Feasibility and efficacy of implementing group visits for women’s health conditions: a systematic review

Since the emergence of group visits in the United States in the early 1990’s [1], the innovative medical delivery model has spread throughout the world. Group visits (also known as shared medical appointments [SMAs], group medical visits [GMVs] or integrative medicine group visits [IMGVs] where complementary therapies are included in the consultations [2]), are patient-centred models of care whereby a group of patients consult with one or more healthcare providers in a concurrent session [3]. Generally, group visits include a consultation with a medical doctor (within the group or privately), measurement of vital signs, medication review, patient education and in some cases, involvement of other allied health professions specific to the needs of the group [4]. Therefore, group visits include all the components of a one-on-one medical appointment along with patient education and peer support. For the purpose of this review, the term ‘group visit’ has been employed to describe any health-care intervention delivered in a group (that would typically be delivered via a one-on-one consultation), including SMAs, IMGVs and GMVs.

Current evidence indicates group visits may have a positive impact on health service delivery. In studies to date, group visits have been shown to (a) be more cost-effective than one-on-one consultations [5, 6], (b) increase accessibility to healthcare in diverse and/or underserved populations [7], (c) be well-received by patients and providers [5, 8], and (d) be effective in managing conditions such as diabetes [9, 10] and chronic pain [11, 12]. The group dynamic can provide additional benefits to patients where a sense of human connection and empowerment may be fostered alongside increased capacity for patient education [3, 13]. To date, no adverse effects have been associated with group-delivered health care [6]. Although several studies suggest patients attending group visits may receive more comprehensive care (than those attending one-on-one care), there may be disadvantages to the model. For example, some studies have favoured one-on-one care for the amount and quality of time spent with the practitioner (audiologist) [6]. Disadvantages reported by Australian providers have mainly been attributed to initial administrative issues which have been overcome at subsequent group visits [8].

In the area of women’s health, group-based antenatal care has been associated with improvements in the disclosure of information (i.e. speaking about issues that women typically would not have spoken about to a provider during one-on-one care) [14]. This disclosure may be facilitated by being in a safe space with other women with similar concerns, and feeling more empowered and self-confident [14]. Group-based antenatal care also has been found to be feasible, more effective and affordable than individual care in a variety of settings and populations [15‐17]; and is associated with a reduced risk of premature birth, lower incidence of low birth weight infants, and reduced health care expenditure [18]. In addition, a high level of patient satisfaction has been reported among women receiving group-based antenatal/prenatal care [19, 20]. Similarly, in women with gestational diabetes mellitus (GDM) or pre-GDM, group-based prenatal care has been associated with significantly lower rates of progression from pre-GDM to GDM, lower rates of insulin prescription [21]; and found to be more cost-effective than individual prenatal care [22].

Evidence supporting the effectiveness and feasibility of group visits in the area of maternal health suggests a need and desire for women to participate in group-delivered healthcare. Female reproductive conditions such as endometriosis, polycystic ovary syndrome (PCOS) and chronic pelvic pain are increasingly common in women of reproductive years. Endometriosis for example, has a similar prevalence as diabetes worldwide [23], and yet evidence indicates mainstream medicine is not meeting the healthcare needs of those living with the condition [24]. Given the chronic nature of many female-specific conditions (for example endometriosis [25] and PCOS [26]), and the evidence in support of group-based maternal care and SMAs for chronic disease management, there is a sound rationale for investigating the effectiveness of SMAs for female-specific conditions.

Although SMAs are an effective model for delivering healthcare to patients with chronic pain and diabetes, as well as expectant mothers, the impact of the model on women and gender-diverse people experiencing female-specific reproductive conditions is currently uncertain. The objective of this systematic review was to determine the feasibility, acceptability and clinical effectiveness of group visits in adults with any female-specific reproductive condition. In doing so, the review investigates the evidence-base for a potentially untapped model of care that may help improve health outcomes for people living with female reproductive conditions. As well as informing clinical practice, the findings from this review help identify important directions for future research examining the use of group visit models of care for the management of female reproductive conditions.

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [27]. The PRISMA checklist can be viewed in Supplementary file 1. A database search was conducted to identify peer-reviewed original research that fulfil the following inclusion criteria: examining SMAs, or group-based medical interventions (i.e. adaptations of the SMA model) for adult patients with female reproductive conditions or pathologic conditions specific to the female reproductive system. Although not a target population of this review, people identifying as gender diverse met the inclusion criteria. For the purposes of this review, SMAs were defined as any health-care intervention delivered in a group (that would typically be delivered via a one-on-one consultation) – this included SMAs, IMGVs and GMVs. Studies examining interventions that are routinely delivered in groups (for example yoga or group therapy) were excluded. The review examined two main outcomes: 1) efficacy (defined as any clinical outcome including health-related quality of life, change in general health status, self-efficacy, emotional health and attitudes, change in disease severity), and 2) feasibility (measured by cost-effectiveness, demand, patient satisfaction, provider satisfaction, implementation) of SMAs for adults with any female-specific reproductive condition.

