Shared Medical Appointments Educate, Encourage MS Patients

Nancy A. Melville

March 03, 2020

WEST PALM BEACH, Florida — An innovative concept of shared medical appointments for multiple sclerosis (MS) patients, in which a group of 10 to 15 patients meet for about 90 minutes of medical care and patient education, is showing benefits ranging from improved social connections to reduced depression and emergency room visits.

"At first, this may sound to patients like an (awkward) concept — they may say, 'Why would I want to have a medical appointment with other people?' " Mary R. Rensel, MD, who is the director of the program at the Cleveland Clinic's Mellen Center for Multiple Sclerosis in Ohio, told Medscape Medical News.

"But once they get there, it's wonderful to see what happens — patients start to encourage each other and share resources and it's enjoyable for the patients and providers alike," she said.

The main objective of the shared appointments concept was to increase education regarding comorbidity prevention and management of MS; however, if patients wish to discuss any issues privately, they are accommodated.

In addition, family members, children and caregivers, are all welcome to attend. "Caregivers need support as well, so their participation is welcome," Rensel said.

A significant benefit of the program is the extended time with providers — an hour and a half, which is a substantially longer period than patients and providers typically spend together, Rensel noted.

"Medical visits are often so rushed, but this gives us much more time together, to learn more and talk about things like brain health," she said.

With guidance from a multidisciplinary team including nurses, wellness providers, psychologists, and other experts, there are currently seven meeting themes that are rotated through the year, focusing on a variety of subjects.

One them, for instance, includes education from a nutritionist; the center includes a kitchen for the group to learn about and try recipes. Other sessions include chair yoga, art therapy, guided imagery, and exercise physiology.

Cleveland Clinic is a leader in the concept of shared medical appointments, and offers the concept to as many as 360 disease states. With this pilot program in MS patients now underway for more than 3 years, Rensel and her team conducted a study to investigate its effects.

For the study, presented here at the 5th annual Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) Forum 2020, the authors collected clinical data on 50 patients who had attended at least one session between January 2016 and June 2019. Among the patients, 94% were female, 80% had relapsing-remitting MS, and their mean age was 50.

Patients had a mean Patient Determined Disease Steps (PDSS) score of 3.1 ± 2.4 and the average 25-foot walk and nine-hole peg test (dominant hand) times were 9.4 ± 7.8 and 25.8 ± 9.1 seconds, respectively.

The most common comorbidity was depression/anxiety, occurring in 44% of patients. However, after participation in the shared medical appointment program, their mean Patient Health Questionnaire-9 scores, with higher scores indicative of worse depression, decreased from pre-treatment scores of 7.3 ±5.5 to post-treatment scores of 5.1 ±5.6 (P = .001).

Notably, the program appears to have had a positive effect on patients' use of healthcare services: While there was a significant decrease in the mean number of emergency room visits (13 visits down to 2, P = .0005), the results showed a favorable increase in mean number of follow-up visits with attendees' primary care providers (19 to 41 visits, P = 3.47), physical therapists (15 to 27 visits, P = .004), or psychologists (6 to 19 visits, P = .003).

"The study was to evaluate the effect of the program after even just one appointment, and we found it really seemed to increase the use of more appropriate care, with less ER utilization and more visits to primary care," Rensel said.

The study even showed a small but significant reduction in pre- and post-outcome body mass index (BMI; 30.2 ±7.3 vs 28.8 ±7.1, P = .03).

A critical metric that was not measured in the study was the effect of social interaction and camaraderie in a condition that can, for many, feel socially isolating, Rensel said.

Amar Dhand, MD, PhD, associate professor of neurology at Brigham and Women's Hospital, Harvard University, Boston, Massachusetts, agreed that the peer support in such medical group settings can be highly valuable.

"Shared medical appointments offer an opportunity for peer-to-peer engagement, support, and education," he told Medscape Medical News. "For many patients, this is a chance to bond with persons who are co-experiencing similar problems, allowing new social connections to emerge."

Dhand, who spoke on the issue of the importance of social networks at the meeting, noted that, for all the numerous benefits that come with shared medical appointments, not all patients may respond well.

"Healthcare settings are one place to stimulate community among peers. This is one important ingredient of addressing social isolation," he said.  "However, there remain challenges such as sustainability of such relationships, paradoxical depression when persons see others with more severe disease, and infrastructure to support such programs."

The findings from the study, however, do suggest favorable responses, he noted.

"I think mechanistically, improved psychosocial outcomes are the most pertinent to the intervention," Dhand said. "The healthcare utilization may be attributed to other factors, and will need to be assessed in a case control design."

Key Benefits of the Shared Medical Appointment  

A recent article from Cleveland Clinic researchers reviewing the concept of shared medical appointments summarizes the program's benefits, based on nine key principles:

  • Group exposure in shared medical appointments combats isolation, which in turn helps to remove doubts about one's ability to manage illness

  • Patients learn about disease self-management vicariously by witnessing the illness experiences of others

  • Patients feel inspired by seeing others who are coping well

  • Group dynamics lead patients and providers to develop more equitable relationships

  • Providers feel increased appreciation and rapport toward colleagues, leading to increased efficiency

  • Providers learn from the patients how better to meet their patients' needs

  • Adequate time allotment of the shared medical appointment leads patients to feel supported

  • Patients receive professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge

  • Patients have the opportunity to see how the physicians interact with fellow patients, which allows them to get to know the physician and better determine their level of trust

The take-home message from the shared medical appointments concept is that "it may hit a quadruple aim," Rensel said. "Access, cost, outcomes, and provider satisfaction."

The Shared Medical Appointment program received a grant from Genzyme. Rensel reported consulting or advisory board relationships with Serono, Biogen, Teva, Genzyme, Novartis, and the National Multiple Sclerosis Society. Dhand has disclosed no relevant financial relationships.

5th annual Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS) Forum 2020: Abstract P271. Presented February 28, 2020.

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