NIHR Signal Group clinics may be better than individual consultations for some elements of diabetes care

Published on 23 February 2016

Group clinics for people with diabetes were effective in improving blood sugar levels, blood pressure and diabetes-related quality of life. There was no evidence of group clinics being better than individual appointments for other diabetes outcomes or in other health conditions. This systematic review examined group clinics, rather than individual appointments for the care of people with chronic conditions. Most of the evidence identified was about clinics set up for people with diabetes and came from the US.

Few people who could take part in group clinics agreed to do so, and there was a lack of feedback from people who were opposed to group care. Therefore the participants may not be representative of all people with chronic conditions. Group clinics were pioneered in America and most of the studies included in the review were US-based. There was little reliable information on cost-effectiveness or on whether these clinics replaced the need for one-to-one consultations. NHS-specific factors would need to be considered if considering planning and implementing group clinics in the UK.

Group clinics may be better than individual consultations for some elements of diabetes care

Why was this study needed?

More than 15.4 million people in England are living with one or more long-term conditions. Managing long-term conditions – such as diabetes, heart disease and arthritis – accounts for around 70% of the NHS budget, a figure which is set to rise as more of us live longer but with on-going health problems.

Group clinics, also sometimes called shared or group medical appointments, involve a small group of patients with the same health condition being seen by a doctor at the same time, rather than individually. Group clinics vary in their content, including education, support provided by others with the same condition (peer support), as well as clinical monitoring and treatment decisions.

This review is of interest to commissioners because if group clinics deliver the same quality of care and improvements in patients’ health as usual one-to-one appointments, they could potentially save time and money for individuals and the health service. This could lead to improvements for instance in hospital outpatient systems. This systematic review investigated the clinical and cost effectiveness of group clinics for chronic disease management, as well as reporting on patient views of them.

What did this study do?

This systematic review included 13 systematic reviews and 22 randomised controlled trials. Additional searches were conducted to identify other study types that reported cost-effectiveness, patient experience and implementation issues (24 identified).

To be included, the intervention had to be delivered by a doctor to a group of adults or children with a chronic health condition, and include clinical management and education. Studies evaluating education-only interventions were excluded.

The definition of group clinics varied greatly, so the interventions being compared in the review may not necessarily be like-for-like. The studies identified by this review included people with a range of different long-term health conditions, though most related to diabetes. So the effectiveness of group clinics may vary between different groups of patients.

No high quality experimental studies have been carried out in the UK, so the review’s findings come mainly from US-based studies.

What did it find?

  • Thirteen of 22 trials were in people with diabetes. Group clinics were effective in improving a long-term measure of blood sugar control (HbA1c) and blood pressure, but not low-density lipoprotein (LDL – “bad”) cholesterol. A few studies also found a beneficial effect on quality of life. For example, for people on insulin, the group clinic intervention reduced HbA1c by the study’s end, by 21% (95% confidence interval 21.8% to 20.2%) compared with usual care.
  • There was no evidence of group clinics being more effective for other diabetes outcomes, or for other chronic conditions.
  • Studies evaluating experiences of group clinics found patients can gain benefit from feeling supported by others with the same condition, sharing information and concerns with others which helps to build trust, and taking a greater role in managing their own care. Similarly clinicians appreciated the opportunity to monitor patients informally outside of routine clinics, especially the chance to identify factors that may influence adherence to treatment. However, it was noted that the views of ethnic minorities, and those who disliked group clinics, were poorly represented.
  • There was no clear evidence of a difference in the cost effectiveness of individual or group appointments. Costs were often poorly defined, so the authors could not be certain that all relevant costs (such as staff training) had been identified and considered. Not all models were true substitutions for individual consultations, making estimates around cost savings difficult.

What does current guidance say on this issue?

