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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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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TABLE OF CONTENTS

Executive Summary

Background.................................................................................................................................................... 1

Methods......................................................................................................................................................... 2

Results ........................................................................................................................................................... 2

Discussion...................................................................................................................................................... 6

Conclusion..................................................................................................................................................... 6

Introduction .......................................................................................................................................................... 7

Methods

Topic Development........................................................................................................................................ 8

Search Strategy............................................................................................................................................ 10

Study Selection............................................................................................................................................ 10

Data Abstraction .......................................................................................................................................... 10

Study Quality............................................................................................................................................... 11

Rating the Body of Evidence....................................................................................................................... 11

Data Synthesis............................................................................................................................................. 11

Peer Review................................................................................................................................................. 12

Results

Literature Flow ............................................................................................................................................ 13

Findings by Key Question........................................................................................................................... 15

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)? .............................................. 15

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

vary by patient characteristics? ..................................................................................................... 15 

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

intervention effects? ...................................................................................................................... 16 

Findings by Clinical Area............................................................................................................................ 16

Arthritis......................................................................................................................................... 16

History of Falls.............................................................................................................................. 17

Asthma, COPD.............................................................................................................................. 24

Hypertension, CHF, CAD ............................................................................................................. 29

Diabetes Mellitus .......................................................................................................................... 33

Multiple Chronic Conditions......................................................................................................... 48

Chronic Pain.................................................................................................................................. 51
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Discussion.............................................................................................................................................................. 54

Generalizability ........................................................................................................................................... 55

Limitations................................................................................................................................................... 56

Future Research........................................................................................................................................... 57

Conclusions ................................................................................................................................................. 57

References............................................................................................................................................................ 58

Tables

Table 1. Characteristics of group visit interventions focusing on education for the management 

of arthritis or falls..................................................................................................................... 18

Table 2. Findings from interventions reporting standardized or validated measures that compare 

group visits to control, stratified by arthritis or falls................................................................ 21

Table 3. Summary of findings from head-to-head group visit interventions and group vs. 

individual visit interventions for patients with arthritis or falls............................................... 23

Table 4. Characteristics of group visit interventions focusing on education for the management 

of asthma or COPD .................................................................................................................. 25

Table 5. Findings from interventions comparing group visits to usual care control for the 

management of Asthma or COPD, stratified by clinical area and outcome category .............. 27

Table 6. Summary of findings from head-to-head group visit interventions and group vs. 

individual visit interventions for patients with asthma or COPD ............................................ 28

Table 7. Characteristics of group visit interventions focusing on education for the management 

of congestive heart failure, coronary artery disease, or hypertension...................................... 30

Table 8. Findings from interventions reporting standardized or validated measures that compare 

group visits to control, stratified by hypertension or CHF....................................................... 32

Table 9. Summary of findings from head-to-head group visit interventions and group vs. 

individual visit interventions for patients with hypertension or CHF...................................... 32

Table 10. Characteristics of group visit interventions focusing on education for the management of 

diabetes mellitus....................................................................................................................... 35

Table 11. Findings from interventions reporting standardized or validated measures that compare 

group visits to usual care in the management of diabetes mellitus.......................................... 40

Table 12. Summary of findings from head-to-head group visit interventions and group vs. 

individual visit interventions for the management of diabetes mellitus................................... 42

Table 13. Characteristics of group visit interventions focusing on education for the management 

of chronic conditions in populations with multiple disease groups......................................... 49

Table 14. Characteristics of group visit interventions focusing on education for the management 

of chronic conditions in populations with multiple disease groups......................................... 50

Table 15. Characteristics of group visit interventions focusing on education for the management 

of chronic pain.......................................................................................................................... 52

Table 16. Findings from interventions comparing group visits to control for the management of 

chronic pain .............................................................................................................................. 53

Table 17. Findings from interventions comparing group visits to control for the management of 

chronic pain .............................................................................................................................. 53

Table 18. Evidence gaps and future research ........................................................................................... 57
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Figures

Figure 1. Analytic framework to evaluate group visits ............................................................................. 9

Figure 2. Literature Flow......................................................................................................................... 14

Figure 3. Effect of group visits compared to usual care on HbA1C at ≤6 month follow-up, by 

study quality ............................................................................................................................. 44

Figure 4. Effect of group visits on HbA1C compared to usual care at ≤6 month follow-up, by 

duration of intervention............................................................................................................ 45

Figure 5. Effect of group visits compared to usual care on HbA1C at 7-12 month follow-up, by 

study quality ............................................................................................................................. 46

Figure 6. Effect of group visits compared to usual care on HbA1C at 7-12 month follow-up, by 

duration of intervention............................................................................................................ 47

Appendix A. Search Strategy............................................................................................................... 67

Appendix B. Inclusion and Exclusion Criteria............................................................................. 73

Appendix C. Quality Assessment......................................................................................................... 75

Table C1. Quality assessment and methodological characteristics of individual studies in 

randomized controlled trials of group visits............................................................................. 76

Table C2. Total number of outcome measures reported in studies of group visit interventions 

focusing on education for the management of chronic disease ............................................... 79

Appendix D. Peer Review Comments and Responses ................................................................. 102

Appendix E. Glossary for Outcomes Used in Included Studies .......................................... 109
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EVIDENCE REPORT

INTRODUCTION

The goal of group-based educational programs led by non-prescribing practitioners 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 of 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. This review serves as a 

companion piece to the recently published shared medical appointments review conducted by the 

Durham Evidence-based Synthesis Program.1

 The shared medical appointments review focuses 

on visits led by a physician or other prescribing provider during which individual-level changes 

in management plan can be made. This review, in contrast, focuses exclusively on literature that 

tests the effectiveness of group visits that have an emphasis on health education and are led by 

facilitators, including but not limited to non-prescribing health professionals such as nurses, 

dietitians, and physical therapists.
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METHODS

TOPIC DEVELOPMENT

The review was commissioned by the Department of Veterans Affairs’ Evidence-based Synthesis 

Program. We conferred with VA experts to refine selection of patient populations and subgroups, 

interventions, outcomes, and setting addressed in the review. The current review focuses on 

studies involving education-based group visits interventions led by facilitators that include nonprescribing health professionals.

We addressed the following key questions in our review of the literature:

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?

The criteria for patient population, treatment and comparator interventions, outcomes of interest, 

and patient care setting are outlined below:

•	 Patients: Diagnosed with DM, HTN, CHF, COPD, asthma, arthritis, pain management, 

history of falls. Exclude comorbid serious mental illness such as schizophrenia. Studies 

with patients who have comorbid depression may be included.

•	 Intervention: Group visits focusing on education that are led by individuals who 

are non-prescribing health professionals as well as lay facilitators (e.g., dietitians, 

nurses, social workers, peer educators, psychologists, pulmonary technicians, physical 

therapists, occupational therapists). Group visits may include prescribing providers (e.g., 

physicians, pharmacists, advanced practice nurses, physician assistants) if they function 

in an advisory capacity only (i.e., do not provide individual care plans or medication 

management).

•	 Comparator: Usual care, non-group visit care

•	 Outcome: Biophysical/physiological (e.g., HbA1c, blood pressure) control of these 

markers/measures, rehospitalizations, medication adherence, ED visits, functional status, 

patient satisfaction, patient participation, and attrition rates. 

•	 Timing: Any

•	 Setting: Any

Figure 1 illustrates the analytic framework that guided our review and synthesis. 
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amework to evaluate group visits 

/ethnicity, age, education/health literacy, rurality/geography, chronic conditions/morbidity, and other patient

socioeconomic influences such as financial strain (e.g., price of gas) directly affect patient participation

KQ2 

Distal Outcomes

 Long‐term symptom 

management 

 Functional status  Quality of life  ED visits   Rehospitalizations  Unplanned office visits  Mortality  Costs 

KQ2 

Proximal Outcomes

 Adherence  Biophysical markers  Self‐efficacy  Patient participation 

Group Visit models

 Led by non‐prescribing 

facilitators 

 Group size (# patients)  Diagnosis, recency diagnosis  Visit components  Visit frequency, duration, 

number of follow‐ups 

 Peer support  Team composition   Other care patients are 

receiving

Usual care

 Individual visit for chronic care   Other quality improvements

KQ1,

KQ3 

Modifiers

 Patient characteristics*  Built environment  Social support  Health care system 

Adverse Outcomes

 Patient confidentiality  Patient participation  Missed  appointments 

KQ1, 

KQ3 

ework to evaluate group visits
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SEARCH STRATEGY

We conducted searches of multiple databases [MEDLINE® (PubMed®), Embase® (Embase.com), 

Cochrane Register of Controlled Trials (Ovid), CINAHL (EBSCO) and PsycINFO (Ovid)] from 

database inception to February 2012 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). See Appendix A for the full search strategy. We obtained additional articles from 

systematic reviews, reference lists of pertinent studies, editorials, and by consulting experts.

STUDY SELECTION

Reviewers trained in the critical analysis of literature assessed the titles and abstracts for 

relevance. Two investigators (AQ, JR, MF, MO, or DK) independently evaluated Englishlanguage articles included at the abstract stage using prespecified inclusion criteria (Appendix 

B). We included studies of group visit educational interventions led by non-prescribing 

facilitators. We excluded group visit studies if any portion of the intervention focused on 

individual-level prescription changes (e.g., blood pressure medication or insulin titration). 

We did not examine studies that focused exclusively on support groups or on group exercise 

classes (e.g., yoga, aerobic exercise, resistance training) without incorporating disease-pertinent 

educational components or comparing these interventions to group educational sessions. Existing 

Cochrane reviews of group exercise summarize the effectiveness of these interventions and 

represent a systematic evaluation of that literature.2,3 We excluded diabetes mellitus studies 

published before 1998 because we felt the overall approach to adult diabetes care was likely to 

have changed substantially after publication of the United Kingdom Prospective Diabetes Study, 

thereby rendering older studies less directly applicable today.4

DATA ABSTRACTION

We abstracted data on the design, objectives, setting, population, demographics, findings, 

structure of the intervention, information on the comparator(s), and participation and attrition 

rates that characterized included studies. We also abstracted information on the content delivered 

in the group visit interventions. We distinguished between group visits whose content was to 

provide didactic-only educational sessions, and those that provided participants with information 

and training on techniques to improve coping and self-management skills. We defined the 

following, and abstracted this information from included studies:

•	 Self-management education (SME): In addition to providing disease-specific information 

to patients, these programs teach patients self-management skills to manage/cope with symptoms, such as goal-setting and contracting, and building skills to reinterpret symptoms (e.g.,

motivational interviewing, goal-setting/contracting, cognitive behavioral therapy (CBT))

•	 Didactic education (DE): Content is informational and format is usually lecture-based 

(e.g., information on the pathophysiology of disease, symptoms, using and reading equipment, potential strategies for reducing pain and stress, understanding nutritional advice)

•	 Experiential education (EE): Instruction based on demonstrations (e.g., exercise, cooking, reading nutritional labels and calculating nutritional information)
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STUDY QUALITY 

Two reviewers independently assessed the quality of each trial according to the following 

criteria: randomization, allocation concealment, blinding and outcome reporting, as well as 

considerations for similarity of compared groups at baseline, adequate reporting of participation, 

loss to follow-up and attrition, the use of intention-to-treat analysis; and ascertainment of 

outcomes.5

 Individual studies were rated as “good,” “fair,” or “poor”; these terms are defined in 

Appendix C. 

