Background
Methods
Realist review (a glossary of terms is included in Table 1)
Realism: The philosophy of realism brings attention to the limits of both logical empiricism which obfuscates the active theorizing of unobservable agents of causation (e.g., as demonstrated through the logic of randomized controlled trials) and constructivism which negates the belief of universal laws in favor of comparing storylines and paradigms. Realist modes of research reflect a mix of these two approaches by posing the kinds of questions that seek out the truth of matters, while at the same time operating from a view of the context bound and contingent nature of human knowledge. |
Realist Review (RR): is a theory-driven approach to synthesizing quantitative, qualitative or mixed methods research, from a perspective based in Realism. It answers questions of the general format ‘what worked, for whom and in what circumstances, how and why?’ The basis of a realist causal explanation is Context + Mechanism = Outcome (Otherwise referred to as the CMO configuration) |
Middle-range theory (MRT): Middle-range theory is an implicit or explicit theory that can used to explain the cause of outcomes for programs and interventions or parts thereof. “Middle- range” means that the theory can be tested with the observable data and is not abstract to the point of addressing larger social or cultural forces (i.e., grand theories) [1]. MRT is formulated at the outset of a realist review and examined in relation to empirical evidence throughout the review process. |
Context-mechanism-outcome (CMO) configurations: CMO configuring is a heuristic used to generate causative explanations pertaining to outcomes in the observed data. The process draws out and reflects on the relationship of context, mechanism, and outcome of interest in a particular program. A CMO configuration may pertain either to the whole program or only to certain aspects. |
Context: Context often pertains to the “backdrop” of programs and research. As conditions change over time, the context may reflect aspects of those changes while the program is implemented. Examples of context include cultural norms and history of the community in which a program is implemented, the nature and scope of existing social networks, or built program infrastructure. They can also be trust-building processes, geographic location (e.g., rural or urban), types of funding sources, and other opportunities or constraints. |
Mechanism: A mechanism is the generative force that leads to outcomes. It typically denotes the reasoning (cognitive or emotional) of the various actors in relation to the work, challenges, and successes of the partnership. Mechanisms are linked to, but not synonymous with, the program’s strategies (e.g., a strategy may be an intended plan of action, whereas a mechanism involves the participants’ reaction or response to the intentional offer of incentives or resources). Identifying the mechanisms advances the synthesis beyond describing “what happened” to theorizing “why it happened, for whom, and under what circumstances.” |
Outcomes: Outcomes are either intended or unintended and can be proximal, intermediate, or final. Examples of intervention outcomes are improved health status, increased use or quality of health services, or enhanced research results. |
Demi-regularity: Demi-regularity means semi-predictable patterns or pathways of program functioning. The term was coined by Lawson, who argued that human choice or agency manifests in a semi-predictable manner—“semi” because variations in patterns of behavior can be attributed partly to contextual differences from one setting to another [2]. |
Overview of the research team
Literature search strategy and article retention
A. | Due-Christensen et al. [29]. Can sharing experiences in groups reduce the burden of living with diabetes, regardless of glycemic control? |
B | Culhane-Pera et al. [23]. Group visits for Hmong adults with type 2 diabetes mellitus. |
C | Clancy et al. [18] Further Evaluating the Acceptability of Group Visits in an Uninsured Population with Diabetes . |
D | Sadur et al. [50] Diabetes Management in a Health Maintenance Organization. |
E | Trento et al. [61]. A 5-Year randomized controlled study of learning, problem solving ability, and quality of life modification in people with type 2 diabetes managed by group care. |
F | Taveira et al. [57]. Pharmacist-led group medical appointments for the management of type 2 diabetes with comorbid depression in older adults. |
G | Kirsh et al. [3]. Shared medical appointments based on the chronic care model: a quality improvement project to address the challenges of patients with diabetes with high cardiovascular risk. |
H | De Vries et. al. [25]. Implementation and outcomes of group medical appointments in an outpatient specialty care clinic. |
I | Harris, M. [35]. Shared Medical Appointments after Cardiac Surgery - The process of Implementing a Novel Pilot Paradigm to Enhance Comprehensive Post Discharge Care. |
J | Miller et al. [45]. Group Medical Visits for Low-Income Women with Chronic Disease. |
K | Meehan et al. [44]. GMA -Organization and Implementation in the Bone Marrow Transplantation Clinic. |
L | Kawasaki L et al. [39] Willingness to attend group visits for hypertension treatment. |
M | Shojania K, Ratzlaff M. [54] Group visits for rheumatoid arthritis patients: a pilot study. |
N | Bray P et al. [14]. Confronting disparities in diabetes care: the clinical effectiveness of redesigning care management for minority patients in rural primary care practices . |
O | Geller JS et al. [67] Impact of a group medical visit program on Latino health-related quality of life. |
