A realist review of shared medical appointments: How, for whom, and under what circumstances do they work?

Abstract

BackgroundShared medical appointments (SMAs) are doctor-patient visits in which groups of patients are seen by one or more health care providers in a concurrent session. There is a growing interest in understanding the potential benefits of SMAs in various contexts to improve clinical outcomes and reduce healthcare costs. This study builds upon the existing evidence base that suggests SMAs are indeed effective. In this study, we explored how they are effective in terms of the underlying mechanisms of action and under what circumstances.MethodsRealist review methodology was used to synthesize the literature on SMAs, which included a broad search of 800+ published articles. 71 high quality primary research articles were retained to build a conceptual model of SMAs and 20 of those were selected for an in depth analysis using realist methodology (i.e.,middle-range theories and and context-mechanism-outcome configurations).ResultsNine main mechanisms that serve to explain how SMAs work were theorized from the data immersion process and configured in a series of context-mechanism-outcome configurations (CMOs). These are: (1) Group exposure in SMAs combats isolation, which in turn helps to remove doubts about one’s ability to manage illness; (2) Patients learn about disease self-management vicariously by witnessing others’ illness experiences; (3) Patients feel inspired by seeing others who are coping well; (4) Group dynamics lead patients and providers to developing more equitable relationships; (5) Providers feel increased appreciation and rapport toward colleagues leading to increased efficiency; (6) Providers learn from the patients how better to meet their patients’ needs; (7) Adequate time allotment of the SMA leads patients to feel supported; (8) Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge; and (9) Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust.ConclusionsNine overarching mechanisms were configured in CMO configurations and discussed as a set of complementary middle-range programme theories to explain how SMAs work. It is anticipated that this innovative work in theorizing SMAs using realist review methodology will provide policy makers and SMA program planners adequate conceptual grounding to design contextually sensitive SMA programs in a wide variety of settings and advance an SMA research agenda for varied contexts.

Process and Systems: A systems approach to embedding group consultations in the NHS

“…Table 1 shows common barriers and solutions to implementation, together with the positive impacts of successful implementation. 69 The common factors that thriving sites shared were attitudinal, including reactions to the model, organisational culture and intrinsic climate. 70 Struggling sites tended to be bureaucratic and to not embrace innovation, and so responded very differently to the same implementation barriers.…”

Dental therapists in general dental practice. A literature review and case‐study analysis to determine what works, why, how and in what circumstances

“…Realist evaluation is an established method in healthcare practice research, particularly for investigating the real-life implementation of interventions, guidelines or protocols. [26][27][28][29][30] The purpose of realist evaluation is to find out why interventions work differently across different contexts, 28,31 moving beyond a descriptive account to uncover deeper causal factors. 32 The aim of this evaluation was to explore: "does it work, for whom, when and why?"…”

The case for shared medical appointments

“…Patients leave SMAs with more confidence to manage their health and, ultimately, it appears to improve their quality of life. 3 Interestingly, the doctor's advice also seems to be more readily taken on and diligently followed when co-signed by other patients in the situation of an SMA. 4 The way the consultation is structured allows patients to direct conversation while the healthcare providers assume a less authoritative role.…”

“…This model of care has been adopted most widely in the USA and Australia, and its benefits are well recognised. [1][2][3][4][5] There are only limited data on SMA practice in the UK; however, group consultations have been included in the Royal College of General Practitioners' '10 High Impact Actions' 6 as an alternative consultation type to relieve pressures and increase capacity in primary care. Despite this, and evidence showing that SMAs result in better health outcomes, increased doctor and patient satisfaction and the potential to increase efficiency in the healthcare system, uptake seems to have been slow in the UK.…”