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.

/pdf/what-is-the-evidence-for-the-effectiveness-appropriateness-4pqtw07ma2.pdf

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

How to ask: Older adults’ preferred tools in health outcome prioritization

Individuals with chronic stress can improve their overall wellness by making lifestyle changes. We describe the design and evaluation of a computer-animated conversational agent that is used in conjunction with Integrative Medical Group Visits (IMGV) to help individuals with chronic pain and depression manage their stress. The agent coaches patients in between group visit sessions, reviewing how to manage stress using non-pharmaceutical techniques (e.g., mindfulness, meditation, yoga self-massage). We conducted a longitudinal clinical trial with 154 participants in which patients in the intervention group interacted with the conversational agent at home on a touch screen tablet to reinforce what they learned in group medical visits. Results from the trial indicate that the conversational agent, in conjunction with medical group visits, leads to significantly more positive stress management behaviors in patients compared to outcomes that arise in usual care, after 9 and 21 weeks.

Augmenting Group Medical Visits with Conversational Agents for Stress Management Behavior Change

Design of the integrative medical group visits randomized control trial for underserved patients with chronic pain and depression.

Chronic diseases pose many challenges to health care providers and the health care system from a human capital, logistic, and financial perspective. To overcome these challenges, efficient and effective health care delivery models that address multiple chronic conditions need to be leveraged. Shared medical appointments are one potential solution to address these issues. This article offers a brief history of group visits and shared medical appointments and reviews the available data regarding their outcomes. It describes the benefits of using lifestyle medicine as the primary therapeutic modality within a shared medical appointment to treat, reverse, and prevent chronic disease. Key considerations and action steps for the implementation of lifestyle medicine shared medical appointments (LMSMAs) are outlined and the potential delivery of these services via telehealth is explored.

https://journals.sagepub.com/doi/pdf/10.1177/1559827620943819

Lifestyle Medicine Shared Medical Appointments.

Chronic disease management using the traditional 15-minute appointment is exceptionally challenging and arguably inadequate to provide comprehensive, prospective, patient-centered primary care. A model of care designed to promote patient education, patient self-management, and improved access to their physicians and other health care providers is needed. Group visits have been identified as one model that allows physicians to deliver extensive patient education and self-management instruction while enhancing financial productivity. A thorough review of the literature on group visits was performed. Fairly consistent results from level I and II quality of evidence from a revised Strength of Recommendation Taxonomy (SORT) rating system indicate that patients who attended group visits demonstrated improved standards of care, improved quality of life, greater patient and physician satisfaction, lower rates of hospitalization and emergency department utilization, and reduced specialty costs. Discrepancies from ...

Group Visits and Chronic Disease Management in Adults: A Review

Sarcopenia, an age-related loss of skeletal muscle mass and function, is correlated with adverse outcomes after some surgeries. This study examined the characteristics of sarcopenic patients undergoing primary total knee arthroplasty (TKA), and identified low muscle mass as an independent risk factor for postoperative TKA complications.A retrospective cohort study examined 452 patients who underwent TKA. The skeletal muscle index (SMI) was obtained via bioelectrical impedance analysis (BIA), along with demographics, the Charlson Comorbidity Index, and medication, laboratory and operative data for 2018-2021. Patients were categorized into normal (n = 417) and sarcopenic (n = 35) groups using the SMI cut-off suggested by the Asian Working Group for Sarcopenia 2019 (males, < 7.0 kg/m2; females, < 5.7 kg/m2). Three postoperative complications were analysed: blood transfusion, delirium, and acute kidney injury (AKI). Baseline characteristics were propensity score-matched to address potential bias and confounding factors.The proportion of sarcopenic patients in primary TKA was 7.7% (35/452). The sarcopenic group had a lower preoperative haemoglobin (12.18 ± 1.20 vs. 13.04 ± 1.73 g/dL, p = 0.004) and total protein (6.73 ± 0.42 vs. 7.06 ± 0.44 mg/dL, p = 0.001). Propensity scoring matching and logistic regression showed that more patients in the sarcopenic group received postoperative blood transfusions (OR = 6.60, 95% CI: 1.57-45.5, p = 0.021); there was no significant difference in AKI or delirium. Univariate receiver operating characteristic curve analysis of the propensity-matched group, to determine the predictive value of SMI for postoperative transfusion, gave an AUC of 0.797 (0.633-0.96) and SMI cut-off of 5.6 kg/m2.Low muscle mass determined by BIA was an independent risk factor for postoperative transfusion in TKA. Multifrequency BIA can serve as a screening tool for sarcopenia that may influence the orthopaedic decision-making process or treatment planning in patients with sarcopenia undergoing primary TKA.III, retrospective cohort study. 

