Objective: To determine the proportion and characteristicsof patients willing to attend groupmedical visits.
Study Design: Cross-sectional survey.
Methods: A telephone survey was administeredto 296 patients with hypertension from an urbanpublic hospital's primary care clinic betweenOctober 2004 and August 2005.
Results: Most respondents were female (79%)and African American (89%), with a monthlyincome of $1000 or less (75%) and a mean age of56 years (age range, 29-81 years). After a briefdescription of the group medical visit, 68%of respondents indicated they were willing toattend the group visit. After offering 3 incentives(reduced wait to see their physician, more timewith their physician, and parking or transportationsubsidies), the total percentage of potentialwilling participants increased to 80%. Personsliving with someone, reporting shorter wait timesafter appointment check-in, and desiring moretime with their physician were more likely to bewilling to attend group medical visits.
Conclusions: Most of the surveyed patients in thestudy were willing to attend group medical visits.Although the effectiveness and cost savings needfurther investigation, group medical visits mayprove to be a desirable chronic disease careapproach for underserved populations.
(Am J Manag Care. 2007;13:257-262)
In this first systematic evaluation of patients' willingness to participate ingroup medical visits, a significant proportion of respondents in an urbancontinuity clinic diagnosed as having hypertension reported willingness toattend for medical care.
Multiple delivery models for chronic disease managementexist.1-7 One of the more recent innovative approaches isthe group medical visit. In this prototype, groups ofpatients with similar healthcare profiles meet regularly forroutine medical care. The meeting is facilitated by their physician withprovision of a comprehensive range of medical care. Randomized clinicaltrials present clinical and systemic benefits, with decreased utilizationpatterns, improved disease-specific standards of care, and high patientand provider satisfaction scores.8-10
However, patients' willingness to participate in this promising modelis unclear.Without knowledge of the acceptance level or target group formaximal participation, full benefits of this group model are likely limited,with inefficient costly recruitment efforts and inadequate participationlevels. In the present study, we performed a telephone survey of patientswith hypertension enrolled in a continuity primary care clinic in an urbanpublic hospital setting (1) to investigate the willingness of patients withhypertension to attend group medical visits, (2) to assess the effect ofsimple inducements on participation levels, and (3) to compare characteristicsof patients willing to attend group medical visits with those whowere unwilling.
In September 2004, we identified patients from the rosters of 4internists practicing at the Medical Center of Louisiana in New Orleans,a public hospital-based faculty-run entity. The population served in thisclinic is largely composed of uninsured or underinsured adult patientsfrom the greater New Orleans metropolitan area. The institutionalhuman subjects committees at Tulane University Health Sciences Centerand Louisiana State University Health Sciences Center, New Orleans,approved the data collection procedures.
International Classification of Diseases,
Ninth Revision, Clinical Modification
All patients 18 years and older with established hypertension were eligiblefor participation. We defined established hypertension as 2 outpatientdiagnoses of hypertension (code 401.x) during the preceding 12months recorded in the clinic's administrativedatabase. Of 1017 eligiblecandidates identified, 696 were notsurveyed because of (1) inactive or incorrect telephone numbersin the database (n = 122), (2) denial of hypertensiondiagnosis (n = 7), (3) unreachable candidates despite a workingtelephone number (n = 519), or (4) terminated effortsbecause of Hurricane Katrina (n = 48). Input error led to 1survey without documented data. Candidates who wereunreachable despite a working telephone number were called3 times at varying times of the day, evening, and weekday.Of those eventually contacted, 24 (7%) refused study participation,resulting in 296 completed surveys.
Survey Instrument Description
The study survey, which was pilot tested for face validity,was conducted by telephone between October 2004 andAugust 2005. After obtaining verbal informed consent, a singletrained interviewer (KH) administered the survey using astandardized script. Of relevance to the present analysis, thesurvey instrument included domains assessing willingness toattend group medical visits, sociodemographics, medical history,hypertension knowledge, self-reported health, self-efficacy,and healthcare experiences. The survey instrument alsoincluded a self-reported history of chronic conditions and traditionalcardiovascular disease risk factors (hypertension, diabetesmellitus, high cholesterol, and cigarette smoking).Hypertension knowledge was ascertained using a modifiedversion of a previously validated instrument.11 Healthcareexperiences included questions on physician accessibility andthe patient-physician relationship.
