Evidence-based Synthesis Program Department of Veterans Affairs

Health Services Research & Development Service

December 2012

Group Visits Focusing on Education 

for the Management of 

Chronic Conditions in Adults: 

A Systematic Review

Prepared for:

Department of Veterans Affairs

Veterans Health Administration

Quality Enhancement Research Initiative (QUERI)

Health Services Research & Development Service

Washington, D.C. 20420

Prepared by:

Evidence-based Synthesis Program (ESP) Center

Portland VA Medical Center

Portland, OR

Devan Kansagara, M.D., M.C.R., Director

Investigators:

Principal Investigator: 

Ana R. Quiñones, Ph.D., M.S.

Co-Investigators: 

Jeannette Richardson, M.S.N., R.N., C.N.S.

Michele Freeman, M.P.H.

Maya E. O’Neil, Ph.D.

Devan Kansagara, M.D., M.C.R.
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Group Visits Focusing on Education for the Management

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PREFACE

Quality Enhancement Research Initiative’s (QUERI) Evidence-based Synthesis Program 

(ESP) was established to provide timely and accurate syntheses of targeted healthcare topics 

of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to 

improve the health and healthcare of Veterans. The ESP disseminates these reports throughout 

VA.

QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The 

ESP Centers generate evidence syntheses on important clinical practice topics, and these reports 

help:

• develop clinical policies informed by evidence,

• guide the implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

• set the direction for future research to address gaps in clinical 

knowledge.

In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central 

Office and the four ESP sites by developing and maintaining program processes. In addition, 

the Center established a Steering Committee comprised of QUERI field-based investigators, 

VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service 

Networks (VISN) Clinical Management Officers. The Steering Committee provides program 

oversight, guides strategic planning, coordinates dissemination activities, and develops 

collaborations with VA leadership to identify new ESP topics of importance to Veterans and the 

VA healthcare system.

Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP

Coordinating Center Program Manager, at nicole.floyd@va.gov.

Recommended citation: Quiñones AR, Richardson J, Freeman M, O’Neil M, Kansagara D. 

Group Visits Focusing on Education for the Management of Chronic Conditions in Adults: A 

Systematic Review. VA-ESP Project #05-225; 2012

This report is based on research conducted by the Evidence-based Synthesis 

Program (ESP) Center located at the Portland VA Medical Center, Portland OR funded 

by the Department of Veterans Affairs, Veterans Health Administration, Office of 

Research and Development, Quality Enhancement Research Initiative. The findings 

and conclusions in this document are those of the author(s) who are responsible for 

its contents; the findings and conclusions do not necessarily represent the views of 

the Department of Veterans Affairs or the United States government. Therefore, no 

statement in this article should be construed as an official position of the Department 

of Veterans Affairs. No investigators have any affiliations or financial involvement 

(e.g., employment, consultancies, honoraria, stock ownership or options, expert 

testimony, grants or patents received or pending, or royalties) that conflict with 

material presented in the report
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EXECUTIVE SUMMARY

BACKGROUND

The goal of group-based educational programs led by non-prescribing facilitators is to 

communicate information and provide training in order to improve self-management skills 

for the large numbers of patients coping with chronic illness. The Veterans Administration 

(VA) has prioritized group visit implementation as part a new primary care model that focuses 

on patient centeredness, The Patient Aligned Care Team (PACT), but the choice of which 

patient populations to target and which interventions to use is unclear. Though the group visit 

intervention delivery model has been widely used, there are vast differences in program structure, 

content, length of intervention, and follow-up time points. Moreover, there is little consensus as 

to whether, and for whom, group visits are an effective tool. Given the variety of interventions, 

the broad array of chronic conditions in which group visit interventions have been studied, and 

the lack of an overall understanding of effectiveness, it is useful to clarify what is known and 

not known about group visit interventions in patients with chronic illness. To our knowledge, no 

recent review has examined group visit interventions across a variety of conditions. 

The objectives of this review are to: 1) summarize the characteristics of group visit interventions 

that have been tested in controlled trials of patients with chronic illness; 2) assess the effects 

of these interventions on quality of life, self-efficacy, health care utilization, and other health 

outcomes; 3) understand whether there are certain patient characteristics associated with 

intervention effectiveness; and 4) examine which components of group visit intervention 

structure and delivery may be associated with intervention effects. 