There are no UK guidelines on the use of group clinics. In 2014 the Royal College of General Practitioners produced a guide to implementing group clinics (Lawson 2014). In this, the College is broadly supportive of the idea. Saying that the patient-centred care provided in a group clinic reinforces the concept of each patient as an individual, with unique life experiences and values. The clinics allow these values and preferences to be taken into account in treatment and discharge planning. They say that group clinics provide an opportunity for clinicians to see and learn things that don’t happen during a one-on-one session, and this provides insights for helping patients manage their condition.

What are the implications?

This review found some evidence for the clinical effectiveness of group clinics – mainly for improving blood sugar control and blood pressure in people with diabetes. Other evidence was either mixed or of insufficient quality to inform practice.

The numbers of people who agreed to take part in group clinics was low, so they may not be representative of all people who would be eligible for group clinics. Also the views of people who did not like group clinics were generally underrepresented, with surveys and other related studies predominantly focusing on positive feedback. So the findings may be skewed towards those most willing and able to take part in group clinics.

Most of the high quality studies included in this review came from the US, which has a different healthcare delivery system from the UK. Therefore findings in terms of effectiveness, patient experience and cost may not be directly transferable. If planning implementation in the NHS, further quality evidence needs to inform which chronic health conditions and patient groups would gain the most benefit from group care and be most cost effective.

Citation and Funding

Booth A, Cantrell A, Preston L, Chambers D, Goyder E. What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review. Southampton (UK): NIHR Journals Library; 2015.

This project was funded by the National Institute for Health Research HS&DR (project number 13/182/02).

Bibliography

Campbell, D. NHS could be 'overwhelmed' by people with long-term medical conditions. The Guardian. 03 January 2014.

Lawson, R. Shared Medical Appointments – a Paradigm Shift. London: Royal College of General Practitioners; 2014.

Why was this study needed?

More than 15.4 million people in England are living with one or more long-term conditions. Managing long-term conditions – such as diabetes, heart disease and arthritis – accounts for around 70% of the NHS budget, a figure which is set to rise as more of us live longer but with on-going health problems.

Group clinics, also sometimes called shared or group medical appointments, involve a small group of patients with the same health condition being seen by a doctor at the same time, rather than individually. Group clinics vary in their content, including education, support provided by others with the same condition (peer support), as well as clinical monitoring and treatment decisions.

This review is of interest to commissioners because if group clinics deliver the same quality of care and improvements in patients’ health as usual one-to-one appointments, they could potentially save time and money for individuals and the health service. This could lead to improvements for instance in hospital outpatient systems. This systematic review investigated the clinical and cost effectiveness of group clinics for chronic disease management, as well as reporting on patient views of them.

What did this study do?

This systematic review included 13 systematic reviews and 22 randomised controlled trials. Additional searches were conducted to identify other study types that reported cost-effectiveness, patient experience and implementation issues (24 identified).

To be included, the intervention had to be delivered by a doctor to a group of adults or children with a chronic health condition, and include clinical management and education. Studies evaluating education-only interventions were excluded.

The definition of group clinics varied greatly, so the interventions being compared in the review may not necessarily be like-for-like. The studies identified by this review included people with a range of different long-term health conditions, though most related to diabetes. So the effectiveness of group clinics may vary between different groups of patients.

No high quality experimental studies have been carried out in the UK, so the review’s findings come mainly from US-based studies.

What did it find?

  • Thirteen of 22 trials were in people with diabetes. Group clinics were effective in improving a long-term measure of blood sugar control (HbA1c) and blood pressure, but not low-density lipoprotein (LDL – “bad”) cholesterol. A few studies also found a beneficial effect on quality of life. For example, for people on insulin, the group clinic intervention reduced HbA1c by the study’s end, by 21% (95% confidence interval 21.8% to 20.2%) compared with usual care.
  • There was no evidence of group clinics being more effective for other diabetes outcomes, or for other chronic conditions.
  • Studies evaluating experiences of group clinics found patients can gain benefit from feeling supported by others with the same condition, sharing information and concerns with others which helps to build trust, and taking a greater role in managing their own care. Similarly clinicians appreciated the opportunity to monitor patients informally outside of routine clinics, especially the chance to identify factors that may influence adherence to treatment. However, it was noted that the views of ethnic minorities, and those who disliked group clinics, were poorly represented.
  • There was no clear evidence of a difference in the cost effectiveness of individual or group appointments. Costs were often poorly defined, so the authors could not be certain that all relevant costs (such as staff training) had been identified and considered. Not all models were true substitutions for individual consultations, making estimates around cost savings difficult.