To assess respondents' interest in participation, the followingscript was read:
Group visits consist of about 10 to 15 men and womenwho have been diagnosed with high blood pressure thatwill meet together. The group would meet about every twoto three months with their usual doctor for about one anda half to two hours. These are medical visits where yourhealthcare needs would be addressed and you would talkabout high blood pressure, its treatment, and complicationsin a setting with other patients. If you needed, youcould see the doctor individually after the group.
Respondents were then asked to reply yes or no to the followingstatement: "I would be willing to attend a group visitfor the treatment of my high blood pressure."
Participants who were not willing to attend group medicalvisits were then asked if any of 3 incentives would influencetheir initial response: (1) not having to wait to see their physician,(2) spending more time with their physician during avisit, and (3) being given money to help pay for parking ortransportation to the group medical visit.
Data entry occurred at the time of interview into a backendapplication of the web-based software (Key Survey,Cambridge, Mass). Data were stored in an ASCII file andwere imported to SAS 9.1 statistical software (SAS Institute,Cary, NC) for analysis.
Characteristics of survey participants were calculated usingmeans for continuous variables and percentages for categoricalvariables. The percentage of patients willing to attendgroup medical visits was calculated before and after incentiveswere offered. These percentages were calculated stratified bydemographic and socioeconomic characteristics, disease history,and healthcare experiences of participants. Percentages ofpatients willing to attend group medical visits across characteristics(eg, men vs women) were compared using the χ2 test.
The mean age of study participants was 56 years (age range,29-81 years). Most participants were African American(89%), female (79%), completed at least 12 years of education(62%), earned $1000 a month or less (75%), and were livingwith someone (66%). Diabetes mellitus was a commoncomorbidity (35%). Most (92%) reported a family history ofhypertension; 53% were diagnosed as having hypertensionwithin the previous 5 years. In terms of healthcare experiences,98% reported satisfaction with their care, 89% reportedadequate time spent with their physician, and 63%indicated they would spend more time with their physician ifpossible. Also, 26% reported that they were sometimes ornever comfortable asking their physician questions when theydid not understand instructions. Approximately one thirdreported that they never waited long after checking in foran appointment.
Sixty-eight percent (n = 202) of participants initiallyreported willingness to attend group medical visits. After 3incentives were offered to the remaining respondents, anadditional 37% (n = 35) reported willingness to attend groupmedical visits, increasing to 80% (n = 237) the percentage ofrespondents willing to attend group medical visits for theirroutine medical care. Among 94 survey respondents initiallyunwilling, the following would provide sufficient incentive toattend group medical visits: 30% (n = 28) indicated a reducedwait time to see their physician, 23% (n = 22) indicated moretime with their physician, and 20% (n = 19) indicated parkingor transportation subsidies.
Before offering incentives, willingness to attend groupmedical visits did not differ substantially across age grouping,race/ethnicity, or sex (Table 1). In contrast, participantsindicating a monthly income exceeding $1000, living withsomeone, and having a history of diabetes mellitus were morelikely to be willing to attend group medical visits. After incentiveswere offered, more than 70% of every demographic,socioeconomic, and disease history subpopulation were willingto attend group medical visits except those with less thanan eighth-grade education (69%) and persons with excellentself-rated health (64%). The only significant differenceamong subgroups in the overall willingness to attendgroup medical visits was cohabitation status. A higherpercentage of persons living with someone werewilling to attend group medical visits.
Significant differences were present in subgroupsdefined by healthcare and hypertension experiences(Table 2). Before and after incentives were offered,higher percentages of participants who reported ashorter wait time after check-in and a desire to spendmore time with their physician were willing toattend group medical visits. Participants reporting alower comfort level in asking questions for clarificationfrom their physician were more willing to attend groupmedical visits after the potential incentives were offered.
