Based on this study, group patient visits are a feasible model for providing care for individuals with PD. While group visits have demonstrated clinical benefits in studies of other chronic conditions,1–6
in this small pilot study we were unable to detect significant differences in quality of life, clinical outcomes, patient satisfaction, or caregiver burden between those receiving group patient visits and usual care.
Group patient visits have the potential to address limitations of support groups and one-on-one visits in PD. While both support groups and traditional visits have clear benefits, a survey of individuals with PD indicates that patients desire a credible group leader for their support groups and more information for them and their caregivers about their disease.19
By incorporating a PD specialist as a group's leader and allocating more time, principally for education, group patient visits can address these limitations. In addition, the longer duration of group patient visits allowed physicians the unique opportunity to observe patients for longer periods and visualize disease characteristics such as wearing off and motor fluctuations, daytime sleepiness, eating, and interpersonal interactions that would not otherwise be observed in a brief one-on-one visit. In our study, for example, we noticed all above, which although often reported in a clinical visit, were more informative to see in person.
Our study design was limited by the use of only one study site, differences in the size of the groups and time spent with patients in each group, and the incorporation of 3 separate study physicians leading different groups for their patients. This created variable group sizes and differences in the way the groups were conducted and may have contributed to modest differences in outcomes by provider, although no significant differences between providers were observed. Our sample size was modest, and this may have contributed to a lack of power to detect significant differences in many important outcome measures. Furthermore, the study population was relatively homogenous (e.g., all white, high school graduates with mild to moderate disease), so these results may not generalize to other populations or individuals with more severe disease. Finally, we did not include a qualitative analysis into this study, which could have provided a better impression of the feelings of participants and caregivers about group visits, including specific factors that they did and did not like.
Certain logistical issues (e.g., need for a large room, scheduling visits in blocks that are atypical) may pose ongoing difficulties when conducting group patient visits. These visits may increase the burden on scheduling and room management, which are currently geared toward traditional one-on-one visits. Physicians must also spend additional time organizing group sessions in advance and be able to manage a group. While the visit duration may facilitate the opportunity to observe patients for extended time periods, there is also the risk that a lack of thorough, one-on-one examination may cause the physician to miss subtle diagnoses or disease characteristics. This issue could be resolved by considering a hybrid treatment model that alternates group and one-on-one patient visits over the course of a year.
Finally, reimbursement remains an issue which may make this model difficult for physicians to sustain. Current guidance from Medicare suggests that billing for services provided within a group can be done using standard evaluation and management codes, but no official payment or coding related to group visits have been published by Medicare.20
With modest group sizes, such as those in this study, physicians could see an equivalent number of patients per unit-time in a one-on-one setting as they could in a group. The recently enacted US health care reform creates a new Center for Medicare and Medicaid Innovation21
whose purpose is to “test innovative payment and service delivery models to reduce program expenditures.”22
Changes in reimbursement could foster alternative delivery models for PD and other chronic neurologic conditions whose burden will only grow in the future.23–25
More broadly, due to their burden and cost,26
studies comparing the effectiveness of alternative health care delivery models for patients with neurologic conditions are limited,27
and additional trials are needed. The Institute of Medicine lists health delivery as its top research priority in its recent report on comparative effectiveness research. Included among the specific priorities are comparing the effectiveness of coordinated, physician-led, interdisciplinary care in multiple settings for individuals with advanced chronic disease, comparing the effectiveness and costs of alternative detection and management strategies for dementia, and comparing the effectiveness of comprehensive care coordination for those with severe chronic disease.28
Future studies are needed that include a larger study population, multiple study sites, and qualitative and economic analyses of group patient visits. This research can guide future care delivery models, inform the design and conduct of future studies of care delivery, and demonstrate the importance of evaluating new models of health care delivery.