We address three key questions in our review of the literature on group visits conducted by nonprescribing health professionals and lay facilitators:

Key Question 1. In adults with chronic medical conditions, how do group visits compared to 

usual care affect the following:

(1) medication adherence, biophysical markers ( e.g., HbA1c, blood pressure)

(2) symptom status, functional status, mortality, patient satisfaction

(3) utilization of medical resources, health care costs

(4) adverse outcomes (e.g., patient confidentiality, participation/missed appointments)?

Key Question 2. For adults with chronic medical conditions, do the effects of group visits vary 

by patient characteristics? Characteristics of interest include medical diagnosis, severity of 

disease, and comorbidities.

Key Question 3. (Depending on the size and comparability of elements identified in the 

literature) Which components of group visits are associated with greater intervention effects?
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METHODS

We conducted searches of multiple databases (MEDLINE® via PubMed®, Embase®, Cochrane 

Register of Controlled trials, CINAHL (EBSCO), PsycINFO) using terms for non-prescribing 

practitioners and group visit interventions, including but not limited to terms for group education, 

group program(me), group session(s). We obtained additional articles from systematic reviews, 

reference lists of pertinent studies, editorials, and by consulting experts. Reviewers trained in the 

critical analysis of literature assessed the titles and abstracts for relevance, and retrieved full-text 

articles for further review. We compiled a narrative synthesis of findings, highlighting studies 

that evaluated the effects of group visits, and describe the common characteristics and themes 

that emerged across studies and disease categories. We conducted meta-analyses of group visit 

trials for patients with diabetes for the mean difference in the change of HbA1c. We describe the 

overall quality of evidence for outcomes in each clinical subsection using a method developed by 

the GRADE Working Group.

RESULTS

We included 87 publications reporting on 81 group visit intervention studies focusing on 

education for the management of arthritis, falls prevention, asthma, chronic obstructive 

pulmonary disease, hypertension, congestive heart failure, diabetes mellitus, or chronic pain. 

We examined findings by key question as well as by clinical area. 

Findings by Key Question 

Key Question 1. In adults with chronic medical conditions, how do group visits 

compared to usual care affect the following: (1) medication adherence, biophysical 

markers (e.g., HbA1c, blood pressure); (2) symptom status, functional status, mortality, 

patient satisfaction; (3) utilization of medical resources, health care costs; (4) adverse 

outcomes (e.g., patient confidentiality, participation/missed appointments)? 

In general, group visit interventions in most clinical areas were associated with short- and 

medium-term improvements in self-efficacy; few studies examined longer-term outcomes. 

However, there was little evidence that interventions improved quality of life, functional status, 

or utilization outcomes. Group visit interventions were associated with modest short-term 

improvements in HbA1c, but the strength of this evidence was low because of inconsistent 

results across studies and methodological concerns in the studies finding the greatest benefit. 

Key Question 2. For adults with chronic medical conditions, do the effects of group visits 

vary by patient characteristics?

Relatively few studies specifically examined how patient characteristics modified intervention 

effects. Overall, studies found little difference in group visit effectiveness according to patient 

demographic and socioeconomic characteristics. However, among studies of arthritis and history 

of falls, two studies found that obese patients tended to respond to aerobic exercise group visits 

more than participants with lower BMI on self-reported disability and falls. Among hypertension 

and heart failure studies, one study found patients with more years of education and better 
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cognitive status showed greater short-term improvements in cardiac-specific quality of life. One 

chronic pain study noted that group visit effectiveness was modified by agency-orientation, with 

high agency-oriented participants experiencing improvements in pain and pain coping resulting 

from group visit sessions. Various authors note that small sample sizes limit the power to detect 

differences in subgroup analyses. In addition, findings of group visit benefit in subgroup analyses 

are tempered by fair and poor quality ratings for many of these studies.

Key Question 3. Which components of group visits are associated with greater 

intervention effects? 