RATING THE BODY OF EVIDENCE

We describe the overall quality of evidence for outcomes in each clinical subsection using 

a method developed by the GRADE Working Group.6 The GRADE method considers the 

consistency, coherence, and applicability of a body of evidence, as well as the internal validity of 

individual studies, to classify the grade of evidence across outcomes as follows: 

• High = Further research is very unlikely to change our confidence on the estimate of 

effect.

• Moderate = Further research is likely to have an important impact on our confidence in 

the estimate of effect and may change the estimate.

• Low = Further research is very likely to have an important impact on our confidence in 

the estimate of effect and is likely to change the estimate.

• Very Low = Any estimate of effect is very uncertain.

DATA SYNTHESIS

During an initial informal review of included studies, we recognized that there was a breadth of 

outcome categories examined, marked variation in outcome metric validity, and a large number 

of different outcomes measured and reported across studies. We anticipated such challenges 

would render a full accounting and synthesis of all outcomes both infeasible and uninformative. 

We chose, therefore, to focus on distal health outcomes measuring quality of life and functional 

status because these are likely to be important to patients and could conceivably be impacted by 

the interventions examined in the studies under consideration. We included utilization outcomes 

when reported, though we anticipated that fewer studies would be powered to examine these 

outcomes. We also examined intermediate outcome metrics, focusing specifically on biophysical 

markers such as hemoglobin A1c, and on self-efficacy or patient activation measures. Selfefficacy refers to personal beliefs in one’s ability to succeed in self-managing illness. In this 

report, we used the term broadly and used it to refer to any measures examining self-efficacy, 

patient activation, coping skills, or illness beliefs. We chose to examine this group of outcomes 

because there are validated tools to assess self-efficacy related concepts,7,8 and these metrics 

were commonly reported in many studies. Furthermore, there is a link, both conceptually and 

empirically, between the knowledge, skills, and attitude changes one might acquire during an 

educational intervention and intermediate health outcomes.9

In compiling data tables, we prioritized well-validated scales and if studies report findings for 

full scales as well as subscales, we report full scales only. If studies did not report any outcome 
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in these categories, or report ad-hoc/non-validated measures, their findings were summarized 

narratively. We also described 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 because we identified HbA1c as a clinically important marker 

for diabetes patients and one that is plausibly amenable to change in the short (0-3 months) and 

medium (4-6 months) term. We abstracted the mean difference and an indicator for variability 

(e.g., standard error) in HbA1c, and total subjects from each treatment arm. We obtained a 

pooled estimate of relative risk (RR) using a random effects model.10 To determine whether the 

effects of group visits were modified by intervention characteristics, we conducted subanalyses 

according to study quality, and duration of the group visit intervention. 

Statistical heterogeneity was assessed by Cochran’s Q test and I2 statistic.11 In order to examine 

publication bias, we used funnel plots and Egger’s test to assess small study effects.12 We also 

conducted multivariate meta-regression analyses to determine whether duration of intervention, 

study quality, or publication year had any bearing on meta-analytic results. All analyses were 

performed using Stata 10.0 (StataCorp, College Station, TX, 2007).

PEER REVIEW

A draft version of this report was sent to the technical expert panel and additional peer reviewers. 

Appendix D details the feedback we received and our responses to reviewer comments. 
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RESULTS

LITERATURE FLOW

We reviewed 2,493 titles and abstracts from the electronic search, and identified an additional 42 

studies from reviewing reference lists. After applying inclusion/exclusion criteria at the abstract 

level, 599 full-text articles were reviewed, as shown in Figure 1. Of the full-text articles, we 

excluded 512 that did not meet inclusion criteria.

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

education for the management of arthritis, falls prevention, asthma, COPD, hypertension, CHF/

CAD, DM, or chronic pain. Tables 1, 4, 7, 10, 13, and 15 present characteristics of group visit 

interventions. Tables 3, 6, 9, 12, and 17 present head-to-head comparisons of multiple active 

group visit treatment arms as well as studies that compared individual visits to group visits. 
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Figure 2. Literature Flow – Group visits focusing on education for the management of chronic conditions in adults: A systematic review

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42 Citations identified from reference lists 

 of review articles, and manual searches 

 for recent, unpublished or ongoing studies 

599 Potentially relevant articles identified for further review

Total excluded articles = 512

Non-English language = 17 

No primary data and not an SR of 

primary studies = 56 

Study population not in scope = 54 

Does not meet intervention criteria = 158 

Not an RCT = 68 

Outcome measures not in scope = 8 

Full text not accessible = 29 

Shared medical appointment led by a 

prescribing provider = 64 

Use for contextual purposes or reference 

mining = 39 

Duplicate publication of same study = 7 

Pre-1998 DM study = 12 

87 articles of 81 primary studies of group 

visits focusing on education for the 

management of chronic conditions in adults 

163 Duplicate citations excluded 

3,408 Citations identified for review of title and abstract

3,450 Potentially relevant citations identified for further review 

 2,851 Citations excluded due to lack 

 of relevance in title or abstract

2,493 Citations identified from electronic 

 database searches: 

 889 from MEDLINE®

 48 from Cochrane library 

 44 from PsycINFO 

 90 from CINAHL 

 1422 from PubMed 

1,097 Citations derived from 

SMA literature search 

Asthma/COPD = 10 

Chronic pain = 4 

Hypertension/congestive heart 

failure = 12 

Arthritis or history of falls = 22 

Diabetes mellitus = 29 

Multiple disease groups = 4 

19 Studies used for SMA review, excluded 
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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; (2) symptom status, functional status, mortality, patient satisfaction; (3) 

utilization of medical resources, health care costs; (4) adverse outcomes?

Tables 2, 5, 8, 11, 14, and 16 present findings of effectiveness of group visit interventions 

compared to usual care in the short (0-3 months), medium (4-6 months), long-term (7-12 

months), or very long-term (13+ months). In addition, we present a full accounting of the total 

number of outcomes examined by studies in Appendix Table C2. Appendix E provides a glossary 

of acronyms and abbreviations for outcomes used in the included studies. We present findings 

from meta-analyses of mean change in HbA1c following group visit intervention for patients 

with diabetes mellitus in Figures 3 to 6. 

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

medium-term improvements in self-efficacy; few studies examining 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. Sixteen studies presented results of group visit interventions by patient characteristics: 

nine diabetes mellitus studies,13-21 two arthritis studies,22,23 two history of falls studies,24,25 one 

hypertension study,26 one CHF study,27 and one chronic pain study.28

Many of these studies examined group visit effectiveness for participants who attended a greater 

number of sessions relative to those with greater absentee rates.13,16,18,19 Overall, the studies found 

some indications of a dose-response with group session attendance, with those participants 

attending the greatest number of sessions benefitting the most from the group visit intervention. 

For the DM studies, many found larger beneficial group visit intervention effects for patients 

with higher initial levels of HbA1c.14,17,21

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

demographic and socioeconomic characteristics (e.g., gender, education, age, race). 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 selfreported disability22 and falls.24 Among hypertension and CHF studies, Smeulders et al. 

found patients with more years of education and better cognitive status showed greater shortterm improvements in cardiac-specific QoL.27 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.28
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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?

Tables 3, 6, 9, 12, and 17 present findings of effectiveness of group visit interventions from 

head-to-head comparisons of multiple active group visit treatment arms, as well as studies that 

compared individual visits to group visits. Overall, in five studies, group visit interventions that 

focused on SME strategies were more effective than sessions that were limited to DE; 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 SME and mailed or automated self-management 

programs, and found no differences in self-efficacy, pain, and functional status outcomes.29,30

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 (eleven studies), didactic (eight 

studies), and experiential approaches (six studies).22,23,29,31-44 Studies varied widely in intervention 

structure, content, and duration, as well as comparison group (Tables 1-3). 

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

skills education. Only one poor-quality study assessed outcomes beyond 12 months.44 Despite 

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

quality of life related measures such as disability41 and depression.32 One US study found a 

self-management education intervention was associated with reduced physician visits,41 but this 

finding was not confirmed in five other studies conducted in Europe and Australia.31,32,34,35,40

Eight studies compared two active interventions (Table 3). Many of these studies were 

comparing interventions with more than one characteristic that differed (i.e., different 

educational content and different number of sessions), making it more difficult to assess which 

intervention components may have been associated with observed effects. One study compared 

a self-management to a didactic education intervention with the same number of sessions and 

found no difference in outcomes between them.36 Another study found that the inclusion of 

significant others along with patients in a self-management education intervention was actually 

associated with lower self-efficacy than the intervention delivered to patients alone.42 Finally, one 

study found similar effects from a mail-delivered individualized self-management program and 

an in-person group self-management education intervention.29
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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 (Tables 1-3).24,25,45,46

Two studies found a group didactic education and exercise intervention improved self-efficacy 

over the short-term,45 while another study which included a “booster” education session at three 

months found improved long-term self-efficacy.24 One study found improved timed-up-and-go 

(TUG) physical performance,24 while another study found the intervention did not improve TUG 

when patients were simultaneously tasked with cognitive activities.25 Only one of three studies 

found a reduction in fall events,24 and no studies found improved quality of life. 

