This study reveals significant differences between group visit (intervention) and control patients in adherence to ADA standards of care and guidelines for PAP smears and screening mammograms.10,12
Perhaps the longer duration of group visits provides more time to address guidelines than a typical primary care encounter. Additionally, providers can deliver consistent messages to multiple patients simultaneously in group visits, rather than repeating them individually to multiple patients. Monthly appointments provide more frequent contact with the physician increasing opportunities to systematically address guidelines. These findings support those from previous studies revealing more frequent primary care visits to be associated with an increased likelihood of diabetic patients having >2 HbA1c levels performed annually.11
Our study refutes results from previous studies suggesting women attending more frequent general internal medicine visits have a higher likelihood of receiving recommendations for mammograms without improved patient adherence14
; group visit women had higher rates of adherence to guidelines for breast and cervical cancer screening.
Though group patients had more overall primary care visits, due to the group visits being scheduled monthly, they averaged 1.0 individual primary care visits over the year compared with 3.8 for control patients. Physicians and patients accepted group visits as physicians continued to schedule groups and patients continued to attend groups after the study period. Furthermore, the show rate for group visits was similar to that for the clinic.
Discussion of individual patient issues in groups may have contributed to other patients’ accepting process-of-care referrals and tests, from diminished anxiety and a desire to show other group members’ commitment to their own health care. With open general discussions in group visits, patients potentially educate each other about referrals and tests experienced; perhaps hearing information from their peers resulted in higher acceptance of suggestions from the physicians.
The direct effects of the education at each group visit are difficult to assess from this study, but improvement in concordance with process-of-care indicators in group patients compared with control patients suggests significant effects. Differences in the number of ADA criteria met by patients seen in groups led by different physicians suggest physician methodologies may have affected group teaching skills and educational topics selected, or there were differences in group dynamics affecting their approach to guideline adherence
Patients’ financial limitations likely led to significant differences in blood sugar, lipid, or blood pressure control, by prohibiting purchase of prescribed medications, thus creating a ceiling effect for benefits of improved guideline adherence. Lack of standardization of group visit content may also have contributed, as providers approached educational topics individually. Perhaps a manualized, consistent curriculum would improve clinical outcomes. The low health literacy level of most of the study patients and the lack of physicians’ awareness of their health literacy levels may have contributed to the lack of clinical outcomes. As group visits were conducted under the control of the providers, positive results (more process-of-care indicators met) were also under the providers’control. Clinical outcomes were under the patients’ control, depending on them following lifestyle guidelines and adhering to medication regimens. Incorporating motivational and behavioral strategies emphasizing patients’ daily responsibilities and skill building for healthy lifestyles compatible with diabetes may affect improvements in clinical outcomes. Also, the study may have lacked enough power to show a significant difference in the outcome clinical variables because the sample size was calculated to detect a difference in proportion of ADA processes of care met by those in group visits compared to usual care.
Six different providers conducting group visits strengthens in this study. These providers also had patients in the usual care arm as part of the general pool of clinic patients; thus, it is possible through contamination that providers may have adopted some of the group visit strategies (e.g., group visit educational content) for control patients. While unlikely, the time constraints of a typical primary care visit may have contributed to the failure to determine a difference in clinical outcome variables. Provider randomization to prevent contamination is unrealistic as it is unlikely in any practice that a provider would deliver care only in group visits.