Overall, in five studies, group visit interventions that focused on self-management educational 

strategies were more effective than sessions that were limited to didactic education; however, in 

four of these five studies, the intervention arms differed considerably from the comparators (e.g., 

having nonequivalent number of sessions), limiting the strength of this conclusion. Studies that

compared group visits to individual education visits found mixed results on a variety of outcomes,

with no appreciable differences found in three studies, positive effects found with group visits 

in four other studies, and improvements with individual education in one study. Findings across 

studies could not be combined because of differences in study design. Two studies compared the 

effects of in-person group self-management education and mailed or automated self-management 

programs, and found no differences in self-efficacy, pain, and functional status outcomes. 

Findings by Clinical Area

Arthritis

Eighteen studies from the US, Europe, and Australia evaluated the effectiveness of educational 

group visit interventions that included self-management skills (11 studies), didactic (8 studies), 

and experiential approaches (6 studies). Studies varied widely in intervention structure, content, 

and duration, as well as comparison group. 

Seven of ten studies found group visit interventions improved short- and medium-term selfefficacy; six of the studies found benefit for the interventions focused on self-management 

skills education. Only one poor-quality study assessed outcomes beyond 12 months. Despite the 

improvements seen in self-efficacy, only two of eleven studies found improvements in quality of 

life related measures such as disability and depression. One US study found a self-management 

education intervention was associated with reduced physician visits, but this finding was not 

confirmed in five other studies conducted in Europe and Australia. 

Overall, there is a moderately strong body of evidence that group self-management education 

interventions can improve short- and medium-term self-efficacy in patients with arthritis, but 

they have little effect on quality of life or utilization outcomes. 

History of Falls

Four studies from the US, Canada, and Australia examine effectiveness of educational group 

visit interventions in patients with a history of falls or at-risk for falling. Overall, didactic falls 

prevention training along with exercise training may improve patient self-efficacy and reduce the 

risk of falls, though the strength of this evidence is low because of inconsistencies among studies 

and the small number of studies. 
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Asthma, COPD

Five studies conducted in the US or Australia examined the effects of group visit interventions 

compared with usual care in patients with asthma. The group interventions involved didactic 

education in four studies and self-management education in one study. Decreased utilization was 

observed in two studies, and improvements in quality of life measures were noted in two studies. 

The studies were limited by selection bias and other methodological issues, however, and study 

quality was generally poor.

Five studies of group visits in COPD patients were conducted in a variety of settings: Northern 

Ireland, the UK, the Netherlands, France, and a VA Medical Center in the US. Three studies 

compared didactic education combined with exercise training to didactic education alone or to 

usual care. Two other studies examined the effects of self-management education compared with 

didactic education, usual care, or individual support. Better exercise capacity was observed in the 

studies that combined exercise training with didactic education, as compared with usual care or 

with didactic education alone. 

Overall, a small body of fair-to-good quality evidence suggests that group exercise training in 

combination with didactic education may be associated with small improvements or less decline 

over time in exercise capacity and COPD symptoms, though the clinical significance of these 

findings is unclear. There is little methodologically sound evidence examining the impact of 

group visits in patients with asthma. 

Hypertension, CHF, CAD

Our literature search identified three fair-quality studies of group visit interventions conducted in 

patients with CHF or CAD, published in four reports. Six studies examined the effects of group 

visits on blood pressure in patients with hypertension. The studies were conducted in a range 

of international settings, and study quality varied widely. Three studies used self-management 

education techniques and two studies used didactic education in comparison with usual care or 

an informational control. One trial compared self-management education directly with didactic 

education. Reductions in blood pressure measurements were noted in all three self-management 

education studies and in one didactic education study. In the trial comparing self-management 

education directly with didactic education, there were no significant reductions in systolic or 

diastolic blood pressure in either group at three months. However, significantly more selfmanagement education patients had controlled blood pressure. 

Overall, there were very few studies of group visits in CHF patients, and their findings on selfefficacy, quality of life, and biophysical measures were largely neutral. Group self-management 

education interventions in patients with hypertension have reported improvements in blood 

pressure control in short-term and long-term studies, but the overall strength of evidence is low. 