What does current guidance say on this issue?

There are no UK guidelines on the use of group clinics. In 2014 the Royal College of General Practitioners produced a guide to implementing group clinics (Lawson 2014). In this, the College is broadly supportive of the idea. Saying that the patient-centred care provided in a group clinic reinforces the concept of each patient as an individual, with unique life experiences and values. The clinics allow these values and preferences to be taken into account in treatment and discharge planning. They say that group clinics provide an opportunity for clinicians to see and learn things that don’t happen during a one-on-one session, and this provides insights for helping patients manage their condition.

What are the implications?

This review found some evidence for the clinical effectiveness of group clinics – mainly for improving blood sugar control and blood pressure in people with diabetes. Other evidence was either mixed or of insufficient quality to inform practice.

The numbers of people who agreed to take part in group clinics was low, so they may not be representative of all people who would be eligible for group clinics. Also the views of people who did not like group clinics were generally underrepresented, with surveys and other related studies predominantly focusing on positive feedback. So the findings may be skewed towards those most willing and able to take part in group clinics.

Most of the high quality studies included in this review came from the US, which has a different healthcare delivery system from the UK. Therefore findings in terms of effectiveness, patient experience and cost may not be directly transferable. If planning implementation in the NHS, further quality evidence needs to inform which chronic health conditions and patient groups would gain the most benefit from group care and be most cost effective.

Citation and Funding

Booth A, Cantrell A, Preston L, Chambers D, Goyder E. What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review. Southampton (UK): NIHR Journals Library; 2015.

This project was funded by the National Institute for Health Research HS&DR (project number 13/182/02).

Bibliography

Campbell, D. NHS could be 'overwhelmed' by people with long-term medical conditions. The Guardian. 03 January 2014.

Lawson, R. Shared Medical Appointments – a Paradigm Shift. London: Royal College of General Practitioners; 2014.

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

Published on 1 January 2016

Booth A, Cantrell A, Preston L, Chambers D, Goyder E

Health Services and Delivery Research Volume 3 Issue 46 , 2016

BACKGROUND: Group clinics are a form of delivering specialist-led care in groups rather than in individual consultations. OBJECTIVE: To examine the evidence for the use of group clinics for patients with chronic health conditions. DESIGN: A systematic review of evidence from randomised controlled trials (RCTs) supplemented by qualitative studies, cost studies and UK initiatives. DATA SOURCES: We 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 METHODS: Data 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. RESULTS: Thirteen 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 HbA1c and 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. LIMITATIONS: This 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. CONCLUSIONS: 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. 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 WORK: The 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. FUNDING: The National Institute for Health Research Health Services and Delivery Research programme.

Expert commentary

Group clinics for chronic disease patients offer an opportunity to deliver supportive care and the potential benefits might span both primary and secondary care. However, in an increasingly complex world of multimorbidity the evidence in this systematic review relates mainly to single diseases, is inconsistent in terms of its definitions and components, and is largely derived from the US.

Some words of caution are therefore warranted: no rigorous evaluation of group clinics has been conducted in the UK to date; the absence of empirical studies along with the extra set–up and running costs means it is therefore hard to justify their uptake before rigorous studies have identified cost effective interventions. The supporting evidence for many candidate programme theories though supports a research agenda to develop further pragmatic interventions.

Professor Carl Heneghan, Professor of Evidence-Based Medicine & Director CEBM, Department of Primary Care Health Sciences, University of Oxford

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