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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Evidence-based Synthesis Program

up visit interventions focusing on education for the management of arthritis or falls

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator(s)

.1 yrs%

ace NR

uration NR

6 weekly (2h) sessions1.5 months4-21 patients

SME 2 leaders

Peer leader, health professional 

Usual care (information book)

.1 yrs% 

% nonwhite

 yrs with arthritis

6 weekly (2h) sessions1.5 months≥10 patients

SME 2 leaders

Peer leaders

Usual care

 yrs%

ace NR

7 yrs with RA

8 weekly (1h) education16 semi-weekly (1.5h) exercise2 monthsGroup size NR

DE, EE 5 team members

Psychologist, PT, OT, dietitian, social worker

Usual care

.6 yrs%

5% Caribbean black

uration NR

6 weekly (2.5h) sessions1.5 months12-18 patients

SME, EE NR Usual care 

(information book)

 yrs%% black

uration NR

3 monthly (1.5h) sessions18 biweekly and monthly calls18 months10-15 patients

DE 2 leaders

Exercise leader, nurse

Group exercise arms: GV2: 36 (1h) aerobic GV3: 36 (1h) resistanceClass sizes 10-15

.4 yrs%

ace NR

5 months with RA

4 weekly (2h) sessions1 monthGroup size NR

GV1: SMEGV2: DE

3 team membersPhysiotherapist, rheumatologist, psychologist

GV2

.8 yrs.1%

ace NR

.1 yrs with RA

8 weekly (6h) sessions1 (4h) booster after 6 months2 months 8-10 patients

DE, EE 10 team members

Rheumatologist, rehab. specialist, dietitian, social assist., nurses, PTs, and OTs

Usual care+: Two information leaflets written by research team

.2 yrs%

ace NR

8 yrs with RA

4 weekly (2h) sessionsOptional home visit 2 wks post1 month4-8 patients + spouses invited

SME 1 leader

Rheumatology OT

Usual care
19

tion for the Management

Evidence-based Synthesis Program

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator(s)

.4 yrs%

ace NR

4 yrs with RA

GV1: 9 sessions (2.5h) over 9 mo12 months 6-10 patientsGV2:5 (2h) sessions1.25 months8-12 patients

GV1: SME, EEGV2: DE, EE

3 leadersRheumatology OT, community OT, rheumatology PT

GV2

.2 yrs%

ace NR

 yrs with RA

GV1:6 weekly (2h) sessions 1 booster session (wk 14)1.5 months 4-9 patientsGV2:1 (1h) sessionDelivered by RA nurse

GV1: SMEGV2: DE

2 leadersClinical psychologist, specialist OT

GV2

.2 yrs

%% nonwhite

uration NR

GV1:1 (2.5h) education session12 weekly (1-2h) counseling4 monthsGV2:1 (2.5h) education sessionGroup size NR

GV1: DE, counselingGV2: DE 

2 leadersPatient counselor, psychiatrist

GV2

.4 yrs%

% nonwhite

uration NR

6 sessions (2h) over 4 months4 months 15-20 patients + family

SME 2 leaders

Trained peer leaders

Usual care

.5 yrs%0% Latino

uration NR

6 sessions (2h) over 6 weeks1.5 months10-15 patients and family

SME Lay leaders Usual care

.2 yrs%% nonwhite

uration NR

6 weekly (2h) sessions1.5 monthsGroup size NR

SME 2 leaders

Trained peer leaders

SMART group: mailed individual self-management program 
20

tion for the Management

Evidence-based Synthesis Program

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator(s)

.4 yrs% 

ace NR

.7 yrs with RA

5 weekly (2h) sessions3 (2h) booster sessions1.25 months8 patients +/- spouses

GV1: SME, EE (patients only)GV2: SME, EE (spouses included)

2 leadersRA nurse, nurse 

GV2, and Usual care+: self-help guide

 yrs%% nonwhite

uration NR

GV1:3x month, months 1-4Biweekly, months 5-6Monthly, months 7-1818 monthsGV2:GV1 structure + 3x/week grp exercise, months 1-4 Group sizes NR

GV1: DE GV2: DE, exercise 

NR GV2, and

Healthy lifestyle group: Monthly (1h) DE GV, months 1-3; monthly phone contact, months 4-5; bimonthly phone contact months 6-18

.6 yrs%

ace NR

3 yrs with RA

5 weekly (2h) sessions1.25 months6-8 patients

SME, EE 2 leaders 

RA nurse, physiotherapist, or social worker

Usual care+: individual referral to physiotherapist

.5 yrs%

ace NR

6 yrs with hip pain

GV1:22 semiweekly (1.5h) sessions2.75 monthsGV2:22 semiweekly (.75h) sessions2.75 monthsGroup sizes NR

GV1: DE, EE, aquatic exerciseGV2: EE, aquatic exercise

2 leadersAquatic fitness instructor, PT

Usual care, and GV2

.4 yrs%

ace NR

uration NR

7 (2h) sessions over 7 weeks1 (1.5h) booster (after 3mo)1.75 months12 patients

DE, EE OT with geriatrics 

experience, team of content experts for educational areas

Usual care+:≤2 home social visits from OT student instructed not to discuss falls or falls prevention

 yrs

%

% black

uration NR

1 (1h) session1 day7-8 women

DE 1 leader

Nurse

Individual visit, and Usual care+: Health promotion session with no falls prevention info

.6 yrs %

% nonwhite

uration NR

6 monthly (1h) sessions6 monthsGroup size NR

DE, exercise 1 leader

Nurse

Usual care (two CDC informational brochures)
21

tion for the Management

Evidence-based Synthesis Program

ntions reporting standardized or validated measures that compare group visits to control, stratified by clinical areas of

come Findings by time period* GV duration # Sessions % Participation†/ 

% Loss to follow-up‡

Study quality 

0-3 mo 4-6 mo 7-12 mo 13+ mo

iQ + NR ≈ NR 1.5 mo 6 25 / 22 Poor

 (pain) NR + NR NR 1.5 mo 6 NR / 22 Fair

SES ≈ NR NR NR 2 mo 24 NR / 6 GoodSES NR + + NR 1.5 mo 6 30 / 24 Fair

coping) NR NR + NR 2 mo + booster @ 4 mo 9 18 / 9 Fair

SES Unclear NR NR NR 1 mo 4 NR / 31 Fair

ge + self

ment scale NR + NR NR 4 mo 6 NA / 16 Fair

SES NR + NR NR 1.5 mo 6 NR / 17 PoorSES ≈ ≈ ≈ NR 1.25 mo+ booster @ 

3, 6, 9 mo

8 26 / 17 Fair

ain, other) ≈ ≈ NR ≈ 1.25 5 54 / 24 Poor 

function) + ≈ NR +

QoL ≈ NR ≈ NR 1.5 mo 6 25 / 22 Fair

epression) NR + NR NR 1.5 mo 6 NR / 22 Fair

AIMS2 ≈ NR NR NR 2 mo 24 NR / 6 Good

-36 NR ≈ ≈ NR 1.5 mo 6 30 / 24 Fair

MS2 NR NR ≈ NR 2 mo + booster @ 

4 mo

9 18 / 9 Fair

function) Unclear NR NR NR 1 mo 4 NR / 31 Fair

isability) NR ≈ NR NR 4 mo 6 NA / 16 Fairisability) NR + NR NR 1.5 mo 6 NR / 17 Poor

/ QALY ≈ ≈ ≈ NR 1.5 mo 6 30 / 24 Fair

AIMS2 ≈ ≈ ≈ NR 1.25 mo+ booster @ 

3, 6, 9 mo

8 26 / 17 Fair

 AIMS ≈ ≈ NR ≈ 1.25 mo 5 54 / 24 Poor

asures

 max + NR NR NR 2 mo 24 NR / 6 Good

visits ≈ NR ≈ NR 1.5 mo 6 25 / 22 Fairvisits NR ≈ NR NR 1.5 mo 6 NR / 22 Fair
22

tion for the Management

Evidence-based Synthesis Program

come Findings by time period* GV duration # Sessions % Participation†/ 

% Loss to follow-up‡

Study quality 

0-3 mo 4-6 mo 7-12 mo 13+ mo

visits NR NR ≈ NR 1.5 mo 6 30 / 24 Fairvisits NR ≈ NR NR 4 mo 6 NA / 16 Fairvisits NR + NR NR 1.5 mo 6 NR / 17 Poor

atient visits NR ≈ ≈ NR 1.5 mo 6 30 / 24 Fair

s efficacy) + NR NR NR 2.75 mo 22 55 / 23 Fair

ES NR NR NR + 1.75 mo + booster @ 

3 mo

8 NA / 15 Good

MS2 ≈ NR NR NR 2.75 mo 22 55 / 23 Fair

-36 NR NR NR ≈ 1.75 mo + booster @ 

3 mo

8 NA / 15 Good

asures

ual task) ≈ NR NR NR 2.75 mo 22 55 / 23 Fair

events NR NR NR + 1.75 mo + booster @ 

3 mo

8 NA / 15 Good

events Unclear NR NR NR 1 day 1 NR / NR Poorevents NR NR ≈ NR 6 mo 6 88 / 5 Fair

UG NR NR + NR

ficance (p<0.05), as follows: ≈ denotes no difference between arms; + denotes in favor of the GV arm; - denotes in favor of the C arm; NR = 

ollment among those invited to participate.

p among those randomized. 
23

tion for the Management

Evidence-based Synthesis Program

from head-to-head group visit interventions and group vs. individual visit interventions for arthritis or falls

m 1 Arm 2 % Participation*/ 

% Loss to follow-up†

Study quality

(Good/ Fair/ Poor)

Key findings

E sessions) GV2 (1 DE session) 15 / 24 Good Beneficial effect of cognitive behavior therapy relative to 

didactic-only single session GV assessed at 4.5 months 

E sessions) GV2 aerobic exercise 

(36 classes)

53 / 17 Fair Beneficial effect of either exercise group vs. education 

group on pain, disability, and functional performance. Dose response for patients who completed more sessions of either exercise program.

E sessions) GV3 resistance 

exercise (36 classes)

E sessions) GV2 (4 DE sessions) 94 / 23 Fair Cognitive-behavioral education program did not 

significantly improve pain or self-efficacy for patients newly diagnosed with RA. 

ME, EE 

ons)

GV2 (5 DE, EE 

sessions)

46 / 37 Fair GV1 was effective in improving short-term pain, 

functional disability, self-efficacy, and reducing physician visits compared to GV2. Longer-term benefits for GV1 for pain, and maintained functional ability compared to declines in GV2.

DE, group 

 sessions)

GV2 (1 DE session) NR / 35 Poor Combination of education and short-term group 

counseling led to improved knowledge and self-esteem.

E sessions) Mailed individual 

program

84 / 32 Good Both programs show moderate improvements in selfefficacy, pain, and disability outcomes. Earlier advantages 

of mailed program narrowed after 3 yrs. GV program had decreased physician visits compared with mailed program. 

ME, EE 

ons)

s only

GV2 (8 SME, EE 

sessions)

Patients and 

significant others

26 / 17 Fair Participation of significant others led to decreases in 

self-efficacy for coping with other symptoms compared to improvements in patients participating without their partners.

E sessions) GV2 (76 DE, exercise 

sessions)

NR / 20 Good GV2 was the most effective in improving function and 

pain when costs were not considered. GV1 was the most cost-effective for reducing weight; GV2 was the most cost-effective for improving function. 

E sessions) GV3 (3 DE sessions)

 EE, aquatic 

classes)

GV2 (22 EE, aquatic 

exercise classes)

55 / 23 Fair Combination of aquatic exercise and education resulted 

in improvements in functional performance vs. aquatic exercise alone.

 DE) Individual (1 DE) NR / NR Poor Small study. Control group experienced the most falls in 

the post period.

ollment among those invited to participate.

p among those randomized. 
24

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

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 (Table 4).48-52 The group interventions involved 

didactic education in four studies49-52 and self-management education in one study.48 Decreased 

utilization was observed in two studies,48,51 and improvements in quality of life measures were 

noted in two studies.48,49 The studies were limited by selection bias and other methodological 

issues, however, and study quality was fair to poor.

