to share concerns not only with a physician but also with others who have their condition.”
He added that shared visits can be coupled with one-on-one visits for individual patient issues.
Seesing agrees. “In our opinion, shared medical appointments should be alternated with individual appointments to offer patients the best of both worlds,” she said. “Especially for patients with a rare disease, information from and contact with peers can be a valuable addition to the medical information.”
This is one of a series of stories on innovative care models. For past stories in the series, go to http://bit.ly/innovcare.
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