This is a plain English summary of an original research article
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.
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).
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.
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