Abstract
Background: Obesity and diabetes are epidemic in the United States, with many treatment options having limited long-term efficacy. A possible effective medical management tool is the shared medical appointment (SMA), which offers an efficient and cost-effective approach to behavior change and aligns with the Triple Aim (reduce costs, improve population health, and improve patient care experience) set forth by the Institute for Healthcare Improvement.
Objectives: To assess the effectiveness of SMAs to achieve the Triple Aim and to improve the management of overweight/obesity or diabetes.
Methods: Peer-reviewed literature from PubMed was searched by the keywords shared medical appointments, group medical appointment, and group medical visit, with no date restrictions and limited to English publications with sample sizes greater than or equal to 20.
Results: Eight articles met inclusion criteria. The Triple Aim was not referenced in the studies, but most reported some combination of reduced costs, improved care, and improved outcomes or patient satisfaction.
Conclusions: Potential benefits of SMAs include improved patient outcomes and satisfaction. Osteopathic and, in particular, primary care medicine could likely benefit from moving toward greater adoption of SMAs; however, more randomized controlled trials are needed to assess their effectiveness with regard to the Triple Aim.
Shared medical appointments (SMAs), while gaining popularity in select health care systems,
1,2 are still not considered a mainstream approach to health care delivery. Also referred to as
group medical visits, SMAs are often undertaken as an alternative to one-on-one appointments in an effort to reduce costs, improve population health, and improve patient care experience (including quality and satisfaction). These 3 priorities make up the Triple Aim set forth by the Institute for Healthcare Improvement (IHI), which is an independent nonprofit organization that promotes improvements in health care.
3 A small but growing body of research indicates that SMAs are effective at achieving aspects of the IHI’s goals,
4-9 but, to the authors’ knowledge, no literature explicitly reports on the effect of SMAs on the Triple Aim. In patients with overweight, obesity, or diabetes for whom social support is of paramount importance,
10,11 SMAs may be especially useful.
Almost 70% of adults in the United States are overweight (body mass index [BMI], 25-29.9) or obese (BMI ≥30).
12 Additionally, just over 33% of children in the United States are overweight (obesity class I; BMI-for-age between the 85th and 94th percentile on the BMI-for-age growth chart), and almost 17.4% meet the criteria for obesity (obesity class II; BMI-for-age ≥95th percentile).
13 Excess body weight is a modifiable risk factor for reducing the incidence of prediabetes and type 2 diabetes mellitus (T2DM), so targeting body weight via SMAs is a sensible approach to risk reduction.
14
Prediabetes is strongly linked to excess body weight and is on the rise among all segments of the US population.
12,15 A diagnosis of prediabetes should be considered when hemoglobin A
1c (HbA
1c) is 5.7% to 6.4% or a fasting blood glucose (FBG) level is between 100 mg/dL and 125 mg/dL.
16 Prediabetes and obesity are highly predictive of T2DM developing.
17 Intervening with SMAs might be effective in managing obesity and prediabetes, which in turn should diminish the risk for the development of T2DM.
Weight loss interventions targeting obesity or diabetes have limited long-term efficacy and, depending on the population, different approaches are used, including SMAs.
18,19 For children, typical interventions include family, community, school, and health care components and are more likely to lead to long-term weight improvements.
20 For adults aged 60 years or older, effective weight loss interventions typically include (1) prescription of a moderate reduced-calorie diet (eg, reducing energy intake by 500 kcal/d); (2) prescription of increased physical activity; and (3) behavioral strategies to facilitate adherence to diet and activity recommendations.
21 A confounding problem is that adults with obesity who are seen by primary care professionals for issues not overtly related to obesity in the patient’s mind (eg, knee and back pain, depression) are frequently not counseled to make lifestyle changes or achieve a healthy weight unless other obesity-related comorbidities are present (eg, sleep apnea, diabetes).
22,23 The Diabetes Prevention Program, while effective for adult weight loss and slower progression to diabetes,
24 lacks primary care facilitation, which is included in SMAs. Wider adoption of SMAs might be able to remedy some of these challenges.
Shared medical appointments follow 1 of 2 general formats: (1) cooperative health care clinics, which are typically used to provide care to elderly patients who fall in the high-use category or patients with chronic conditions, or (2) drop-in group medical appointments, in which patients attend SMAs only when they have a specific need.
25
In contrast to traditional one-on-one appointments with health care professionals, which usually last less than 20 minutes,
26,27 SMA facilitation is done by an interprofessional team comprising a primary care health care professional and an allied health care professional (often an educator such as a nurse or registered dietitian) and lasts 60 to 120 minutes. Patients are assigned to SMAs based on a shared chronic condition (eg, diabetes, chronic pain, asthma). Acting as both a medical appointment and a peer social support group, SMAs are typically structured to accommodate approximately 10 to 15 patients and occur 1 to 2 times per month.
28 Some studies we reviewed provided information on billing, how a clinic operates, and coding for SMA.
25,29-31 More details on personnel, scheduling, coding, and billing are available from the American Academy of Family Physicians (
http://www.aafp.org/practice-management/payment/coding/group-visits.html and
http://www.aafp.org/dam/AAFP/documents/patient_care/fitness/GroupVisitAIM.pdf) and eMDs, Inc (
http://www.e-mds.com/scheduling-and-coding-group-visits).
The proposed benefit of the SMA approach is twofold: (1) SMAs can positively alter the course of a patient’s body weight and overall health; and (2) SMAs can offer a medically supervised social support mechanism. This combination has a domino effect on the obesity-related comorbidities of prediabetes, T2DM, and cardiovascular disease.
The goal of this literature review was to summarize and update the current findings concerning the degree to which SMAs were shown to achieve the IHI’s Triple Aim and the role of SMAs in managing overweight/obesity or diabetes. Patient experiences, perceptions of health care professionals, physician efficiency, clinical efficacy, cost, and the use of osteopathic tenets were the outcomes of interest. We focused on the cooperative health care clinic model of the SMA, as it was designed to target chronic disease management.
To our knowledge, this is the first review of the literature focused on studies that used an SMA design among a patient population with overweight/obesity or diabetes and that considered how SMAs may have addressed the goals of the Triple Aim. Osteopathic medicine is well-suited to adopting an SMA approach given its primary care, patient-centered focus. Many primary care practices have large numbers of patients with overweight, obesity, prediabetes, diabetes, and other chronic diseases.
The articles included were only those available in English through PubMed, and several articles were pilot studies. The Triple Aim was also not mentioned in any of these studies, so inferences were made during our review process based on experiences of patients and health care professionals, as well as costs. The heterogeneity of the studies reviewed is also a limitation.
Further research on the SMA model using randomized controlled trials with larger populations and in more diverse clinical settings is warranted. This will allow researchers to quantify the impact of SMAs on patients with overweight/obesity or diabetes and determine the economic ramifications on health care professionals and the health care system.