Overall, 68% of surveyed patients from an urban, predominantlyminority, public hospital clinic setting expressed willingnessto attend group medical visits for hypertensionmanagement. After offering 3 simple inducements, this rateincreased to 80%.
In our survey, 89% of participants reported spending adequateamounts of time with their physician. However, 63%then indicated they would like to spend more time with theirphysician. This desire to spend more time with their physicianwas significantly correlated with willingness to attend groupvisits and may be explained by a strong patient-physician relationship.Previous studies12,13 support the importance of thepatient-physician relationship, associating high patient satisfactionwith factors such as the amount of time spent withproviders. We propose that a positive patient-physician relationshipmay facilitate patients' readiness to explore newtreatment strategies, such as group visits.
An alternative view suggests that the desire by patients toseek more time with their physicians may stem from a need forsocial or emotional support. This, in turn, may lead to overutilizationof services (ie, patients attending group visits whilestill attending traditional physician visits). Previous evidencesuggests that group medical visits reduce clinical visits andhealthcare resources and costs compared with usual care.9,10However, data for low-income populations are limited.
Health system perceptions were a second determinant ofwillingness to attend group medical visits. Participants whoperceived shorter wait times after check-in were more likely toexpress an interest in attending group visits. Other studies14,15have demonstrated similar associations; longer wait timeswere correlated with a greater degree of patient dissatisfaction.We propose that greater health system satisfaction and associatedexperiences support a patient's willingness to attemptnew treatment models.
The findings of our study need to be interpreted in the contextof the limitations. First, although the participation ratewas high among those patients reached in this study, there wasa substantial number of individuals selected for inclusion whowere not reached. Therefore, the sample included in theanalysis may not be fully representative of the urban clinicpopulation. Second, we recruited patients from a single urbanclinic site serving primarily uninsured and underinsuredAfrican American female adult patients, limiting the generalizabilityof our findings. Third, with self-reported measures,participants may have given responses thought to be wellaccepted. To maximize the validity and reliability of the data,a single trained interviewer strictly followed a standardizedscript for data collection. The questionnaire was also structuredwith simple detailed questions and was pilot testedbefore implementation. Fourth, the cross-sectional nature ofthe study would allow us only to correlate patient characteristicswith self-reported willingness to attend group visits. Thestudy goal did not include implementation of the group visits,limiting to an assessment of willingness rather than actualattendance rates.
There are notable strengths in this study. To our knowledge,this study is the first systematic evaluation of patients' willingness to attend group medical visits. Studies8-10 to datehave highlighted clinical outcomes without an associatedunderstanding of patients' correlates in attending. The fullclinical effect of group visits is dependent on adequate interestand participation. Finally, the sample size was adequate,the response rate was good from contacted participants, anda single trained interviewer collected data in a consistentmanner.
In conclusion, based on the results of the present survey,most contacted patients are willing to attend group visits forroutine medical care, with an increase in the number of thosewilling from simple inducements. Given this acceptance, clinical and fiscal effectiveness of this alternative model of caredeserves further study for more widespread implementation.
From the Section of General Internal Medicine andGeriatrics, Department of Medicine, School of Medicine (LK, PM, KH, KBD),and Department of Epidemiology, School of Public Health and TropicalMedicine (PM, ADH, KBD), Tulane University, New Orleans, La.
This study was supported by grant 1 P20 HS11834-01from the Agency for Healthcare Quality and Research. Dr Kawasaki is supportedby grant 1 K01 HP 00131-02 and a title Geriatric Academic Career Awardfrom the Division of State, Community, and Public Health, Bureau of HealthProfessions, Health Resources and Services Administration, and Departmentof Health and Human Services. Dr DeSalvo is supported by the Robert WoodJohnson Foundation Generalist Faculty Physician Program and by grant K-12HD 43451 from the National Institutes of Health.