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

Ireland,53 the UK,54 the Netherlands,55 France,56 and a VA Medical Center in the US.57 Three 

studies compared didactic education combined with exercise training to DE alone54,55 or to usual 

care.56 Two other studies examined the effects of SME compared with DE,57 usual care,53 or 

individual support.53 The group education sessions were held weekly or biweekly for four to 

eight weeks, and two studies with exercise components continued the exercise sessions monthly 

for up to a year (Table 4).54,55 Better exercise capacity was observed in the studies that combined 

exercise training with DE, as compared with usual care56 or with DE alone (Tables 5 and 6).54,55

One of these was a small, good-quality study that also found the intervention improved the 

symptom subscale of the St. George’s Respiratory Questionnaire but not activity level.56 In 

a smoking cessation intervention study, five weeks of SME group sessions had no effect on 

smoking cessation at 12 months, compared with usual care.53 A study comparing DE group visits 

with cognitive-behavioral therapy SME group visits among US Veterans with COPD found that 

both types of group visits significantly improved QOL, anxiety, depression, and 6MWD, with no 

significant differences between groups.57

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. 
25

tion for the Management

Evidence-based Synthesis Program

up visit interventions focusing on education for the management of asthma or COPD

size

g

m 

if 

ble

Demographics:

Mean age

% male

% minority

Mean disease 

duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

NR 4 weekly sessions

1 month6-8 patients

SME 1 leader

Nurse educator

3 comparators: 1) individual education2) usual care with workbook3) usual care with no supplemental education

 

nt 

Mean age 45.640% maleRace NRDuration NR

3 weekly sessions3 weeksUp to 13 patients

DE 1 leader

Nurse educator

Usual care

Mean age 4046% maleRace NRDuration NR

4 weekly sessions4 weeks10-12 patients

DE 2 leaders

Asthma educators

Usual care

Mean age 3834% male67% non-whiteDuration NR

3 sessionsDuration NR6-10 patients

DE 1 leader

Nurse educator

Usual care

s

Mean age 2845% maleRace NRDuration NR

2 sessions, NOSDuration NR8-12 patients

DE 1 leader

Respiratory therapist

Usual care

Mean age 6148% maleRace NRDuration NRCurrent smokers

5 weekly sessions5 weeks totalN per session NR

SME 1 leader

Respiratory Nurse Specialist

Usual care (n=35), Individual support (n=27)
26

tion for the Management

Evidence-based Synthesis Program

size

g

m 

if 

ble

Demographics:

Mean age

% male

% minority

Mean disease 

duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

Mean age 6696% male16% Black3% Hispanic

8 weekly sessions8 weeksUp to 10 patients

SME: CBT 1 leader

Psychology intern or post-doctoral fellow with CBT experience

DE group education

Mean age 6951% maleRace NRDuration NR

16 DE bi-weekly sessions, 8 weeks total (both groups), followed by 10 EE monthly sessions, 1 year total (exercise group only)N per session NR

DE + EE: exercise NR DE group education

s

ve

Mean age 6358% maleRace NRDuration NR35% smokers

DE: 4 weekly sessions/1 month total; 5 patientsEE: 2-3 times/week, 11 months total; 2-3 patients

DE + EE: exercise 2 leaders

Respiratory nursePhysiotherapist

DE group education

Mean age 6384% maleRace NRDuration NR26% smokers

8 sessions, 2x week4 weeks total

DE + EE: exercise 2 leaders

DE led by health professional, EE led by exercise trainer

Usual care
27

tion for the Management

Evidence-based Synthesis Program

ntions comparing group visits to usual care control for the management of Asthma or COPD, stratified by clinical area

Outcome Findings by time period* GV duration #visits % Participation†/ 

% Loss to follow-up‡

Study 

0-3 mo 4-6 mo 7-12 mo 13+ mo quality

hma Attitudes and 

iefs Questionnaire

NR ≈ NR NR 3 weeks 3 71 / 38 Poor

AQLQ + ≈ NR NR 3 weeks 3 71 / 38 Poor

thma bother scale NR NR + NR 3-4 months 4 56 / 14 Fair

Acute visits NR NR ≈ + 1 month 4 56 / 14 Fair

ER visits NR + ≈ NR NR 3 45 / 7 Fair

moking cessation NR NR ≈ NR 5 weeks 5 60 / NR Fair

SGRQ NR NR ≈§ NR 4 weeks 8 NA / 16 Good

asures

6MWD ≈ NR ≈ NR 8 weeks 8 19 / 55 Good6MWD NR NR + NR 4 weeks 8 NA / 16 Good

ays in hospital for 

COPD admission

NR NR ≈ NR 4 weeks 8 NA / 16 Good

ficance (p<0.05), as follows: ≈ denotes no difference between arms; + denotes in favor of the GV arm; - denotes in favor of the C arm; NR = 

ollment among those invited to participate.

p among those randomized. 

al SGRQ score in GV compared with usual control, but the difference did not reach statistical significance (p=0.06). There was a significantly 

mptom subscale associated with GV, but no significant differences in the Activity or Impacts subscales. 
28

tion for the Management

Evidence-based Synthesis Program

from head-to-head group visit interventions and group vs. individual visit interventions for the management of asthma or

1 Arm 2 % Participation†/ 

% Loss to followup‡

Study quality

(Good/ Fair/ Poor)

Key findings

sessions) IV (3-5 weekly SME 

sessions)

56 / 14 Fair No significant differences between GV and IV. GV and 

IV were equally effective compared with UC. Reduced bother and improved MDI technique observed with both small group and individual education.

+ 26 EE 

xercise)

GV (16 DE sessions) NR / 16 Fair Compared with DE alone, pts in exercise group had 

improved exercise capacity (shuttle walking distance) that lasted 6 months. For QoL (CRQ, SGRQ) there were mixed results at 6 months, and no differences between groups at 1 year. 

up to 120 

ons)

GV (4 DE sessions) 41 / 11 Fair COPE-active group experienced an improvement in 

maximal exercise capacity compared to the steady decline in the control group.

essions) GV (8 SME sessions: 

CBT)

19 / 55 Good CBT and COPD education groups were comparable and 

significantly improved QoL, anxiety, depression, and 6MWD, with no significant differences between groups, and improvement was maintained till the end of the study (52 weeks).
29

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

Hypertension, CHF, CAD

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

patients with CHF or CAD,58,59 and one good-quality study published in two reports27,60 (Table 7). 

One study compared cardiac education lectures with usual care in US Veterans with moderately 

severe CHF, and found no difference in quality of life after 15 weeks of DE sessions.59 A study 

conducted in a non-Veteran US population used cognitive-behavioral change counseling to 

increase exercise maintenance in patients with MI, CABG or angioplasty, and found that subjects 

in the usual care group were significantly more likely to stop exercising in the year following 

completion of a cardiac rehabilitation program compared with subjects in the intervention group, 

although standardized self-efficacy measures indicated no differences between groups (Table 

8).58 The study conducted in the Netherlands27,60 used the Chronic Disease Self-Management 

Program (CDSMP) developed by Lorig and colleagues for the management of multiple chronic 

diseases.61 The CDSMP was associated with short-term improvements in cognitive symptom 

management, self-care behavior, and cardiac-specific QOL among patients with CHF in the 

Netherlands, but no long-term effects were found.27,60

Seven studies examined the effects of group visits on blood pressure in patients with 

hypertension.26,62-67 The studies were conducted in a range of international settings, and study 

quality varied widely (Table 7). Three studies used SME techniques26,63,66 and three studies 

used DE62-64,67 in comparison with usual care or an informational control. One trial compared 

SME directly with DE.65 Reductions in blood pressure measurements were noted in all three 

SME studies26,63,66 and in one DE study.62 In the trial comparing SME directly with DE, there 

were no significant reductions in SBP or DBP found in either group at three months. However, 

significantly more SME patients had controlled BP, defined as the proportion of patients with 

mean 24-h BP <140/90 mm Hg, compared with DE (70% vs 44%, p=0.04). 

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. 
30

tion for the Management

Evidence-based Synthesis Program

up visit interventions focusing on education for the management of congestive heart failure, coronary artery disease, or 

ize

g

ame, 

ble

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

her

Mean age 67 73% male Race NR Duration NR

6 weekly sessions 6 weeks total 6-12 patients

SME 2 leaders 

Cardiac nurse specialist CHF patient peer leader

Usual care

Mean age 69 % male NR 17% non-white Duration NR

15 weekly sessions 15 weeks total Group size NR

DE Experts on medical, pharmaceutical, lifestyle, nutrition, 

and psychosocial issues 

Usual care

Mean age 62 17% black 2% non-white, NOS Duration NR

5 sessions: 3 weekly followed by 2 monthly 3 months total 6-8 patients

SME 1 leader 

Cardiac nurse

Usual care

Mean age 57.939% maleRace NRDuration 6.77 yr

Frequency NR2 months totalGroup size NR

DE + EE 1 leader

Health education researcher

Usual care

Mean age 55 10% black 16% Mexican-American Duration NR

8 weekly sessions 8 weeks total Group size NR

DE 2 leaders 

Nurse, psychologist

Informational control (audiotape)

Mean age 61 40% male Race NR Duration NR

3 sessions 8 weeks total 6-7 patients Duration NR

SME 1 leader 

Nurse

Usual care

Mean age 53 21% male 100% Mexican-American, 87% born in Mexico Duration NR

4 sessions at weeks 1, 2, 3, 8 8 weeks total 15-20 patients

DE 2 leaders 

Promotoras (MexicanAmerican community health workers)

Informational control
31

tion for the Management

Evidence-based Synthesis Program

ize

g

ame, 

ble

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

Mean age 69 57% male Duration NR

4 weekly sessions 4 weeks 10 patients

SME Physicians with experience in 

HTN education/management

DE

Mean age 62 42% male Race NR Duration NR

3 sessions 4 months total 4-5 patients

SME 1 leader

Moderator, tutor assistants

Informational control

Mean age 60.5 39% male 37% black 1% Hispanic Duration NR

20 weekly sessions 6 months total 10-15 patients

SME 2 leaders 

Behavioral interventionist, assistants (community health advisors)

Usual care
32

tion for the Management

Evidence-based Synthesis Program

ntions comparing group visits to usual care control for the management of CHF/CHD/Hypertension, stratified by clinical

Outcome Findings by time period* GV duration Visits % Participation†/ % Loss to follow-up‡ Study 0-3 mo 4-6 mo 7-12 mo 13+ mo quality

GSES ≈ ≈ ≈ NR 6 weeks 6 44 / 16 Good

 self-efficacy: KCCQ ≈ ≈ ≈ NR

tive Symptom Scale + ≈ ≈ NR

f-Regulation; Exercise Bar

herence Self-Efficacy Scale ≈ NR NR ≈ 3 months 5 50 / 19 Fair

diac-specific QOL + ≈ ≈ NR 6 weeks 6 44 / 16 Good

HADS - Anxiety ≈ ≈ ≈ NR

ADS - Depression ≈ ≈ ≈ NR

Living with Heart Failure 

Questionnaire

NR ≈ NR NR 15 weeks 15 17 / 13 Fair

iophysical: BMI ≈ ≈ ≈ NR 6 weeks 6 44 / 16 Good

SBP and DBP + + NR NR 8 weeks 4 36 / 0 PoorSBP and DBP + NR NR NR 8 weeks 3 70 / 12 Poor

