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Review ArticleClinical Review

Group Visits: A Qualitative Review of Current Research

Raja Jaber, Amy Braksmajer and Jeffrey S. Trilling
The Journal of the American Board of Family Medicine May 2006, 19 (3) 276-290; DOI: https://doi.org/10.3122/jabfm.19.3.276
Raja Jaber
MD
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Amy Braksmajer
MPH
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Jeffrey S. Trilling
MD
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    Table 1.

    Summary of Research on Group Visits, Including Study Sample, Type of Group Visit, Strength of Evidence, and Outcomes

    Primary AuthorYearSampleNVisit TypeLength/ Frequency of VisitRate of AttendanceRCT?Intent-to-Treat Analysis?≥80% Follow-up?Significantly Favorable OutcomesNonsignificant Outcomes
    Beck1997Chronically ill, high-utilizing older adults321CHCC; individual visits as needed2 hours, once a month for 1 yearAverage number of sessions attended: 6.62 (55% of sessions)YesYesNearly (78.5%)
    • Emergency room visits

    • Subspecialist visits

    • Repeat hospital admissions

    • Same-day internal medicine visits

    • Imaging tests

    • Influenza and pneumonia vaccinations

    • Aggregate cost savings ($14.79 per participant per month)

    • Patient satisfaction

    • Number of laboratory tests prescribed

    • Prescription medications

    • Admissions to SNFs

    • Receiving VNS

    • Length of hospital stays

    • Median hospital charges

    • Mobility

    • ADLs

    • IADLs

    • Depression (Short Geriatric Depression Scale)

    Blumenfeld2003Headache497Headache Management Program; 2 comprehensive individual visits with NP.2 hours; one session (offered weekly), led by neurologist followed by 2 self-management consultations with an NP 2 and 8 weeks laterN/A (one session)NoN/AN/A
    • Decreased primary care visits

    • Decreased emergency visits

    • Decreased CT scans

    • Quality of life (migraine-specific)

    • Physical function (SF-36)

    • Symptom improvement

    • Medication use (injected and oral narcotics)

    • Increased neurology visits

    • Nonsignificant increase in non-headache visits

    • Nonsignificant increase in oral triptan use

    Clancy2003*Type II diabetes120CHCC; individual visits every session2 hours; once per month for 6 monthsNot describedYesNot reportedYes (data obtained via chart abstraction)
    • Improvement in ADA standards of care

    • Improved sense of trust in physician

    • HbA1c

    • Lipid profiles

    • Perceptions of better coordination of care, community orientation, and culturally competent care (trend towards significance) (Patient Care Assessment Tool)

    • All other aspects of the Patient Care Assessment Tool

    Coleman1999Frail older adults at high risk of hospitalization169Chronic Care Clinic; individual visits every sessionOne half-day; once every 3 to 4 months over 2 years53% attended 2 or more sessions; 29% attended noneYesYesYes
    • Decreased urinary incontinence at 12-month follow-up

    • Primary care visits

    • Emergency visits

    • Hospitalizations

    • Mean hospital days

    • Urinary incontinence at 24-month follow-up

    • Frequency of falls

    • Depression (CES-D)

    • Patient satisfaction

    • Functional status (SF-36)

    • Rate of use of high-risk medications

    • Costs

    Dodds1992Physicians (quality of care study)31′Group discussions′ individual visits every session53 minutes; 14 sessions offeredN/A (physicians, not patients, were studied)NoN/AN/A
    • Recommended content covered in the following areas: safety, nutrition, behavior and development, and sleep

    • Recommended content regarding family and parenting issues

    Maizels2003Headache264Headache Clinic; individual visits every sessionOne session; 25 separate sessions offered; length not describedN/A (one session)NoN/AN/A
    • Increase in triptan costs (nearly all accounted for by for previous non-users of triptans); no statistical analysis

    • Decrease in triptan costs among previously high utilizers of triptans; no statistical analysis

    • Decrease in frequency of severe headaches; no statistical analysis

    • Reduction in total costs; no statistical analysis

    • Reduction in headache-related total and emergency visits; no statistical analysis