/pdf/low-muscle-mass-is-an-independent-risk-factor-for-135zua2z.pdf

Low muscle mass is an independent risk factor for postoperative blood transfusion in total knee arthroplasty: a retrospective, propensity score-matched cohort study

Sarcopenia, an age-related loss of skeletal muscle mass and function, is correlated with adverse outcomes after some surgeries. Here, we present a deep-learning-based model for automatic muscle segmentation and quantification of full-leg plain radiographs. We illustrated the potential of the model to predict sarcopenia in patients undergoing total knee arthroplasty (TKA). A U-Net-based deep learning model for automatic muscle segmentation was developed, trained and validated on the plain radiographs of 227 healthy volunteers. The radiographs of 403 patients scheduled for primary TKA were reviewed to test the developed model and explore its potential to predict sarcopenia. The proposed deep learning model achieved mean IoU values of 0.959 (95% CI 0.959–0.960) and 0.926 (95% CI 0.920–0.931) in the training set and test set, respectively. The fivefold AUC value of the sarcopenia classification model was 0.988 (95% CI 0.986–0.989). Of seven key predictors included in the model, the predicted muscle volume (PMV) was the most important of these features in the decision process. In the preoperative clinical setting, wherein laboratory tests and radiographic imaging are available, the proposed deep-learning-based model can be used to screen for sarcopenia in patients with knee osteoarthritis undergoing TKA with high sarcopenia screening performance.

/pdf/deep-learning-based-muscle-segmentation-and-quantification-bqv1s32c.pdf

Deep Learning-Based Muscle Segmentation and Quantification of Full-Leg Plain Radiograph for Sarcopenia Screening in Patients Undergoing Total Knee Arthroplasty

Deep learning-based landmark recognition and angle measurement of full-leg plain radiographs can be adopted to assess lower extremity alignment


 Background: Sarcopenia, an age-related loss of skeletal muscle mass and function, is correlated with adverse outcomes after some surgeries. This study examined the incidence and characteristics of sarcopenic patients undergoing primary total knee arthroplasty (TKA), and identified sarcopenia as an independent risk factor for postoperative TKA complications.Methods: A retrospective cohort study examined 452 patients who underwent TKA. The skeletal muscle index (SMI) was obtained via bioelectrical impedance analysis (BIA), along with demographics, the Charlson Comorbidity Index, and medication, laboratory and operative data for 2018–2021. Patients were categorized into non-sarcopenia (n = 417) and sarcopenia (n = 35) groups using the SMI cut-off suggested by the Asian Working Group for Sarcopenia 2019 (males, < 7.0 kg/m2; females, < 5.7 kg/m2). Three postoperative complications were analyzed: blood transfusion, delirium, and acute kidney injury (AKI). Baseline characteristics were propensity score-matched to address potential bias and confounding factors.Results: The incidence of sarcopenia in primary TKA was 7.7% (35/452). The sarcopenia group had a lower preoperative hemoglobin (12.18±1.20 vs. 13.04±1.73 g/dL, p=0.004) and total protein (6.73±0.42 vs. 7.06±0.44 mg/dL, p=0.001). Propensity scoring matching and logistic regression showed that more patients in the sarcopenia group received postoperative blood transfusions (OR = 6.60, 95% CI: 1.57–45.5, p=0.021); there was no significant difference in AKI or delirium. Univariate receiver operating characteristic curve analysis of the propensity-matched group, to determine the predictive value of SMI for postoperative transfusion, gave an AUC of 0.797 (0.633–0.96) and SMI cut-off of 5.6 kg/m2.Conclusions: Sarcopenia determined by BIA was an independent risk factor for postoperative transfusion in TKA. Multifrequency BIA can serve as a screening tool for sarcopenia. Orthopedic surgeons should be aware of this, as it could influence the decision-making process or treatment plan of patients with sarcopenia undergoing primary TKA.Level of evidence: III, retrospective cohort study

/pdf/sarcopenia-is-an-independent-risk-factor-for-postoperative-1x7f4ion.pdf

Sarcopenia is an Independent Risk Factor for Postoperative Blood Transfusion in Total Knee Arthroplasty: A Retrospective, Propensity Score-Matched Cohort Study

Do Hwang

Papers

Group Visits and Chronic Disease Management in Adults: A Review

Low muscle mass is an independent risk factor for postoperative blood transfusion in total knee arthroplasty: a retrospective, propensity score-matched cohort study

Deep Learning-Based Muscle Segmentation and Quantification of Full-Leg Plain Radiograph for Sarcopenia Screening in Patients Undergoing Total Knee Arthroplasty

Deep learning-based landmark recognition and angle measurement of full-leg plain radiographs can be adopted to assess lower extremity alignment

Sarcopenia is an Independent Risk Factor for Postoperative Blood Transfusion in Total Knee Arthroplasty: A Retrospective, Propensity Score-Matched Cohort Study