& Waist circumference ≈ NR NR NR 8 weeks 4 NR / 0 Poor

SBP and DBP NR NR NR + 4 months 3 NR / 42 PoorSBP and DBP NR + NR ≈ 6 months 20 56 / 12 Good

rom head-to-head group visit interventions and group vs. individual visit interventions for the management of hypertension

1 Arm 2 % Participation /

% Attrition

Study quality Key findings

essions) GV (4 DE sessions) NR / 17 Good More SME patients had controlled BP (defined as the proportion of 

patients with mean 24-h BP <140/90 mm Hg) compared with DE: 70% vs 44%, p=0.04. No significant reductions in SBP or DBP in either group. 
33

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

Diabetes Mellitus

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

(Table10). We conducted meta-analyses of the 17 studies comparing the effects of a group visit 

intervention to usual care on HbA1c (Figures 3-6). Overall, in 14 studies, group visit interventions

reduced HbA1c slightly more over six months of follow-up than usual care, though there was

significant heterogeneity which should temper confidence in these results (Figure 3, mean 

difference HbA1c -0.27%; 95% CI -0.44 to -0.11; I2

=67.1%). 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 (mean difference HbA1c 0.02; 95% CI -0.14 to 0.17; I2

=0.0%). Group 

visit interventions lasting more than three months appeared to have a more pronounced effect 

on HbA1c improvement than those of shorter duration (-0.49% vs -0.20%), but the quality of 

these longer duration intervention studies was also lower (Figure 4). We found similar effects 

on HbA1c at 7 to 12 months in the 10 studies with longer-term follow-up (Figures 5 and 6). 

Funnel plot analyses showed no evidence of publication bias for 6 month outcomes (Egger bias 

coefficient=-1.62, 95% CI [-3.73 to 0.48]), but some evidence of publication bias for 12 month 

outcomes (Egger bias coefficient=-2.14, 95% CI [-3.62 to -0.66]). Multivariate meta-regression 

models showed that none of the covariates examined—duration of the group visit intervention, 

study quality, or year of publication—were independently associated with changes in HbA1c. 

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

studies finding positive effects beyond six months of follow-up (Table 11). 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.19,30,68,69

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 (Table 11). One 

large, good-quality cluster-randomized trial in patients with newly diagnosed diabetes compared 

a six-hour self-management skills program to a control group which received equal contact 

time but no self-management training. Though the intervention was associated with sustained 

improvements in illness beliefs, there was no detectable effect on quality of life, depression or 

biomedical outcomes over the long-term.68,70 Few studies reported or were powered to evaluate 

utilization outcomes. 

Eleven studies compared a group visit intervention to one or more active interventions (Table 

12). 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.14,71,72

Two studies compared group to individual education: one was a small good-quality trial which 

found individual education was associated with better outcomes,73 while the other was a poorquality study showing similar effects of group and individual education.74 One fair-quality study 

found that an automated telephone-based self-management intervention performed similarly to 

an in-person group self-management skills intervention.30
34

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

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. 
35

tion for the Management

Evidence-based Synthesis Program

oup visit interventions focusing on education for the management of diabetes mellitus

tion:

ng

am 

, if 

able

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

63.1 yrs54% Minority NR6.6 yrs with DM 

4 (2.5h) sessions 1 booster (2.5h) within 7 months5-8 patients

DE 7 physicians and 12 diabetes specialist nurses Usual care 

61 yrs18% 96% minority8.5 yrs with DM

6 weekly (2h) sessions1.5 monthsGroup size NR

SME Certified diabetes educators Usual care

r 

order 

nitia

54 yrs36 % Race NR 7.85 yrs with DM

12 weekly, 12 biweekly, 3 monthly (2h) sessions12 monthsGroup size NR

DE, EE Bilingual Mexican 

American nurses, dietitians, local community workers 

Usual care

r 

order 

nitia

49.6 yrs40% Race NR5.1 yrs with DM

GV1:3 weekly, 12 biweekly, 3 monthly (2h) sessions12 monthsGroup size NRGV2:8 weekly (2h) sessions 3 support @ 3, 6, and 12 months8 patients

DE, EE Bilingual Mexican 

American nurses, dietitians, local community workers 

GV2

67.4 yrs 70.1% Minority NR 64.5% diagnosed <5 yr

3 (1.5h) sessions every 3wks3 monthsGroup size NR

SME Clinical psychologist Usual care; 

individual visit arm: 3 (15min ) visits with similar content to GV 
36

tion for the Management

Evidence-based Synthesis Program

tion:

ng

am 

, if 

able

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

61.6 yrsGender NRRace NR6.7 yrs with DM

6 weekly (2h) sessions1.5 months16 patients (mean) 

SME 1 diabetes research dietitian/ educator Usual care+: diabetes education and review 

with individual appointments with a dietitian (30 min), practice nurse (15 min) and physician (10 min)

76% aged 60+ 48% Race NR Duration NR

1 session7 patients

DE Diabetes nurse educator Usual care

63 yrs54%Race NRAll diagnosed ≤ 2yrs

10 (2h) sessions over 9 mo9 months5-8 patients

SME Diabetes nurses Usual care

ND

59.5 yrs 55% male6% minorityDuration NR

1 (6h) session 1 day or 2 half-daysGroup size NR

SME Healthcare professional Usual care+: 

(resources to provide equivalent contact time as intervention)

Mean age 55.650.3% maleRace NRMean duration 6.6 yrs

GV1: 4 DE sessions GV2: 12 SME sessions GV3: 6 SME sessions + 6 IV Duration NR Group size 6-10

GV1: DE

GV2: SME

Health psychologist Self-management 

education - 6 90 min group lessons and 6 90 min individual lessons

66.55 yrs35.7% 32.7% minorityDuration NR

6 weekly (2.5h) sessions1.5 months 10-15 patients

SME Peer leaders Usual care

58 yrs20%100% Mexican originDuration NR

8 weekly (2h) sessions2 months6 patients (English class)23 patients (Spanish class)

DE 2 leaders

Promotoras, nurses, dietitians, social workers 

Usual care (2 pamphlets)
37

tion for the Management

Evidence-based Synthesis Program

tion:

ng

am 

, if 

able

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

46 yrs0% 100% minorityDuration NR

11 weekly (1-2h) sessions 3 months Group size NR

SME Nurse practitioner Culturally neutral 

group DE (10 weekly sessions) 

72.5 yrs47%17% black7.2 yrs

GV1:10 weekly (1.5-2h) sessions2.5 monthsGroup size NRGV2:Offered 6 (2h) sessionsGroup size NR

GV1: DE, EE

GV2: DE

Dietitian GV2

(participants were mailed printed material if they did not attend the group session)

Dulce

50.7 years29% maleMinority NRDuration NR 

8 weekly (2h) sessions 8 monthly support groups 10 monthsGroup size NR

DE Trained peer educator Usual care

Mean age 60 yrs 99% male Race NR Duration NR

4 daily sessions4 sequential days 4-6 patients

DE Physician, nurse, 

nutritionist, pharmacist, exercise physiologist, social worker, and diabetes educator 

2 comparators: passive education and nointervention

Mean age 52.5 34% male Race 7% non-white?Duration 0.9 yrs

4 sessions (at 0, 2 wks, 3 mo, 6 mo) 6 months total

DE A diabetes nurse specialist (RN) and diabetes 

nutrition specialist (RD) 

Individual education sessions

n 

83.7% aged 45+23.4% 87.7% minority 31.3% diagnosed <5 yr

12 weekly + 8 monthly First session (1h) individual Remaining (2.5h) group11 months Group size NR

SME, EE Nutritionist or health 

educator and lay leader or 3 supervised lay leaders

Usual care

66 yrs55%0%5 yrs with DM

3 biweekly (5h) sessions1.25 months8-10 patients

DE, EE Diabetes nurses; also 

included physician, physiotherapist, nutritionist, and lay person

Usual care
38

tion for the Management

Evidence-based Synthesis Program

tion:

ng

am 

, if 

able

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

Mean age 66% male NRRace NR Duration 5.9 yrs treatment; 2.6 yrs control

12 monthly sessions 1 year total Group size NR

DE Pharmacists trained to be 

facilitators, and a nurse specialist

Usual care

59 yrs47%9.4% black10.5 yrs

4 weekly (2h) sessions1 month8-10 patients

DE NR Usual care

56.1 years41% male92.3% minorityDuration NR

9 monthly (1.5h) sessions 9 months6–10 patients 

SME 2 leaders

Physician and languageconcordant health educator

Usual care; automated telephone selfmanagement support group (39 weekly, automated calls over 9 months, nurse phone follow-up)

67.05 yrs35% Minority NR14 yrs with DM

4 (70min) sessions 1 month Group size NR

DE Physician, specialist 

of endocrine disorder, diabetes nurse, and nutritionist

Usual care

Mean age 61.8 50.6% male 22.1% Hispanic 5.5% Black Duration 11.7 yrs

4 weekly sessions4 weeks total 1-10 patients (mean 5)

DE Nurses and dietitians 

trained to facilitate GE sessions

3 individual education sessions at 1-month intervals

MP

59.8 yrs71.2% male 51% minority10.8 years

5 weekly (2.5h) sessions 1 booster (2.5h) @ 3 months 1.25 monthsGroup size NR

SME Diabetes specialist 

nurses and dietitians

Usual care

Mean age 57.4 58.3% male 8.3% Black 1% Asian

5 weekly sessions5 weeks totalGroup size NR

EE NR DE group visits
39

tion for the Management

Evidence-based Synthesis Program

tion:

ng

am 

, if 

able

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

en!

