Publisher's Synopsis
Optimal care of chronic illness requires both high-quality care (i.e., excellent clinical outcomes) and ready access to care. However, health care systems struggle with providing access and quality simultaneously-and to achieve both these objectives while simultaneously maintaining staff job satisfaction is a formidable undertaking. Although Veterans Affairs (VA) has made large strides in delivering quality care over the past two decades, quality gaps remain, both gaps in technical quality (e.g., still only 70 to 75% of patients have appropriate blood pressure control) and gaps in timeliness of services. Group medical visits offer the promise of improving the effectiveness, timeliness, and efficiency of health care. Additionally, because clinicians may prefer to work in collaborative, multidisciplinary settings, group medical visits also have the potential to improve staff satisfaction. Group medical visits are defined as multiple patients seen together while in the same clinical setting. A subset of group clinics-referred to as shared medical appointments (SMAs)-is defined by groups of patients meeting over time for comprehensive care, usually involving a practitioner with prescribing privileges, for a defining chronic condition or health care state. SMAs often use educational and/or self-management enhancement strategies, paired with medication management, in an effort to achieve improved disease outcomes. SMAs have been scientifically studied in an array of primary care settings over the last 10 to 15 years. However, there has been great variability among these studies. In particular, the settings of these studies have been heterogeneous; different chronic health care states have been assessed; and the impact on clinical, cost, and utilization outcomes has been variable. Most important, there has been significant variation in the SMA intervention itself-in particular, which types of clinical, educational, and self-efficacy approaches are included in the specific SMA under evaluation. This uncertainty regarding the optimal design and impact of SMAs led the VA to commission this evidence synthesis report. Our objective in this evidence synthesis was to summarize the results of the diverse studies of SMAs in an effort to understand their impact on staff satisfaction, patient experience, and clinical outcomes along with effects on health care utilization. A second objective was to determine whether the impact of SMA visits varies by clinical condition or specific components of the intervention. This review was commissioned by the VA Evidence-based Synthesis Program. The topic was nominated after a topic refinement process that included a preliminary review of published peer reviewed literature, consultation with internal partners and investigators, and consultation with key stakeholders. We further developed and refined the key questions based on a preliminary review of published peer-reviewed literature in consultation with VA experts. The final key questions were: Key Question 1. For adults with chronic medical conditions, do shared medical appointments (SMAs) compared with usual care improve the following: Patient and staff experience?; Treatment adherence?; Quality measures such as (a) process of care measures utilized by VA, National Quality Forum, or National Committee for Quality Assurance and (b) biophysical markers (laboratory or physiological markers of health status such as HbA1c and blood pressure)?; Symptom severity and functional status?; Utilization of medical resources or health care costs? Key Question 2. For adults with chronic medical conditions, do the effects of SMAs vary by patient characteristics such as specific chronic medical conditions and severity of disease? Key Question 3. Is the intensity of the intervention or the components used by SMAs associated with intervention effects?