Diabetes Mellitus

We included 30 publications of 29 studies of group visit interventions in patients with diabetes 

mellitus. We conducted meta-analyses of the 17 studies comparing the effects of a group visit 

intervention to usual care on HbA1c. Overall, in 14 studies, group visit interventions reduced 

HbA1c slightly more over six months of follow-up than usual care, though there was significant 
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heterogeneity which should temper confidence in these results. At least part of the heterogeneity 

seemed to be associated with study quality. The two good quality studies found no short-term 

improvements in HbA1c. Group visit interventions lasting more than three months appeared to 

have a more pronounced effect on HbA1c improvement than those of shorter duration, but the 

quality of these longer duration intervention studies was also lower. We found similar effects on 

HbA1c at 7 to 12 months in the 10 studies with longer-term follow-up. 

Five of ten studies found improvements in self-efficacy or illness belief scores, with four of these 

studies finding positive effects beyond six months of follow-up. Perhaps not surprisingly, four 

of the five studies finding beneficial effects on self-efficacy involved interventions specifically 

focused on broader self-management skills training rather than didactic education. Despite 

finding that some interventions may improve self-efficacy, there was little evidence that group 

visit interventions improved quality of life over the short- or long-term. Few studies reported or 

were powered to evaluate utilization outcomes. 

Eleven studies compared a group visit intervention to one or more active interventions. Three of 

these studies found that interventions focused on self-management skills training were associated 

with greater improvements in glycemic control than didactic educational approaches, though 

there were multiple other differences in the interventions being compared, making it difficult to 

draw firm conclusions about the effects of educational approach alone. Two studies compared 

group to individual education. One fair-quality study found that an automated, telephone-based, 

self-management intervention performed similarly to an in-person group self-management skills 

intervention.

Overall, we found group visit interventions in patients with diabetes may have modest effects 

on glycemic control over the short- and long-term, but the strength of evidence supporting 

this conclusion is low mostly because of inconsistencies across studies and methodological 

weaknesses of the studies finding the most positive effects. Interventions focused on selfmanagement skills training were associated with improved self-efficacy and illness belief scores 

over the short- and long-term. However, there was no consistent evidence that group visit 

interventions improved quality of life. 

Multiple Chronic Conditions

Four studies evaluated the Chronic Disease Self-Management Program (CDSMP) in populations 

with various chronic conditions not limited to a particular disease group. Overall, the peer-led, 

community-based CDSMP appears to be associated with medium-term improvements in selfefficacy, health status, and health care utilization; and these effects may persist long-term. These 

findings are based on moderately strong evidence from two large US trials, though findings were 

not replicated in other countries, and the findings likely apply most to patients engaged enough in 

care to agree to attend a multi-week course.

Chronic Pain

Four studies evaluated the effects of group-based interventions compared to usual care, 

educational reading materials, or individual treatment in patients with chronic pain. Though 

many findings from the studies were not statistically significant and did not differ from the 
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comparison, some results favored the group-based interventions. Overall, a very small body of 

literature suggests group-based, self-management education interventions may improve pain 

coping skills at least over the short-term, though the strength of this evidence is low because 

there were few studies and the methodological quality of one of the studies finding benefit was 

poor.

DISCUSSION 

We found 79 trials examining the effects of group visit interventions across a variety of chronic 

illnesses. Despite the large evidence base, it is difficult to draw overall conclusions about 

the effectiveness of group visit interventions in patients with chronic illness, in part because 

of the diversity of patient populations studied, interventions tested and outcomes reported. 

Nevertheless, in general, many group visit interventions appear to be able to improve short- and 

medium-term patient self-efficacy, but there was little consistent, fair-to-good quality evidence 

that they improved quality of life, health outcomes, or health care utilization. We found that 

diabetes group visit interventions were likely associated with small short-term improvements in 

glycemic control. The longer-term effects of group visit interventions are largely unknown since 

the vast majority of studies focused on short-term effects. 

CONCLUSION

Whether group visit expenditures are warranted may depend on how highly more proximate 

outcome measures like self-efficacy are valued by patients and the health system. On the other 

hand, peer-led, community-based self-management programs are a low-cost intervention which 

appears to improve self-efficacy and, in mixed groups of patients with various chronic illnesses, 

may improve health and utilization outcomes. Group visits may be as effective as individual 

education visits and may represent a reasonable alternative for educating patients with chronic 

illness, though the varied and sometimes low participation and retention rates suggest they 

should not be the sole alternative.