57.11 yrs0 %100% minority10.4 yrs with DM

2.5-day retreat + 36 weekly and biweekly sessions12 monthsGroup size NR

DE, EE Bilingual physician, 

dietitian, exercise instructor, bilingual facilitator

Usual care

52.5 yrs49.5%10.3% minority17.2 yrs with DM

5 (2h) sessions over 6 wks1.5 monthsGroup size NR

SME Certified diabetes 

educator

Unlimited access to individual DM nurse and dietitian visits 

Mean age 62 yrs 36% male

12 monthly sessions 1 year total 18 patients

DE Clinical dietitian All subjects 

received 4-wk group education. Controls received usual care with no further group education.
40

tion for the Management

Evidence-based Synthesis Program

entions reporting standardized or validated measures that compare group visits to usual care in the management of 

tcome Findings by time period* GV duration # Sessions % Participation†/ 

% Loss to follow-up‡

Study quality 

0-3 mo 4-6 mo 7-12 mo 13+ mo (Good/ Fair/ Poor)

ecific health 

le (control)

≈ NR ≈ NR 12 months 27 NR / NR Poor

 specific 

onnaire

NR NR ≈ NR 7 months (max) 5 53 / 13 Fair

Q-R + + + + 1 day or 2 half-days 1 NA / 11 Good

AM NR + NR NR 1.5 months 6 NA / 15 Fair

Self-Efficacy 

cale

NR + NR NR

HBM ≈ +§ NR NR 2 months 8 NR / 6 Fair

ecific scale 

ysical activity 

ange)

NR + + NR 11 months 19 57 / 16 Fair

AM NR ≈ ≈ NR 1.25 months 3 91 / 9 Fair

QIP NR NR + NR 9 months 9 73 / 10 Fair

 (total) ≈ NR NR NR 1.25 months + 

booster @ 3 months

6 51 / 16 Poor

OCSC NR + + NR 12 months 37 61 / 22 Fair

WHO QOL NR NR ≈ NR 7 months (max) 5 53 / 13 Fair

OL-BREF NR NR NR ≈ 1 day or 2 half-days 1 NA / 11 Good

ADS ≈ ≈ + ≈

depression) NR + NR NR 1.5 months 6 NA / 15 Fair

physical) NR ≈ ≈ NR 1.25 months 3 91 / 9 Fair

(mental) NR ≈ ≈ NR

Q-5D NR ≈ ≈ NR

physical) NR NR ≈ NR 9 months 9 73 / 10 Fair

(mental) NR NR ≈ NR

DQOL + NR NR NR 1.25 months + 

booster @ 3 months

6 51 / 16 Poor

F-36 ≈ NR NR NR

althy Days 

ysical)

NR ≈ ≈ NR 12 months 37 61 / 22 Fair

althy Days 

ental)

NR ≈ ≈ NR
41

tion for the Management

Evidence-based Synthesis Program

tcome Findings by time period* GV duration # Sessions % Participation†/ 

% Loss to follow-up‡

Study quality 

0-3 mo 4-6 mo 7-12 mo 13+ mo (Good/ Fair/ Poor)

asures‖

ood pressure NR ≈ NR NR 1 day 1 13 / 55 Poor

MD visits NR ≈ NR NR 1 day 1 13 / 55 Poor

 visits NR ≈ NR NR 1.5 months 6 NA / 15 Fair

 visits NR ≈ NR NR

ospitalized NR ≈ NR NR

an visits NR ≈ ≈ NR 1.25 months 3 91 / 9 Fair

ficance p<0.05: ≈ indicates no difference between arms; + indicates in favor of the GV arm; - indicates in favor of the C arm; NR = not 

ollment among those invited to participate.

p among those randomized. 

utcome change with the intervention group experiencing less of a decline.

uded for meta-analysis of mean change in HbA1c did not report quality of life, self-efficacy, or utilization outcomes.17,18,79,82,83 As a result, these 

11. 
42

tion for the Management

Evidence-based Synthesis Program

from head-to-head group visit interventions and group vs. individual visit interventions for the management of diabetes mellitus

Arm 2 % Participation1/

% Loss to followup2

Study quality

(Good/ Fair/ 

Poor)

Key findings

E) Individual (3 DE) 20 / 32 Fair Significant improvements with group compared with individual 

visits in glycemic control, total cholesterol level, body weight, BMI and waist circumference, reduced requirement for diabetes medication, increased consumption of fruit and vegetables, enjoyment of food, knowledge of diabetes, self-empowerment, self-management skills and treatment satisfaction.

E) Individual (3 SME) 78 / 5 Good No improvement in biophysical health outcomes for patients 

in the GV arm compared to individual visit arm. Individual visit participants showed significant improvements in waist circumference, FBG, HbA1c, and total cholesterol compared to control arm.

E) GV2 (12 SME) 

GV3 (6 Group + 6 

individual SME)

50 / 6 Fair GV2 (SME) had significantly lower HbA1c at 15 months 

compared with both GV1 (DE) and GV3 (group + individual SME). GV2 (SME) also had significant improvements in BMI, anxiety, and exercise relative to GV1 (DE).

lly 

ME)

GV2 

(10 culturally neutral 

DE)

NA / 11 Fair Both arms had significant, similar reductions in HbA1c at 24 

months. The culturally relevant SME group had significantly lower levels of diabetes-related emotional distress at 24 months compared with the culturally neutral DE group.

E)

GV2 

(6 DE, or mailed 

materials)

NA / 6 Fair Intense nutrition education GV improved glycemic control

E) Individual (4 DE) NR / 46 Poor Individual and group education resulted in similar improvements 

at 6 months in HbA1c, weight, BMI, health-related QOL, attitudes, and medication regimen. 

E) ATSM: automated 

telephone selfmanagement 

(39 SME calls)

73 / 10 Fair No statistical differences between GV and ATSM arms in selfefficacy, or quality of life (physical). Improvement for ATSM 

relative to GV in quality of life (mental).

E) Individual (3 DE);

Usual care

82 / 2 Fair HbA1c deceased significantly more with individual DE compared 

with group DE and usual care. Individual DE significantly reduced distress (PAID) and increased self-efficacy compared with group DE.
43

tion for the Management

Evidence-based Synthesis Program

Arm 2 % Participation1/

% Loss to followup2

Study quality

(Good/ Fair/ 

Poor)

Key findings

E) GV2 (5 DE + EE) NA / 24 Poor At 1-year follow-up, patients who received training in stress 

management in addition to DE had a 0.5% reduction in HbA1c relative to DE alone. No differences between groups in anxiety (STAI) or psychological distress (GHQ; PSS) measures. 

E) Individual DE 

(unlimited access to 

DM nurse and dietitian 

visits)

89 / 3 Fair GV (SME) had significantly greater reduction in HbA1c levels 

over 1 year compared with individual DE. No differences in QOL, and self-efficacy measures.

 + 

)

GV2 (4wk DE) 100 / 0 Poor All subjects received 4-wk group education. GV2 received usual 

care with no further group education. Significant reductions in HbA1c and body weight over 1 year in GV1 (12-month continuation DE) compared with GV2. 

ligible/#invited 

mized
44

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

Figure 3. Effect of group visits compared to usual care on HbA1C at ≤6 month follow-up, by study

quality

49 

Overall (I-squared = 67.1%, p = 0.000)

Study

Miller, 2002

Steed, 2005

Lujan, 2007

Good

Lorig, 2009

Rosal, 2011

Khunti, 2012

Subtotal (I-squared = 66.2%, p = 0.007)

Toobert, 2011a

Scain, 2009

De Greef, 2011

Rygg, 2012

Philis-Tsimikas, 2011

Anderson, 2005

Fair

Subtotal (I-squared = 0.0%, p = 0.975)

Poor

Subtotal (I-squared = 63.2%, p = 0.028)

Sharifirad, 2012

-0.27 (-0.44, -0.11)

Mean

-0.50 (-0.78, -0.22)

-0.37 (-0.98, 0.24)

-0.75 (-1.20, -0.30)

0.06 (-0.18, 0.31)

-0.53 (-0.92, -0.14)

-1.42 (-2.27, -0.57)

0.02 (-0.14, 0.18)

-0.35 (-0.57, -0.12)

-0.40 (-0.83, 0.03)

-0.40 (-0.87, 0.07)

0.01 (-0.60, 0.62)

-0.10 (-0.40, 0.20)

-0.10 (-0.72, 0.52)

0.21 (-0.31, 0.73)

0.02 (-0.14, 0.17)

-0.32 (-0.69, 0.05)

-0.32 (-0.51, -0.13)

difference (95% CI)

-0.27 (-0.44, -0.11)

-0.50 (-0.78, -0.22)

-0.37 (-0.98, 0.24)

-0.75 (-1.20, -0.30)

0.06 (-0.18, 0.31)

-0.53 (-0.92, -0.14)

-1.42 (-2.27, -0.57)

0.02 (-0.14, 0.18)

-0.35 (-0.57, -0.12)

-0.40 (-0.83, 0.03)

-0.40 (-0.87, 0.07)

0.01 (-0.60, 0.62)

-0.10 (-0.40, 0.20)

-0.10 (-0.72, 0.52)

0.21 (-0.31, 0.73)

0.02 (-0.14, 0.17)

-0.32 (-0.69, 0.05)

-0.32 (-0.51, -0.13)

difference (95% CI)

-2 -1.5 -1 -.5 0 .5 1

Favors treatment Favors control 
45

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

Figure 4. Effect of group visits on HbA1C compared to usual care at ≤6 month follow-up, by

duration of intervention

50 

 

Overall (I-squared = 67.1%, p = 0.000)

Steed, 2005

Sharifirad, 2012

Scain, 2009

Lorig, 2009

Khunti, 2012

Rygg, 2012

Group sessions <= 3 months

Lujan, 2007

Miller, 2002

Rosal, 2011

De Greef, 2011

Anderson, 2005

Group sessions >3 months

Toobert, 2011a

Brown, 2002

Study

Subtotal (I-squared = 38.4%, p = 0.165)

Subtotal (I-squared = 70.0%, p = 0.001)

Philis-Tsimikas, 2011

Poor

Poor

Fair

Fair

Good

Fair

Fair

Fair

Fair

Good

Poor

Fair

Poor

Quality

Poor

-0.27 (-0.44, -0.11)

-0.37 (-0.98, 0.24)

-0.32 (-0.51, -0.13)

-0.40 (-0.87, 0.07)

0.06 (-0.18, 0.31)

0.02 (-0.14, 0.18)

-0.10 (-0.40, 0.20)

-0.75 (-1.20, -0.30)

-0.50 (-0.78, -0.22)

-0.53 (-0.92, -0.14)

0.01 (-0.60, 0.62)

0.21 (-0.31, 0.73)

-0.40 (-0.83, 0.03)

-1.42 (-2.27, -0.57)

Mean

difference (95% CI)

-0.49 (-0.80, -0.18)

-0.20 (-0.38, -0.01)

-0.10 (-0.72, 0.52)

-0.27 (-0.44, -0.11)

-0.37 (-0.98, 0.24)

-0.32 (-0.51, -0.13)

-0.40 (-0.87, 0.07)

0.06 (-0.18, 0.31)

0.02 (-0.14, 0.18)

-0.10 (-0.40, 0.20)

-0.75 (-1.20, -0.30)

-0.50 (-0.78, -0.22)

-0.53 (-0.92, -0.14)

0.01 (-0.60, 0.62)

0.21 (-0.31, 0.73)

-0.40 (-0.83, 0.03)

-1.42 (-2.27, -0.57)

difference (95% CI)

-0.49 (-0.80, -0.18)

-0.20 (-0.38, -0.01)

-0.10 (-0.72, 0.52)

-2 -1.5 -1 -.5 0 .5 1

Favors treatment Favors control 
46

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

Figure 5. Effect of group visits compared to usual care on HbA1C at 7-12 month follow-up, 

by study quality

51 

Overall (I-squared = 56.9%, p = 0.013)

Scain, 2009 

Hornsten, 2008

Subtotal (I-squared = 0.0%,

p = 0.698)

Khunti, 2012

Toobert, 2011

A. Philis-Tsimikas, 2011 

Subtotal (I-squared = 37.6%, p = 0.141)

Rosal, 2011

Schillinger, 2009

Poor

Adolfsson, 2007

Fair

Subtotal (I-squared = .%, p = .)