The search strategy employed keywords and MeSH terms adapted from common terminologies used in existing literature, the OVID resource centre verified filter for women’s health [28] and previously used literature searches [29, 30]. The search included electronic databases (Scopus [Elsevier], MEDLINE [Ovid], EMBASE [Ovid], CINAHL [Ovid], AMED [Ovid] and Google Scholar as a supplementary search limited to first 10 pages) and two clinical trials registries (Australian New Zealand Clinical Trials Registry [ANZCTR] and ClinicalTrials.gov), with dates ranging from database inception through to 26^th January 2022. No limits to language were applied. Reference lists of included articles were also hand-searched for eligible studies. An example of the terms and syntax used in the MEDLINE search are presented in Supplementary file 2. All citations retrieved from the search were imported into Endnote™ (X9) bibliographic management software (for duplicate removal), and subsequently imported into Covidence (a systematic review management tool).

The title and abstract of each article were screened by one author (SG). Full-text articles were screened by two authors independently (SG and JW). Disagreements between the two authors were discussed with additional authors (AS and ML) and resolved as a group. Abstracts of articles not written in English were translated to English in order to assess eligibility.

Data were extracted using a customised data extraction form. The form collected information on study design, participants, sample size, setting, diagnosed reproductive condition(s), intervention (including duration and description), comparator, study outcomes and main findings (Table 1). The methodological quality of included studies was assessed using The Joanna Briggs Institute (JBI) critical appraisal tool for quasi-experimental studies. The purpose of the tool was to examine the extent to which included studies addressed potential biases in their design, conduct and analysis [31]. The methodological quality of the articles was assessed by two authors (SG and JW), independently. All studies presented evidence with high heterogeneity, therefore the body of literature was not amenable to meta-analysis and as such, the findings were presented as a narrative synthesis. The review protocol is registered with PROSPERO, ID: CRD42020196995.

The search identified 2584 studies. A total of 841 duplicates were removed, leaving 1743 studies. The screening of titles and abstracts eliminated 1718 studies as they did not meet the review selection criteria. Of the remaining 25 studies selected for full-text analysis, 21 were excluded as they used group interventions not aligned with the SMA model (n = 11), included participants with a condition not specific to women or the female reproductive system (n = 8), or were not original research (n = 2). Supplementary file 3 provides on overview of articles excluded at full text screening. A total of four articles, published between 2015 and 2019, were included in the review. Figure 1 represents an overview of the article selection process.

All included studies were conducted in the United States. The studies comprised of a non-randomised, uncontrolled pilot study [32], two pilot feasibility trials [33, 34] and a non-randomised, uncontrolled feasibility study [35]. A total of 163 women participated in the four included studies and no studies including gender diverse participants were identified. Sample sizes ranged from 11 to 105 with a median sample size of 23.5. The characteristics of included studies are presented in Tables 1 and 2.

The included studies used a diverse range of outcome measures and interventions, and investigated varied female reproductive conditions; accordingly, the studies were both clinically and methodologically heterogeneous. The included studies sampled women with breast cancer (n = 1 studies) [35], chronic pelvic pain (n = 1) [33], polycystic ovary syndrome (PCOS) (n = 1) [32], and varying gynaecologic cancers (n = 1) [34]. The interventions included IMGV (n = 1) [33] and GMVs (otherwise known as SMAs with terminology varying across studies) (n = 3) [32, 34, 35]. All included studies reported on feasibility and acceptability as outcomes, and all but one study [34] reported on clinical outcomes.

Critical appraisal using the JBI checklist for quasi-experimental studies indicated there was a clear identification of ‘cause’ and ‘effect’ across all studies, although no studies included a comparator group. Multiple measurements of study outcomes were used both pre- and post-intervention in all studies where this was applicable (n = 3). Outcomes were measured in a reliable way in all studies, and appropriate statistical analysis was used in all studies except one where this was not clear [34].

Findings are reported in two categories according to the objectives of the review: (1) feasibility and acceptability, and (2) clinical outcomes.

This review is the first to analyse the best available evidence of the effectiveness, feasibility and acceptability of group medical and allied health interventions for women’s health conditions. Focusing only on group interventions that are traditionally delivered via one-on-one consultation (rather than interventions usually delivered in groups such as yoga or group psychotherapy), the review revealed a dearth of research in this area. Notwithstanding, the findings align with nominal research on SMAs for non-gender specific chronic disease management conducted in other settings [5, 8, 36]. As the majority of studies included in the review were pilot feasibility studies, and not all studies reported on clinical outcomes, the hypotheses that can be drawn from the available evidence have a notable emphasis on the feasibility and acceptability of group medical interventions, rather than effectiveness.

