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Are Shared Medical Appointments the Future for Cancer Care?

Brophy Marcus, Mary

doi: 10.1097/01.COT.0000470859.19234.97
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Shared medical appointments (SMAs) may provide an innovative approach to caring for cancer patients, especially in the survivorship years, according to a recent literature review in Journal of Oncology Practice (2015;11:6-11). And while more research is needed to help determine the best use of the approach in cancer settings, those authors and other experts interviewed for this article say that further evaluation is warranted.

“SMAs offer an innovative and potentially huge opportunity in caring for and addressing the needs of cancer survivors,” said the first author of the review, Sarah Reed, MSW, MPH, a doctoral student at Betty Irene Moore School of Nursing at the University of California Davis.

She and her coauthors—Ann H. Partridge, MD, MPH, and Larissa Nekhlyudov, MD, MPH—searched for studies on shared medical appointments in all settings from 1974 to 2012, noting that such group appointments began to be integrated into primary care settings and specialty clinics in 1999.

The typical shared appointment includes eight to 12 patients and one or more health care providers—a doctor, nurse practitioner, or physician assistant. Appointments usually involve measuring and logging patients' vital signs and reviewing medications and any problems. Physical exams are conducted privately. Sometimes a behavioral health expert is present, too, to discuss key health messages and help facilitate the overall group dynamic, as well as sometimes a nutritionist or pharmacist.

In non-cancer settings shared appointments are linked to techniques to improved blood pressure and overall health-related quality of life, the authors wrote, and the literature also suggests there may be improved outcomes, better communication between health care providers and patients, and cost-saving benefits.

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With the growing number of cancer survivors, new models of care are needed, Reed said. “Overall we still know very little about how best to care for cancer survivors,” Reed said.

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Varying Models

Asked for her perspective for this article, Linda Jacobs, PhD, CRNP, Director of the Living Well After Cancer Program at Abramson Cancer Center of the University of Pennsylvania, said the shared appointment model is used at many cancer centers for pre-treatment chemotherapy education.

Jacobs said every cancer center needs to examine models of care within their own institution and consider multiple factors prior to determining the usefulness of the SMA model within their own settings: “Despite the positives noted in the article, there are many models that have been tested and some that are sustainable in a variety of settings. At Penn, we have numerous models in play depending upon the population. However, the integrated care model—having survivorship care provided by providers who are treating the patient—is the most sustainable and cost-effective one well.”

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Which Patients?

Also asked for an opinion, Kathryn Ruddy, MD, MPH, Director of Cancer Survivorship for the Department of Oncology at the Mayo Clinic, said she is particularly interested in learning more about which types of cancer survivors may benefit most from shared appointments. “As the authors note, some groups of survivors may benefit much more than others from a group visit, and these visits may be much more feasible in some settings than others.

“Optimizing the quality and efficiency of the way we care for cancer survivors is of critical importance, and it is very intriguing that certain populations of cancer survivors might benefit from group visits to oncologic providers. The opportunity to include psychosocial experts and an emphasis on emotional support and wellness in these visits is a particularly appealing aspect of this approach,” Ruddy said, adding that additional research is badly needed to study the impact of shared medical appointments on patient and provider satisfaction, physical and psychosocial outcomes, and cost effectiveness.

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Help Relieve Anxieties

Laurel Ralston, DO, a psycho-oncology psychiatrist at the Cleveland Clinic, said that from a psychological perspective, cancer can be a very isolating diagnosis and group medical appointments may help normalize some of the anxieties or insecurities facing patients.

“Not all patients are comfortable with this idea because maintaining privacy of their medical history is a priority. Oncologists may also shy away from SMAs because they don't provide the same level of individualized care. There are some situations in oncology where an SMA setting is not appropriate, and I think it's important that any patient participating in an SMA maintain access to traditional individual appointments when necessary,” Ralston said.

In terms of financial factors, she added that from a strictly numbers standpoint, it is, of course, more cost effective to have one 90-minute shared medical appointment for six to eight people than to see three or four individual patients in that time frame. “But the question is whether it is cost effective over the long term in patient outcomes and satisfaction. This is one of the reasons Cleveland Clinic's Cancer Institute has yet to commit to SMAs,” she said, noting though that Cleveland Clinic has been running a successful women's mental health SMA for close to a decade.

“It's a model that I think can be transposed to psycho-oncology. Right now, distance and the limited number of specialized providers restricts some of our cancer patients from accessing our psychosocial support services.

Offering mental health-based SMAs at various sites would help to address this problem,” Ralston said. “If adding psycho-oncology SMAs at a regional cancer site will improve access and help patients better manage the emotional distress of cancer, then it would make sense to develop this further.”

While SMAs were defined in the study as multiple patients meeting with one or more health care providers, some medical centers are structuring shared appointments the other way around.

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Best Practices at the University of Colorado Hospital

For example, Tom Purcell, MD, MBA, Executive Medical Director of Oncology Services at the University of Colorado Hospital, said the hospital has seven multidisciplinary cancer clinics, where shared medical appointments are already being used as best practice models for the initial intake and evaluation of cancer patients. Overall, the Hospital has been using SMAs since October 2012 when they started using multidisciplinary clinics.

But, he said that whereas most cancer centers bring health care providers in to see multiple patients, at the University of Colorado multiple specialists are brought in for one appointment with a single patient: “Cancer is a disease that requires numerous types of physicians to come together and provide the absolute best care in a multidisciplinary fashion—it requires multiple opinions.”

After cancer patients are initially seen by an intake person in the clinic, they are then seen by numerous other types of providers such as dieticians, physical therapists, and social workers, he explained. “Patients go through a process where we give them education and other information, and then we present our case in a tumor conference. Based on the situation with that patient, if they need to see multiple physicians, then multiple physicians will go see the patients and do their own evaluations during one encounter.

“The bottom line is that if someone comes in and needs to see three different oncologists, then three different physicians see that patient because it's appropriate. Elsewhere, such specialists would typically see patients in serial fashion two or three days apart, but we're committed to putting the patient first, and we establish it so that our schedules allow us to see the patient all together. I'm a medical oncologist so I may be seeing patients with a radiation oncologist or a surgical oncologist, depending on the type of cancer.”

Purcell said that depending on the type of malignancy, a pulmonary specialist or gastroenterologist may also be there. “But most of the time it is medical, surgical, and radiology, because there are often multiple components to a patient's treatment. The benefit to the physicians and the patients is that we get a plan very quickly and are able to move forward with treatment.”

In the 1990s and early 2000s, the health care system was structured around physicians, he noted: “We'd like to change the structure to be around the patient. Inherently, it can be a very inefficient process for physicians, because doctors are dedicating a significant part of their day to only a few patients. But I would suspect that because we get the best outcomes, and many times save patients procedures, that the team approach is going to lead to the best outcomes. And patients love it. We have measured our patient satisfaction as very high.”

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Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
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