Rygg, 2012 

S. A. Brown, 2002 

Good

Study

-0.23 (-0.44, -0.02)

difference (95% CI)

-0.40 (-0.92, 0.12)

-0.94 (-1.60, -0.28)

-0.71 (-1.18, -0.24)

0.05 (-0.10, 0.20)

0.00 (-0.48, 0.48)

-0.60 (-1.34, 0.14)

-0.20 (-0.43, 0.02)

-0.25 (-0.72, 0.22)

0.20 (-0.25, 0.65)

-0.30 (-0.80, 0.20)

0.05 (-0.10, 0.20)

-0.10 (-0.45, 0.25)

-0.79 (-1.40, -0.18)

Mean 

-0.23 (-0.44, -0.02)

difference (95% CI)

-0.40 (-0.92, 0.12)

-0.94 (-1.60, -0.28)

-0.71 (-1.18, -0.24)

0.05 (-0.10, 0.20)

0.00 (-0.48, 0.48)

-0.60 (-1.34, 0.14)

-0.20 (-0.43, 0.02)

-0.25 (-0.72, 0.22)

0.20 (-0.25, 0.65)

-0.30 (-0.80, 0.20)

0.05 (-0.10, 0.20)

-0.10 (-0.45, 0.25)

-0.79 (-1.40, -0.18)

-2 -1.5 -1 -.5 0 .5 1

 Favors treatment Favors control 
47

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

Figure 6. Effect of group visits compared to usual care on HbA1C at 7-12 month follow-up, 

by duration of intervention

52 

 

Overall (I-squared = 56.9%, p = 0.013)

Schillinger, 2009

Hornsten, 2008

Subtotal (I-squared = 53.8%, p = 0.043)

Khunti, 2012

Philis-Tsimikas, 2011

Brown, 2002

Subtotal (I-squared = 33.8%, p = 0.221)

Rosal, 2011

Study

Group sessions > 3 months

Scain, 2009

Rygg, 2012

Group sessions <=3 months

Toobert, 2011

Adolfsson, 2007

Quality

Fair

Fair

Good

Poor

Poor

Fair

Fair

Fair

Fair

Fair

-0.23 (-0.44, -0.02)

difference (95% CI)

0.20 (-0.25, 0.65)

-0.94 (-1.60, -0.28)

-0.33 (-0.63, -0.03)

0.05 (-0.10, 0.20)

-0.60 (-1.34, 0.14)

-0.79 (-1.40, -0.18)

-0.05 (-0.26, 0.16)

-0.25 (-0.72, 0.22)

Mean

-0.40 (-0.92, 0.12)

-0.10 (-0.45, 0.25)

0.00 (-0.48, 0.48)

-0.30 (-0.80, 0.20)

-0.23 (-0.44, -0.02)

difference (95% CI)

0.20 (-0.25, 0.65)

-0.94 (-1.60, -0.28)

-0.33 (-0.63, -0.03)

0.05 (-0.10, 0.20)

-0.60 (-1.34, 0.14)

-0.79 (-1.40, -0.18)

-0.05 (-0.26, 0.16)

-0.25 (-0.72, 0.22)

-0.40 (-0.92, 0.12)

-0.10 (-0.45, 0.25)

0.00 (-0.48, 0.48)

-0.30 (-0.80, 0.20)

-2 -1.5 -1 -.5 0 .5 1

Favors treatment Favors control 
48

Group Visits Focusing on Education for the Management

of Chronic Conditions in Adults Evidence-based Synthesis Program

Multiple Chronic Conditions

Four studies evaluated the Chronic Disease Self-Management Program (CDSMP)61 in 

populations with various chronic conditions not limited to a particular disease group (Tables 13 

and 14).89-92 The CDSMP was designed as a workshop held in community settings such as senior 

centers, churches, libraries and hospitals. People with different chronic health problems attend 

together, meeting 2.5 hours once per week for six to seven weeks. The workshops are facilitated 

by two trained leaders, one or both of whom are non-health professionals with chronic diseases 

themselves. 

The largest study evaluated the CDSMP in multiple community-based sites in the US and found 

it was associated with improved health behaviors, including cognitive symptom management, 

reduced hospital utilization, and improved self-rated health and disability at six months.92 Of 

note, the 17 percent of patients who did not complete the study tended to have more illness 

related disability than those completing the trial, though there was no differential loss to followup between the two groups. The authors report that a full intent-to-treat analysis was conducted 

and that results were similar, but they fully report only the per-protocol analysis. Seventy-two 

percent of the wait-list control group elected to enroll in the CDSMP after the trial. A pre-post 

two-year follow-up study of all CDSMP participants found long-term reductions in ER and 

outpatient visits as well as improved self-efficacy.93 The authors estimate the cost of the program 

to be about $70 per participant (in 1999). 

A large northern California study of the Spanish-language adaptation of the CDSMP found the 

intervention improved self-efficacy in the medium- and long-term, as well as decreased ER 

visits at 4 and 12 months.91 Another large study in China found medium-term improvements on 

a cognitive symptom scale, but not in self-efficacy nor on ER visits.90 Self-efficacy scales also 

showed mixed findings, with benefits noted in some studies but not in other studies that used 

the same measures (Table 14). The Dutch study was of poor-quality and found no effect of the 

intervention on outcomes.89

Overall, the peer-led, community-based CDSMP appears to be associated with medium-term 

improvements in self-efficacy, 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. 
49

tion for the Management

Evidence-based Synthesis Program

oup visit interventions focusing on education for the management of chronic conditions in populations with 

e, 

Demographics:Mean age% male% minorityMean disease duration

GV structure:# Visits, frequencyDurationGroup size

GV content:SME (self-mgmt)DE (didactic)EE (experiential)

GV leaders:Number of leadersProfession type

Comparator

Mean age 6535% male9.7% non-whiteDuration NR (heart disease, lung disease, arthritis, and stroke)

7 weekly sessions7 weeks total10-15 patients

SME 2 trained peer leaders Usual care

Mean age 57 21% male Race NR Duration NR

6 weekly sessions 6 weeks total 10-15 patients

SME 2 trained peer leaders Usual care

Mean age 64 29% male Race NR Duration NR

7 weekly sessions 7 weeks total Group size NR

SME 2 trained peer 

volunteer leaders

Usual care

Mean age 68 37% male Race NR Duration NR

6 weekly sessions 6 weeks 10-13 patients

SME 2 psychologists or 1 

psychologist plus peer leader

Usual care

ysis. Results are reported as being similar in ITT and per-protocol analysis, but full results reporting only available for the group 
50

tion for the Management

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entions comparing group visits to usual care control for the management of chronic conditions in studies of populations 

me measure

Findings by time period*

GV intervention 

duration #visits % Participation† / % Loss Follow-up‡ Study 0-3 mo 4-6 mo 7-12 mo 13+ mo quality

e symptom 

agement

NR + NR NR 7 weeks 7 NR / 17 Fair

-efficacy scale NR + + NR 6 weeks 6 NR / 51 Fair-efficacy scale NR ≈ NR NR 7 weeks 7 NA / 13 Fair

ymptom scale NR + NR NR

16 (Dutch) ≈ ≈ NR NR 6 weeks 6 26 / 10 Poor

ymptom scale ≈ ≈ NR NR

ed health§ NR + NR NR 7 weeks 7 NR / 17 Fair

ity (HAQ) NR + NR NR

 physical and 

omponents

≈ ≈ NR NR 6 weeks 6 26 / 10 Poor

ian visits NR ≈ NR NR 7 weeks 7 NR / 17 Fair

tal stays NR + NR NR

ian visits NR ≈ ≈ NR 6 weeks 6 NR / 51 Fair

 visits NR + + NR

ital days NR ≈ ≈ NR

ian visits NR ≈ NR NR 7 weeks 7 NA / 13 Fair

 visits NR ≈ NR NR

ital days NR ≈ NR NR

ficance p<0.05: ≈ indicates no difference between arms; + indicates in favor of the GV arm; - indicates in favor of the C arm; NR = not reported. 

ollment among those invited to participate.

p among those randomized. 

measure94
51

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of Chronic Conditions in Adults Evidence-based Synthesis Program

Chronic Pain

Four studies evaluated the effects of group-based interventions compared to usual care,95,96

educational reading materials,97 or individual treatment98 in patients with chronic pain (Tables 15-

17). Providers for the group-based interventions varied, and included psychologists, physicians, 

rehabilitation specialists, nurses, physiotherapists, and physical therapists. All of the studies 

examined group interventions with self-management skills education components. The groupbased interventions ranged from 7 to 12 sessions conducted weekly or every-other-week, and 

most included approximately six patients per group. Length of follow-up for the studies was 

generally short, approximately 0 to 3 months following completion of the group; however, two 

studies evaluated some outcomes up to a year following intervention completion. Though many 

findings from the studies were not statistically significant and did not differ from the comparison, 

some results favored the group-based interventions. The studies all reported results from multiple 

outcome measures. 

Ersek and colleagues reported similar effects of a group-based intervention and educational 

reading materials on functional status and self-efficacy measures at three months.97 Gustavsson 

and colleagues (2010) reported that compared to usual individual physical therapy care, a 

group-based intervention had largely similar effects on multiple measures of pain control and 

self-efficacy, but was associated with more improvement on the Neck Disability Index and 

the Coping Strategies Questionnaire at 20 weeks of follow-up.98 The group visits intervention 

group also reported using less medication for pain at 20 weeks. One poor-quality study found 

group self-management education was associated with improved pain scores, reduction in 

psychological distress, and decreased self-reported physician visits compared to a usual care 

control group over 12 months. However, numerous methodological flaws including marked 

differences in follow-up rates between groups limit confidence in these results.28,95 Finally, a 

paper by Vlaeyen and colleagues (1996) describes two group-based interventions (only one 

including an SME component) compared to each other and to a waitlist control group.96 They 

report no significant differences between the group-based interventions at 6 and 12 month 

follow-up on almost all of the 12 outcome variables included, but report that both group-based 

conditions showed a benefit over waitlist control on about half of the outcomes (knowledge, pain 

coping, pain control, relaxation, pain behavior, and fear).