P | Naik AD et al. [46]. Comparative effectiveness of goal setting in diabetes mellitus group clinics. Randomized controlled trial. |
Q | Lavoie JG et al. [40]. Group medical visits can deliver on patient centred care objectives: results from a qualitative study. |
R | Cohen S et al. [20] Veteran experiences related to participation in shared medical appointments. |
S | Esden JL, Nichols MR. [33] Patient-centered group diabetes care: a practice innovation. |
T | Vachon GC et al. [64] Improving access to diabetes care in an inner-city, community-based outpatient health center with a monthly open-access, multistation group visit program. |
Middle range theory
Results
CMOc Subsection | Context + Mechanism = Outcome | ||
---|---|---|---|
1. Combats Isolation | Isolation | Social contact (resource) → Correcting misperceptions(response) | Likely improved in self-efficacy |
2. Vicarious Learning | Isolation | Exposure to others’ illness (resource) → gaining perspective on one’s illness situation (response) | Likely improved self-efficacy |
3. Feeling inspired by successful peers | Low/high motivation for self-management behavior | Exposure to others’ successes (resource) → trying to emulate success (response) | Likely improved self-efficacy |
4. Friendships develop between patients and providers | SMAs are more relaxed than one-on-one clinical encounters | New patient-provider friendships developed (resource) → fostering trust amongst all parties (response) | Likely improved motivations and self-efficacy |
5. Improved collegiality amongst providers | Providers typically work in isolation | Team members are able to witness and interact (resource) → leading to mutual appreciation of respective roles and bonding (response) | Likely improved service delivery and work satisfaction |
6. Provider learning | Providers unaware of patient needs | Group setting encouraged creative thinking about meeting people’s needs | Likely improved service delivery |
7. Adequate time allotment | SMAs are longer sessions than one-on-one clinical visits | Allows patients and providers to get to know each other, relax (resource) → leads to a sense of comfort for the patient (response) | Likely improved self-management |
8. First-hand health knowledge | Isolation | Group visit allows patients to share, confirm/dispute information (resource) → leads to patients feeling reassured about health knowledge provided (response) | Likely improved application of information given |
9. Increased trust in physician | Mistrust of physicians a common experience in healthcare | SMA creates more even power dynamics between patient and provider (resource) → leads to patient feeling increased trust in physician (response) | Improved doctor-patient relationship and likely improved self-efficacy |
CMOc 1: group exposure combats isolation, which in turn helps to remove doubts about one’s ability to manage illness [21, 25, 29, 33, 35, 40, 54]
‘you have a feeling of not being capable enough, you feel you are the only one who is not able to manage it, everyone else is capable for sure, but I do not know anyone else. Therefore you get relaxed when you meet others who feel the same way.’ [29] (p. 253)
CMO configuration (CMOc): Feelings of inadequacy prevailed coupled sometimes with isolation (context). The SMA created social contact amongst a group of people with similar illness experiences. This exposure helped to correct misperceptions about their capabilities and the capabilities of others in self-efficacy (mechanism). The social contact combined with people sharing similar experience contributed to esprit de corps which promoted self-efficacy (outcome).
CMOc 2: patients in SMAs learn about disease self-management vicariously by witnessing others’ illness experiences [21, 25, 35, 44, 54]
‘Many patients had no inkling that others were experiencing the same or similar symptoms and stated that they were often comforted knowing that they were not alone in dealing with their post-cardiac surgery problems…Having others present in the conference room who had similar surgeries or surgeons sparked a lot of lively discourse among the participants, as they were curious to know if they were ambulating as well or had similar amounts of pain, wound issues, or musculoskeletal symptoms after discharge.’ [35] (p. 128)
‘all patients highlighted the knowledge they had gained from other patients who shared similar issues and concerns.’ [44] (p. 88)
CMOc: Patients typically experience their illness in isolation (context). The group visit offered patients the opportunity to compare their illness experience with the experience of others who are in similar situations. Patients were curious to know how other patients were managing, because such comparisons help to understand one’s own illness experience (mechanism). This most likely led to improved self-efficacy and reduction of stress, supporting disease management and healing (outcome).
CMOc 3: patients feel inspired by seeing others who are coping well [21, 25, 35]
‘…Some participants set high goals for physical activity and this encouraged other members. They also had the opportunity to share their knowledge and had a feeling of usefulness or altruism’ [25]. (p. 5)
“There used to be a guy here…he lost like 40 some pounds and we really clapped for that fellow cause he really worked hard for that. And it gave us something to try for.” [21] (p. 1289)
CMOc: SMA brought patients together, some of whom had lower motivation for self- management behavior and others who had relatively higher motivation (context). This led to feelings of usefulness and altruism (mechanism) for the former group, and motivation to do better for the latter (mechanism). Either way, these mechanisms most likely led to improved self-efficacy and disease management (outcome).