    N/A
    Masley2001Coronary artery disease97Group Education; no individual medical visits1.5 hours; 14 sessions over 1 year (weekly during the first month, monthly thereafter)Not describedYesNoYes
    • Increased health behaviors (eating fruits and vegetables, cooking with monounsaturated fat) compared to controls

    • Reductions in low-density lipoprotein reductions among intervention patients (compared to baseline)

    • Total per member per month expenses

    • Total and saturated fat intake

    • Difference in LDL reduction between groups

    • Total cholesterol/HDL ratio, triglycerides, and HDL

    • HbA1c

    • Total and pharmacy PMPM expenses

    Miller2004Chronically ill, low-income women (ages 40 to 64)28CHCC; individual visits within the group every session1.5 hours; 6 sessions over a 9-month period57% attended 3 or more sessions, 32% attended 1 or 2 sessions, and 11% attended only the orientation session; overall 51% attendance rateNoN/AYes
    • Decrease in emergency and urgent care visits

    • Overall frequency of clinic visits (including emergency, urgent care, primary provider and specialty visits)

    Noffsinger2001All patients in 4 practices.Avg. 41.8/wkDIGMA1.5 hours (3 practices); 1 hour (1 practice); 1 session offered weeklyThe average attendance rate for pre-registered patients was 81%. This was not a cohort.NoN/AN/A
    • Increased patient satisfaction

    • Increased physician satisfaction (qualitative)

    N/A
    Osborn1981Mother-infant pairs78′Group visits′ group discussion; individual visits every session45 group sessions, each followed by individual visit; at least 3 visits during first 6 months of baby’s lifeThose attending group visits averaged 3.4 visits in first 6 months; controls completed 2.9 visits. 28% of control infants and 10% of group infants did not complete 3 visitsNoNoYes
    • Increased attendance at prescribed well-child visits

    • Increased likelihood of stating their child had not been ill

    • Decreased likelihood of seeking advice between visits

    • Less time discussing physical aspects of care and more time discussing personal issues in baby’s daily care

    • Decrease in direct questions and reassurance from baseline, but increased explanations.

    • Decrease in indirect questions and reassurance compared to controls, but an increase in direct questions

    • Clinician time spent per infant

    • Utilization of health care services

    • Patient satisfaction

    Power1983Diabetes (type unclear)203′Group visits′ different patients each visit; individual visits as needed6 sessions; 1 hour each over the course of a year. Patients scheduled for groups according to need.10 patients did not complete the study (4.9%). Long-term no-show rate for return visits was 10%.YesNoYes
    • Improved control of mean blood glucose compared to baseline among group patients

    • Body weight

    • Insulin use

    Power1992Obese patients (20 lbs. or more above ideal body weight)121′Group visits′ no individual visit1-hour classes held weekly, biweekly, and monthly over 5 years.′Patients stayed long enough to be followed for 5 years.′NoN/AYes
    • Reduction in obesity (significance not reported; 20%)

    • Reduction in blood pressure (significance not reported; 20%)

    • Reduction in cholesterol (significance not reported; 80%)

    N/A
    Sadur1999Type I and II diabetes185Cluster visits led by diabetes nurse educator; rare individual medical visits2 hours; once per month for 6 months. Between meetings, the nurse educator reviewed diabetes management by telephone according to patient needs.Not describedYesNot reportedYes
    • Decrease in HbA1c levels compared to controls at six months

    • Increase in medication use (insulin, sulfonylureas, metformin) compared to controls

    • Increased nutritionist consultation

    • Increased frequency of blood glucose monitoring)

    • Decrease in average home blood glucose level over the past month

    • Increase in self-efficacy compared with the control group (balancing one’s diet to maintain blood glucose, the ability to recognize and treat blood glucose, maintaining blood glucose when ill)

    • Satisfaction with diabetes care compared to controls

    • Lowered frequency of hospitalizations compared to controls

    • Decrease in non-physician visits compared to controls

    • Decrease in physician visits (although this was almost significant)

    • Urgent care clinic visits

    • Emergency visits

    • Optometry and ophthalmology visits

    • Difference between control and intervention HbA1c at 12 months

    • Proportion of subjects monitoring blood glucose at home

    • Self-assessed ease of maintaining an acceptable blood glucose level

    • Frequency of foot self-exam

    • Exercise

    • Self-efficacy (follow a low-fat diet, exercise regularly, monitor blood glucose regularly, communicating with physicians, expressing feelings about diabetes to family and friends)