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. 
52

tion for the Management

Evidence-based Synthesis Program

oup visit interventions focusing on education for the management of chronic pain

e, 

Demographics:

Mean age

% male

% minority

Mean disease duration

GV structure:

# Visits, frequency

Duration

Group size

GV content:

SME (self-mgmt)

DE (didactic)

EE (experiential)

GV leaders:

Number of leaders

Profession type

Comparator

Age 81.9Gender 13%Race 84.71% CaucasianDuration NR

7 weekly sessions8 weeks3-8 patients

SME 2 leaders 

Doctoral-level health providers

Receipt of an educational booklet on pain

Age 45.7Gender 11%Race NRDuration NR

7 weekly sessions7 weeks + 1 booster at week 20Group size NR

SME, EE 1 leader 

Physical therapists

Individual physical therapy sessions

Age 43.08Gender 2.27%Race NRDuration 9.89 years

12 every-other-week sessions9 months (including a summer break)6-10 patients

SME 2 leaders

Nurses, physicians physiotherapists

Usual care

Age 44Gender 12%Race NRDuration 10.2 years

12 sessions6 weeksMaximum of 6 patients

GV1: SME, EEGV2: DE, EE

Rehabilitation staff, psychologist

Usual care
53

tion for the Management

Evidence-based Synthesis Program

entions comparing group visits to control for the management of chronic pain

Outcome Findings by time period* GV duration #visits % Participation†/ 

% Loss Follow-up‡

Study 

0-3 mo 4-6 mo 7-12 mo 13+ mo quality

Survey of Pain Attitudes ≈ NR NR NR 8 weeks 7 NA / 13 Fair

CSQ (pain control) + NR NR NR 20 weeks 8 84 / 20 Good

Self Efficacy Scale ≈ NR NR NR 20 weeks

Pain coping construct + NR NR NR 6 weeks 12 NR / 20 FairPain coping construct + NR NR NR

SF-36 (physical and physical 

functioning)

≈ NR NR NR 8 weeks 7 NA / 13 Fair

Graded chronic pain scale – 

activity interference

≈

VAS (pain) ≈ NR +§ NR 9 months 12 NA / 33 Poor

Neck Disability Index + NR NR NR 20 weeks 8 84 / 20 Good

Self-reported MD visits + NR +§ NR 9 months 12 NA / 33 Poor

ficance p<0.05: ≈ indicates no difference between arms; + indicates in favor of the GV arm; - indicates in favor of the C arm; NR = not reported. 

ollment among those invited to participate.

p among those randomized. 

from head-to-head group visit interventions and group vs. individual visit interventions for the management of chronic

m 1 Arm 2 Key findings

E sessions) Educational booklet on pain There was a significant improvement in physical role functioning and in pain intensity 

directly following treatment, but not 3 months after treatment, though no significant effect 

was noted for other primary outcome variables including physical functioning, activity interference, and depression.

EE, DE sessions) GV (12 DE, EE sessions) Significant improvement of knowledge, pain coping, pain control, and relaxation for both GV

groups compared to control at immediate follow-up; non-significant differences between GV groups at 6 and 12-month follow-up on all primary outcomes.

on, SME, EE) Individual physical therapy GV was positively associated with most assessed outcomes including pain coping, pain 

control, catastrophizing, pain scores, and anxiety, though effects on depression were nonsignificant. 
54

Group Visits Focusing on Education for the Management

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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. 

As the description of studies in our review suggests, educating patients with chronic illness is a 

highly complex endeavor with interventions varying in their intended purpose, content delivered, 

leadership, intensity, format and more. Studies comparing two or more active interventions can 

begin to help elucidate whether or not there are certain intervention factors associated with better 

outcomes. There were few studies directly comparing a purely didactic, informational education 

approach to one focused on core self-management skills, though, not surprisingly, most studies 

finding improvements in self-efficacy focused on the latter. Group and individual approaches to 

education appear to have similar effects. Other comparisons are summarized in the tables above, 

but there were not enough studies to draw conclusions about the effects of other intervention 

elements. 

Learning and mastering chronic illness self-management is a time-consuming process. 

Theoretically, one might reasonably expect the duration of an intervention to be associated with 

its effectiveness, but we found it difficult to confirm this hypothesis. For example, we did find 

greater improvement in glycemic control among those interventions lasting longer than 3 months 

compared to interventions of shorter duration. However, the interventions of longer duration 

were also of lower methodological quality. Unfortunately, we found few studies examining 

the effects of a “booster” session (i.e., a refresher session conducted some time after the initial 

intervention ended). 

It is unclear why the group visit interventions literature has not found a consistent impact on 

health, utilization, or quality of life outcomes despite the logical inference that improved selfefficacy and self-management skills should lead to improved self-management, improved disease 

control and coping, and resultant improved outcomes. It is possible that intervention or follow-up 

duration has been inadequate as discussed above. It is also possible that - in an era promoting 

guideline dissemination, electronic health records, and quality improvement - it is becoming 

increasingly difficult to demonstrate incremental benefits of an educational intervention because 

usual care has improved over time. Indeed, a recent trial of intensive diabetes treatment found 

few health outcome effects in part, as the authors speculate, because treatment in the usual care 

group was quite good.99

We found no formal cost-effectiveness data to guide decision-making about the wisdom of 

widespread investment in group visit education modalities. However, one can easily infer that 

there is likely to be great variation in costs of different interventions depending on the personnel 
55

Group Visits Focusing on Education for the Management

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leading the visits, the duration of the intervention, and the number of visits. For example, some 

interventions – such as cognitive behavioral therapy – are fairly intensive and would involve 

allocating a professional’s time. Many of the self-management skills training interventions 

improved self-efficacy but not health outcomes. 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 – such as the 

CDSMP – may represent a low-cost way of improving self-efficacy and perhaps improving other 

outcomes. However, such programs do not provide some of the core skills and information 

patients with a given chronic illness might need to help self-manage their illness (e.g., glucose 

self-monitoring, dietary plans, CHF management plans). It is not clear from most studies how 

this core information was provided. If VA were to implement such peer-led self-management 

programs, it would likely still need a structure for providing basic disease-specific informational 

needs, though this could be accomplished in different ways including single group visit, 

educational pamphlets, etc. It is also not clear how much the community-based nature of the 

intervention matters. Offering the programs in local churches, and community centers may 

make it easier for patients to participate on an ongoing basis and perhaps may provide a less 

threatening environment. It would be useful to use qualitative and formative evaluation methods 

if implementation of such programs were considered, in order to shed more light on such issues. 

Although we did not find direct harms associated with group visits, the lack of robust 

findings that group visits improve long-term health outcomes invites caution around blanket 

recommendations for widespread and rapid group visit implementation. This is especially true 

for patient populations with specific health needs. For instance, travel and participation time 

involved in getting to and participating in group visits may preclude participation for patients 

with limited work schedule flexibility, and may be prohibitive for frail, older participants. 

Of note, we excluded studies focused on experiential exercise (i.e., group exercise classes) 

without a distinct educational component, so we cannot comment on their effectiveness. Other 

reviews may provide more information on the utility of experiential exercise sessions.2,3 We 

found few studies examining the incremental benefits of experiential exercise added to group 

education, so were unable to draw conclusions about the utility of such interventions. 

GENERALIZABILITY

Participation rates, when reported, ranged from 13 to 100 percent though many studies provided 

little information about the recruitment process. The broad range of participation, in part, reflects 

the many levels of potential eligibility, and the higher rates may be misleading. For instance, in 

one study, over 21,000 patients were identified in an administrative database.57 Only one-third of 

these patients were successfully contacted by letter, only one-quarter of who were screened by 

phone, and then only a small portion of these patients attended in-person screening. Though 91 

percent of those eligible at this stage were randomized, only one percent of patients identified 

through the administrative database actually enrolled in the study. In practical terms, these 

studies generally represent a small fraction of the total number of patients with chronic illness 

and, therefore, will apply to relatively few people identified through patient registries. Findings 
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Group Visits Focusing on Education for the Management

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from the studies included in this review are likely to be most applicable to those patients who are 

easy to contact, have time to participate in an intervention, and who have enough motivation to 

enter into a study in the first place. 

We identified four studies that examined group visit interventions in Veteran populations, one 

each in hypertensive,62 congestive heart failure,59 chronic obstructive pulmonary disease,57

and diabetes populations.80 These studies investigated interventions that were similar to other 

interventions tested in non-Veteran populations. We found no studies evaluating interventions 

that were specific to a given setting (e.g., tied to a specific technology unavailable in VA) or that 

would not be potentially feasible in a VA setting. 

LIMITATIONS

In setting out to perform this systematic review of group visit interventions led by nonprescribing facilitators, a chief limitation is comparability of studies given the vast heterogeneity 

and complexity of intervention content and outcomes examined. Although there have been 

many published studies testing group visit effectiveness, we found few with similar enough 

characteristics to be explicitly compared in meta-analyses. The sheer number and variety of 

outcomes reported across studies precluded reporting of all outcomes. We prespecified those 

outcomes that were either likely to be commonly reported, represented clinically important 

outcomes, or measured self-efficacy since this was, in many cases, the intended effect of the 

intervention. We acknowledge, however, that there may be other important outcomes not 

captured in this report. Most notably, we did not consider knowledge improvement outcomes. 

Many studies reported various knowledge outcomes, but few were standardized and they varied 

so broadly that any comparison across studies would have been impossible. Moreover, one 

could argue the clinical importance of short-term knowledge gains if they do not translate into 

gains in self-efficacy, health outcomes, or quality of life. Additionally, we found good quality 

trials testing the effectiveness of multicomponent interventions that included both, group and 

individual elements.100 Unfortunately, these trials were not included in our review because the 

independent effects of the group visit component could not be evaluated.
57

Group Visits Focusing on Education for the Management

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FUTURE RESEARCH

We identify gaps in evidence of the effectiveness of group visit interventions in Table 18. 

Table 18. Evidence gaps and future research 

Evidence Gap Recommendations / Types of studies to consider

Patients/Populations

Low participation of eligible study participants 

and high attrition of randomized participants. 

Few good quality studies in patients with 

asthma, COPD, CHF, chronic pain, and 

multiple chronic conditions.

Better reporting of recruitment population and improved 

recruitment and retention practices. More trials in these 

populations. 

Interventions

Lack of clarity as to which intervention 

components are important in achieving 

improvements. 

Few studies of group interventions using 

modern technologies such as mobile platforms 

and video-based interventions. 

Head-to-head comparative trials. More trials of interventions 

using technologies allowing remote participation. Studies 

assessing whether use of such technologies to deliver 

interventions improves participation and retention rates. 

Comparator

Relatively few studies with active 

comparison groups. 

Comparative effectiveness trials. For example, studies showing 

that mailed and phone-based self-management education 

programs were as effective as in-person group visits are 

interesting and point to alternative educational forums that may

appeal to patients with time or geographic constraints. Also, 

more studies comparing individual to group-based education 

could better clarify the relative merits of each approach. 

Outcomes

Studies evaluated dozens of different outcomes, 

many of which were non-standardized metrics 

of uncertain validity

Standardized approach to outcome measurement and use of 

well validated scales.

Timing

Lack of studies examining long-term outcomes. 

Few trials assessed the effects of booster 

sessions. 

Trials with longer-term follow-up. 

Trials evaluating the effects and timing of booster sessions. 

Setting

Few trials in community and rural settings Test telehealth trials of group visits and trials located in 

community settings such as churches and community centers.

CONCLUSION

A large number of studies have evaluated group visit interventions in a variety of patient 

populations. Intervention characteristics and effects differed depending on the chronic illness 

in which they were studied. Overall, group visits have the potential to improve patient selfefficacy, though there is little consistent data that they improve health, utilization, or quality of 

life 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. 
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