CMOc 4: group dynamics lead patients and providers to develop more equitable relationships [21, 33, 45, 54]
‘A number of the study participants expressed the concept of becoming friends with the GMV provider. The informal structure of the GMV may have allowed the patient and provider to develop a partnership rather than having a more traditional active-passive relationship.’ [45] (p. 223).
‘I got to meet new people and really get a feel for my doctor.’ [33] (p. 47)
CMOc: Because of the structure of group visits with many patients involved, the clinical encounters are more informal, relaxed and friendly than one-on-one clinical encounters (context). This allowed new patient-provider relationships, including friendships, which fostered trust amongst all parties (mechanism). Stronger, more trusting relationships between patients and provider was a result (outcome)
CMOc 5: providers feel increased appreciation and rapport toward colleagues leading to increased efficiency [3, 40, 44, 50]
‘We have discovered a high level of satisfaction and enhanced team-building among the transplantation care providers. This type of appointment is a team-based approach to care, with each member of our bone marrow transplantation team playing an important role in the overall success of the program. This not only led to increased efficiency and team rapport but also to a mutual appreciation for the helpful role that each team member plays in the process …Because this type of visit is so novel, there is increased physician satisfaction. The team approach to health care also offers care providers with the help, encouragement, and assistance of an entire care delivery team, which rapidly evolves into a cohesive, goal oriented health-care team’ [44] (p. 89–90)
CMOc: Typically providers work in isolation with patients (context). The SMA, in which team members could interact with each other and gain mutual appreciation of their roles increased bonding, and mutual appreciation (mechanism). This led to improved service delivery and work satisfaction. Staff felt supported and collectively created a more cohesive team (outcome)
CMOc 6: providers learn from the patients how better to meet their patients’ needs [3, 40, 50]
“I think that it [the GMV {sic – equivalent to SMA}] has helped me to be more creative in looking at ways to meet people’s needs. Some of that just comes from the patients themselves because they often have some really neat ideas about how to overcome challenges or difficulties in dealing with the diabetes. So I think that, not only have I become more aware but I’ve also, they’ve given me some really good tips and ideas. I think there’s stuff I learned that I wouldn’t have learned if I had done it on an individual basis. There’s a lot of value that comes out of that, that kind of impromptu patient teaching of each other” Provider #28 [40]. (p. 5–6)
CMOc: The SMA created an environment in which patients with a common illness experience shared information and brainstormed ideas about self-management (context). This environment allowed the service provider to appreciate new ways of thinking about how to serve the patient population (mechanism). This in turn most likely led to improved service provision (outcome)
CMOc 7: adequate time allotment of the SMA led patients to feel supported [40, 44, 46]
‘We have discovered that patients are often encouraged and more hopeful when they spend time with other patients with similar or worse conditions’. Patients spend more time with their care providers and the specialty team in this setting. This provides a sense of comfort to each patient [44]. (p. 89)
CMOc: Due to having multiple patients in the clinical encounter, SMAs require substantially longer timeframes than regular visits (context). This added time allows patients and providers the opportunity to really get to know each other and have patients open up and relax in the clinical setting. This has been identified as comforting to the patient (mechanism). This relaxation and comfort presumably leads to better self-management (outcome).
CMOc 8: patients received professional expertise from the provider in combination with first-hand information from peers, resulting in more robust health knowledge [21, 25, 44, 54]
During one of the GMAs (sic. Group Medical Appointments are equivalent to SMAs), a patient asked about travelling with oxygen and another patient explained how easy it was to travel. The NP may have been able to produce the same information but not the firsthand experience and the reassurance that it would not be complicated.’ [25] (p. 5)
CMOc: The SMA allows health information to be shared not only by the health professional, but also by other patients through firsthand experience (context). Patients receiving such knowledge felt reassured by the experience of other patients (mechanism). This likely led to decreased stressed, and improved application of the information given during sessions (outcome).
CMOc 9: patients have the experience of witnessing the physician interact with fellow patients, which allows them to get to know the physician better and determine levels of trust. [3, 21, 40, 67]
“I’ve learned to trust him. I trust him more than I used to and that’s important, that bond of trust has to be there. I trust him more when I see that he’s open to learning and figuring out new things that are only happening in group dynamics” Patient #8 [40]. (p. 6)
“Do you know…what [SMA] helps me to see is what the physician, his devotion of trying to solve a health problem and trying to correct it. That actually reestablishes my faith in the medical system because you can see that they’re really devoted to trying to figure out really what is ailing you” Patient #13 [40]. (p. 5–6)
CMOc: Mistrust of physicians is pervasive in the health care setting (context). The SMA created an environment in which patients and providers are on more equal grounding. This led patients to feel that the physician is trustworthy (mechanism) leading to improved doctor-patient relationships and presumably improved health outcomes (outcome).