    • Satisfaction with general medical care

    Scott2004Chronically ill, high-utilizing older adults294CHCC; individual visits as needed90 minutes; once per month for 24 monthsAverage number of sessions attended: 10.6 (40.8% of sessions); 25.5% attended 2 or fewer sessionsYesYesNearly (78%)
    • Decreased inpatient admissions

    • Decreased emergency visits

    • Decreased professional services

    • Decreased ED costs

    • Increased quality of life compared to controls (general)

    • Increased self-efficacy regarding communicating with physicians compared with compared to controls

    • Increased patient satisfaction with primary care physician, physician unhurriedness, time spent with physician, overall quality of care, learning medication management from pharmacists, and learning self-management from nurses compared to controls

    • Outpatient hospital visits

    • Observation unit admissions

    • Pharmacy services

    • Home health care

    • SNF use

    • Health status

    • ADLs

    • Hospital, professional, and health-plan termination costs (trend towards significance)

    • Pharmacy costs, total costs

    • Self-efficacy regarding disease management, doing chores, participating in social/recreational activities, and controlling/ managing depression

    Trento2002Type II diabetes112′Group Care′ shared similarities with both Chronic Care Clinics and DIGMAs; individual visits as needed69 minutes, including elective individual care; approximately once every 3 months for 4 yearsUnclear, but implied to be high.YesYesYes
    • Stable serum nitrogen compared to control group, in which it increased

    • Increases in health behaviors (compared to controls, in whom they decreased)

    • Less progression of retinopathy

    • Total patient costs: $159.11 for group patients, $95.25 for controls (significance not reported)

    • For other outcomes, see Trento 2004

    • Relative CVD risk

    • Systolic/disatolic blood pressure

    • Microalbuminuria

    • For other outcomes, see Trento 2004

    Trento2004Type II diabetes112′Group Care′ shared similarities with both Chronic Care Clinics and DIGMAs; individual visits as needed69 minutes, including elective individual care; approximately once every 3 months for 5 years (continuation of prior study; slightly different outcomes examined)Not describedYesYesNo
    • Increase in problem-solving ability from baseline (controls worsened)

    • Stable HbA1c compared to controls (in which it increased)

    • Increased quality of life (diabetes-specific)

    • Increased diabetes knowledge (compared to controls, in whom it decreased)

    • Decrease in hypoglycemic agents (compared to controls, in whom they increased)

    • BMI

    • Body weight

    • HDL

    • Use of antihypertensive and lipid-lowering medication

    • Triglyceride

    • Creatinine

    • Fasting blood glucose

    Wagner2001Type II diabetes707Chronic Care Clinic; individual visits every sessionOne half-day; once every 3 to 6 months over 2 yearsMajority attended 3 or more sessions (up to 6); 35% attended noneYesYesYes
    • Increased quality of care (number of recommended preventive procedures, increased participation in patient education)

    • Fewer bed disability days

    • Lowered frequency of specialty visits

    • Lowered frequency of emergency room visits

    • Improved general health status (SF-36 subscale)

    • Primary care visits (trend towards significance)

    • Hospitalization frequency

    • Rates of foot exams, retinal exams, and medication reviews

    • Patient satisfaction (diabetes-specific and overall)

    • Physical function, physical role function (two SF-36 subscales)

    • Depression (CES-D)

    • Restricted-activity days

    • Total health care costs

    • HbA1c and cholesterol

    • * Clancy et al. published three articles that month using the same study data.

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The Journal of the American Board of Family Medicine: 19 (3)
The Journal of the American Board of Family Medicine
Vol. 19, Issue 3
May-June 2006
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Group Visits: A Qualitative Review of Current Research
Raja Jaber, Amy Braksmajer, Jeffrey S. Trilling
The Journal of the American Board of Family Medicine May 2006, 19 (3) 276-290; DOI: 10.3122/jabfm.19.3.276

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Group Visits: A Qualitative Review of Current Research
Raja Jaber, Amy Braksmajer, Jeffrey S. Trilling
The Journal of the American Board of Family Medicine May 2006, 19 (3) 276-290; DOI: 10.3122/jabfm.19.3.276
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