The information or content and conclusions are those of the authors andshould not be construed as the official position or policy of, nor should anyendorsements be inferred by, the Bureau of Health Professions, HealthResources and Services Administration, Department of Health and HumanServices, or the United States.
This study was presented in part at the Southern Society for GeneralInternal Medicine meeting; February 25, 2005; New Orleans, La.
Lumie Kawasaki, MD, MBA, Section of GeneralInternal Medicine and Geriatrics, Department of Medicine, School ofMedicine, Tulane University, 1430 Tulane Ave, SL-16, New Orleans, LA70112. E-mail: firstname.lastname@example.org.
The authors (LK, PM, ADH, KH, KBD) report norelationship or financial interest with any entity that would pose a conflict ofinterest with the subject matter discussed in this manuscript.
Concept and design (LK, PM, KBD); acquisitionof data (KH, KBD); analysis and interpretation of data (LK, PM, ADH,KBD); drafting of the manuscript (LK, ADH); critical revision of the manuscriptfor important intellectual content (LK, PM, ADH, KBD); statisticalanalysis (PM, ADH, KBD); provision of study materials or patients (LK, KH,KBD); obtaining funding (KBD); administrative, technical, or logical support(LK, KBD); supervision (PM, KBD).
1. Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-managementprogram: 2-year health status and health care utilization outcomes.2001;39:1217-1223.
2. Bodenheimer T,Wagner EH, Grumbach K. Improving primary carefor patients with chronic illness. 2002;288:1775-1779.
Am J Orthopsychiatry.
3. Krause CM, Jones CS, Joyce S, et al.The impact of a multidisciplinary,integrated approach on improving the health and quality of carefor individuals dealing with multiple chronic conditions. 2006;76:109-114.
4. Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that achronic disease self-management program can improve health statuswhile reducing hospitalization: a randomized trial. 1999;37:5-14.
5. Lorig KR, Ritter PL, Laurent DD, Plant K. Internet-based chronic diseaseself-management: a randomized trial. 2006;44:964-971.
Lippincotts Case Management.
6. Schaefer J, Davis C. Case management and the chronic care model:a multidisciplinary role. 2004;9:96-103.
7.Wagner EH, Grothaus LC, Sandhu N, et al. Chronic care clinics fordiabetes in primary care: a system-wide randomized trial. 2001;24:695-700.
8. Clancy DE, Cope DW, Magruder KM, Huang P, Salter KH, Fields AW.Evaluating group visits in an uninsured or inadequately insured patientpopulation with uncontrolled type 2 diabetes. 2003;29:292-302.
J Am Geriatr Soc.
9. Beck A, Scott J, Williams P, et al. A randomized trial of group outpatientvisits for chronically ill older HMO members: the CooperativeHealth Care Clinic. 1997;45:543-549.
J Am Geriatr Soc.
10. Scott JC, Conner DA,Venohr I, et al. Effectiveness of a group outpatientvisit model for chronically ill older health maintenance organizationmembers: a 2-year randomized trial of the Cooperative HealthCare Clinic. 2004;52:1463-1470.
Arch Intern Med.
11. Williams MV, Baker DW, Parker RM, Nurss JR. Relationship of functionalhealth literacy to patients' knowledge of their chronic disease: astudy of patients with hypertension and diabetes. 1998;158:166-172.
Soc Sci Med.
12. Hall JA, Dornan MC. What patients like about their medical careand how often they are asked: a meta-analysis of the satisfaction literature.1988;27:935-939.
J Ambul Care Manage.
13. Drain M. Quality improvement in primary care and the importanceof patient perceptions. 2001;24:30-46.
J Ambul Care Manage.
14. Leddy KM, Kaldenberg DO, Becker BW.Timeliness in ambulatorycare treatment: an examination of patient satisfaction and wait timesin medical practices and outpatient test and treatment facilities.2003;26:138-149.
Qual Manag Health Care.
15.Wolosin RJ.The voice of the patient: a national, representativestudy of satisfaction with family physicians. 2005;14:155-164.