What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review

Abstract

BackgroundGroup clinics are a form of delivering specialist-led care in groups rather than in individual consultations.ObjectiveTo examine the evidence for the use of group clinics for patients with chronic health conditions.DesignA systematic review of evidence from randomised controlled trials (RCTs) supplemented by qualitative studies, cost studies and UK initiatives.Data sourcesWe searched MEDLINE, EMBASE, The Cochrane Library, Web of Science and Cumulative Index to Nursing and Allied Health Literature from 1999 to 2014. Systematic reviews and RCTs were eligible for inclusion. Additional searches were performed to identify qualitative studies, studies reporting costs and evidence specific to UK settings.Review methodsData were extracted for all included systematic reviews, RCTs and qualitative studies using a standardised form. Quality assessment was performed for systematic reviews, RCTs and qualitative studies. UK studies were included regardless of the quality or level of reporting. Tabulation of the extracted data informed a narrative synthesis. We did not attempt to synthesise quantitative data through formal meta-analysis. However, given the predominance of studies of group clinics for diabetes, using common biomedical outcomes, this subset was subject to quantitative analysis.ResultsThirteen systematic reviews and 22 RCT studies met the inclusion criteria. These were supplemented by 12 qualitative papers (10 studies), four surveys and eight papers examining costs. Thirteen papers reported on 12 UK initiatives. With 82 papers covering 69 different studies, this constituted the most comprehensive coverage of the evidence base to date. Disease-specific outcomes – the large majority of RCTs examined group clinic approaches to diabetes. Other conditions included hypertension/heart failure and neuromuscular conditions. The most commonly measured outcomes for diabetes were glycated haemoglobin A1c(HbA1c), blood pressure and cholesterol. Group clinic approaches improved HbA1cand improved systolic blood pressure but did not improve low-density lipoprotein cholesterol. A significant effect was found for disease-specific quality of life in a few studies. No other outcome measure showed a consistent effect in favour of group clinics. Recent RCTs largely confirm previous findings. Health services outcomes – the evidence on costs and feasibility was equivocal. No rigorous evaluation of group clinics has been conducted in a UK setting. A good-quality qualitative study from the UK highlighted factors such as the physical space and a flexible appointment system as being important to patients. The views and attitudes of those who dislike group clinic provision are poorly represented. Little attention has been directed at the needs of people from ethnic minorities. The review team identified significant weaknesses in the included research. Potential selection bias limits the generalisability of the results. Many patients who could potentially be included do not consent to the group approach. Attendance is often interpreted liberally.LimitationsThis telescoped review, conducted within half the time period of a conventional systematic review, sought breadth in covering feasibility, appropriateness and meaningfulness in addition to effectiveness and cost-effectiveness and utilised several rapid-review methods. It focused on the contribution of recently published evidence from RCTs to the existing evidence base. It did not reanalyse trials covered in previous reviews. Following rapid review methods, we did not perform independent double data extraction and quality assessment.ConclusionsAlthough there is consistent and promising evidence for an effect of group clinics for some biomedical measures, this effect does not extend across all outcomes. Much of the evidence was derived from the USA. It is important to engage with UK stakeholders to identify NHS considerations relating to the implementation of group clinic approaches.Future workThe review team identified three research priorities: (1) more UK-centred evaluations using rigorous research designs and economic models with robust components; (2) clearer delineation of individual components within different models of group clinic delivery; and (3) clarification of the circumstances under which group clinics present an appropriate alternative to an individual consultation.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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

“…Finally, previous systematic reviews have highlighted some gaps in the evidence. [1][2][3][4][5][6][7][8][9][10][11] Also, some of the studies are small and underpowered as pointed out by Edelman et al . 9 Further, as Booth et al highlighted 'although there is consistent and promising evidence for an effect of group clinics for some biomedical measures, this effect does not extend across all outcomes', but scaling-up can confirm both feasibility and real-world efficacy.…”

“…9 Further, as Booth et al highlighted 'although there is consistent and promising evidence for an effect of group clinics for some biomedical measures, this effect does not extend across all outcomes', but scaling-up can confirm both feasibility and real-world efficacy. 10 There remains an absence of evidence for assessing new patients, especially presenting to secondary care, and a paucity of educational research on group consultations. More work is also needed on measuring and understanding the peer support effects and how much this affects future consultation behaviour.…”

“…For example, multiple RCTs showing improved outcomes in diabetes group care compared to usual care including tighter HbA1c control, improved hypertension, 40 knowledge, selfmanagement, self-efficacy and less consistent effects on weight and cholesterol. [4][5][6][7][8][9][10] At the same time, a recent review highlights the need for more rigorous scientific evidence for diabetes. 7 Groups improve blood pressure, medicine compliance, physical activities, diet, self-reported health and self-efficacy in a trial of 1,024 hypertensive patients.…”

“…Group consultations are an important care option that is starting to gain traction in the USA and Australia, with some practise now in the UK. [1][2][3][4][5][6][7][8][9][10][11] Group consultations are an ABSTRACT overarching term to describe care models where several patients are seen by one or more clinicians concurrently. They can be contrasted with conventional models of care: usual 1:1 clinics; education groups where only education is delivered; and round robin annual review clinics, with serial 1:1 consultation.…”

Promises and Perils of Group Clinics for Young People Living With Diabetes: A Realist Review

“…Group clinics are assumed to provide a space for experimentation and reassurance; when a behavior is normalized in the group, it might become easier to perform it in public (36). Especially for those experiencing their diagnosis and self-management as stigmatizing, peer support in group clinics may help instill a sense of normalcy, which could lead to rethinking self-monitoring and management in social settings (CMOC 3) (19,31,(36)(37)(38).…”