The studies in this review suggest group visits may be a feasible approach to managing women’s health conditions. All four included studies reported high levels of patient satisfaction, with participants indicating that their expectations of the SMAs had been met or exceeded, and that they would recommend the group to other patients. The one study examining adoption and maintenance of an IMGV reported a 100% adoption rate amongst providers offering women’s health-focused services, albeit across a small number of settings [33]. Reports of positive provider satisfaction corroborate findings from other group visit research in non-gender-specific populations [3, 5].

These overall findings on feasibility are broadly supported by other studies on SMAs [8], where group visits have been found to be feasible, acceptable, cost-effective and time-efficient in diverse populations [5, 11, 37]. Two of the four included studies incorporated either an integrative medicine component in the intervention or lifestyle medicine (e.g. culinary medicine, yoga) [33, 35], suggesting the IMGV subset of SMAs may provide a practicable method for integrating evidence-based complementary therapies and lifestyle medicine into patient care. This has implications for the management of female reproductive conditions – for example endometriosis (often characterised by CPP), where conventional medicine alone does not meet the health care needs of those living with the condition and a multi-disciplinary approach is recommended [24]. While IMGVs may be a more effective way to support patients with such conditions by proffering an effective model for inclusion of multidisciplinary services and patient education into routine care (via improved efficiency of primary care delivery), further research is needed to investigate their use.

In addition to the evidence supporting group visits for non-gender specific chronic conditions, research examining group visits for preconception and prenatal care also demonstrate promising results in terms of both efficacy and feasibility. For example, in the area of maternal health, research findings have typically favoured group care over one-on-one care for birth outcomes and clinical parameters in conditions such as gestational diabetes mellitus [38], thus complementing the findings of this review. While there is limited research examining the effectiveness of group visit interventions for female reproductive conditions, current evidence supporting group visits for other areas of women’s health (such as group prenatal care) provides a solid basis for proposing larger and longer-term studies of group visits for female-specific conditions.

Despite inconclusive evidence for the clinical efficacy of group visits for female reproductive conditions, some noteworthy changes in clinical outcomes were observed (albeit in small studies) for conditions such as CPP and PCOS. The promising clinical results observed in the study of IMGVs for CPP [33] complements prior research highlighting the limitations of gynaecological treatments for CPP, suggesting a multidisciplinary approach may help improve the management of this condition [39]. Furthermore, improvements in self-efficacy suggest group-based models of care may be helpful in addressing the needs of some patients living with a diagnosis of PCOS. Interestingly, patients in the aforementioned study [32] suggested continuing the group-based care intervention for at least a year, indicating that the duration of the intervention may not have been sufficient, which may account for the lack of health behaviour change reported by patients. Similarly, research investigating group visits in other populations has shown patients prefer, and demonstrate better clinical outcomes, when exposed to more frequent visits and longer intervention timeframes [5, 33, 40]. Thus, future research of group-based care should consider using longer intervention periods, more frequent group meetings and larger sample sizes. We suggest future research also needs to be conducted to investigate the efficacy of group medical visits with analysis for each different population living with a female reproductive condition and their unique healthcare needs. Although no known adverse events have been associated with group visits in the literature, one study in this review hypothesised that the personal nature of conditions such as CPP may serve as a hindrance for some people to participate. It is possible that this hypothesis may also apply to people with other gynaecological conditions, adding to the case for further research.

There are several limitations to this review. As the review comprised of mostly quasi-experimental pilot and feasibility studies, and the sample sizes were small, the generalisability of the review findings are somewhat limited. The broad nature of the review and heterogeneity of studies also meant that meta-analysis of the data was not possible; instead, the data were presented as a narrative synthesis. Although a limitation in part, this also represents a strength of the review as narrative syntheses (relative to meta-analyses) allow for deeper analysis of meaning and interpretation [41]. Given the studies did not utilise control groups, and only one study included a comparison group, it is unknown how the effect of the intervention compares with usual (one-on-one) care. Further, all included studies were conducted in the USA – where heterogeneous private and public insurance measures and funding models may better support group care – and thus, may not readily translate to other settings affected by different social, economic or health parameters. Despite these limitations, group visits for female reproductive conditions appear to be feasible; thus more clinical trials addressing previous limitations are encouraged.

This review provides insight into the feasibility and acceptability of group visits for the management of female reproductive conditions. Given the small number and methodological limitations of studies included in this review, no conclusions regarding the clinical effectiveness of group visits for female-specific conditions (relative to one-on-one consultations) can be drawn from this evidence. However, the evidence suggests that group interventions may be feasible and acceptable to women with female reproductive conditions such as breast cancer, gynaecological cancer, CPP and PCOS. Accordingly, group visit interventions, such as SMAs and IMGVs, may be an untapped model of care for people living with female reproductive conditions, particularly where conventional models are not meeting the health care needs of people living with these conditions. Given the evidence of effectiveness, acceptability and reach for group visits in other populations, further research investigating the effectiveness and feasibility of group-based integrative women’s health interventions is justified.