Evidence-based Synthesis Program 

(ESP)

Educational Group Visits for the 

Management of Chronic Health 

Conditions 

A Systematic Review

Portland VA Medical Center

April 1, 2013

1 
Evidence-based Synthesis Program 

(ESP)

Acknowledgements

Report Authors 

o Ana Quiñones, PhD

o Jeannette Richardson, MSN, RN, CNS

o Michele Freeman, MPH 

o Maya O’Neil, PhD

o Devan Kansagara, MD

Report Nominators & Reviewers

o Beverly Priefer, PhD, RN

o Storm Morgan, BSN, RN, MBA

o Christine Engstrom, PhD, CRNP, AOCN

o Tom Carr, MD

o Tatjana Bulat, MD

o Susan Kirsch, MD

o Michelle Lucatorto, DNP, FNP-BC 

o Jamie Olsen, RD, CDE

o Kevin Rosborough, RN

o Suzanne Seta, RN

2 

Presenters & Discussants

o Ana Quiñones, PhD

o Jeannette Richardson, MSN, RN, CNS

o Sharon Watts, DNP, RN-BC, CDE

o Susan Kirsch, MD
Evidence-based Synthesis Program 

(ESP)

Disclosure

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

Synthesis Program (ESP) Center located at the Portland VA Medical Center 

funded by the Department of Veterans Affairs, Veterans Health 

Administration, Office of Research and Development, Health Services 

Research and Development. 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. 3 
Evidence-based Synthesis Program 

(ESP)

VA Evidence-based Synthesis (ESP)

Program Overview

• Sponsored by VA Quality Enhancement Research Initiative 

(QUERI) Program.

• Established to provide timely and accurate 

syntheses/reviews of healthcare topics identified by VA 

clinicians, managers and policy-makers, as they work to 

improve the health and healthcare of Veterans. 

• Builds on staff and expertise already in place at the 

Evidence-based Practice Centers (EPC) designated by AHRQ. 

Four of these EPCs are also ESP Centers: 

o Durham VA Medical Center; VA Greater Los Angeles Health Care 

System; Portland VA Medical Center; and Minneapolis VA Medical 

Center. 4 
Evidence-based Synthesis Program 

(ESP)

• Provides evidence syntheses on important clinical practice 

topics relevant to Veterans, and these reports help:

o develop clinical policies informed by evidence, 

o the implementation of effective services to improve patient 

outcomes and to support VA clinical practice guidelines and 

performance measures, and 

o guide the direction for future research to address gaps in 

clinical knowledge.

• Broad topic nomination process – e.g. VACO, VISNs, field – 

facilitated by ESP Coordinating Center (Portland) through 

online process: 

 http://www.hsrd.research.va.gov/publications/esp/TopicNomination.cfm

5 
Evidence-based Synthesis Program 

(ESP)

• Steering Committee representing research and operations 

(PCS, OQP, ONS, and VISN) provides oversight and guides 

program direction.

• Technical Advisory Panel (TAP)

o Recruited for each topic to provide content expertise.

o Guides topic development; refines the key questions.

o Reviews data/draft report.

• External Peer Reviewers & Policy Partners

o Reviews and comments on draft report

• Final reports posted on VA HSR&D website and disseminated 

widely through the VA. 

http://www.hsrd.research.va.gov/publications/esp/reports.cfm

6 
Evidence-based Synthesis Program 

(ESP)

Current Report

Educational Group Visits or the Management 

of Chronic Health Conditions: 

A Systematic Review

(December 2012)

Full-length report available on the ESP website:

http://vaww.hsrd.research.va.gov/publications/esp/group-visits.cfm

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Evidence-based Synthesis Program 

(ESP)

Questions for the Audience

(Respond in your “Q&A” tab, upper left corner)

• Question 1: What is your reason for 

joining us on the cyberseminar today? 

o General interest in group visits

o I am involved with a group visit at my clinic

o I conduct research on group visits

o None of the above

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Evidence-based Synthesis Program 

(ESP)

Questions for the Audience

(Respond in your “Q&A” tab, upper left corner)

 

• Question 2: Does your clinic currently conduct 

group visits for chronic disease management?

• Question 3: If so, in what area?

o Obesity

o CHF/hypertension

o Diabetes

o Arthritis/falls prevention

o Other—specify 

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Evidence-based Synthesis Program 

(ESP)

Overview of Today’s Presentation

• Background 

• Scope of the review

• Results (87 publications of 81 studies)

• Description of included studies 

• Summary of results by clinical area

• Implications for VA

• Future research

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Evidence-based Synthesis Program 

(ESP)

Background

• The goal of group-based visits led by non-prescribing 

facilitators is to reinforce chronic disease education 

and provide training in order to improve selfmanagement skills for the large numbers of patients 

coping with chronic illness. 

• The Veterans Administration (VA) has prioritized group 

visit implementation as part a new primary care model 

that focuses on patient centeredness, The Patient 

Aligned Care Team (PACT).

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Evidence-based Synthesis Program 

(ESP)

Background (2)

• Vast differences in group visit program structure, content, 

length of intervention, and follow-up time points. 

• Given the heterogeneity among interventions and chronic 

conditions in which group visits are tested, the objectives of 

this review are to:

1. Summarize the characteristics of GV interventions

2. Assess the effects of these interventions on outcomes 

3. Examine patient characteristics associated with effectiveness 

4. Examine which components of GV structure and delivery are 

effective 

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Evidence-based Synthesis Program 

(ESP)

Scope of the Review

• Key Question 1: In adults with chronic medical 

conditions, how do group visits compared to usual 

care affect the following:

o medication adherence, biophysical markers

o symptom status, functional status, mortality, 

patient satisfaction

o utilization of medical resources, health care costs 

o adverse outcomes?

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Evidence-based Synthesis Program 

(ESP)

Scope of the Review (2)

• Key Question 2: For adults with chronic medical 

conditions, do the effects of group visits vary by 

patient characteristics? 

• Key Question 3: Which components of group visits 

are associated with greater intervention effects?

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Evidence-based Synthesis Program 

(ESP)

Scope of the Review (3)

• Criteria:

o Patients: DM, HTN, CHF, COPD, asthma, arthritis, chronic 

pain, history of falls, multiple chronic conditions.

o Intervention: educational GV led by individuals who are 

non-prescribing health professionals as well as lay facilitators. 

o Comparator: Usual care, non-GV care

o Outcome: Biophysical/physiological, health care utilization, 

functional status, patient satisfaction, participation, attrition 

o Timing: Any

o Setting: Any

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Evidence-based Synthesis Program 

(ESP)

Methods

• Searched MEDLINE (PubMed), Cochrane Database of 

Systematic Reviews (Ovid), Embase, CINAHL (EBSCO), and 

PsycINFO (Ovid) through February 2012 (update search 

January 2013)

• Additional articles and reviews considered for inclusion were 

obtained from reference lists and reviewer suggestions

• Excluded:

• Non-English language

• Non-adult study population

• Support group only; group exercise classes only

• Individual-level medication management

• DM studies published prior to 1998

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Evidence-based Synthesis Program 

(ESP)

Methods (2)

• Data extraction

• Study design, objectives, setting, population, 

demographics, findings, structure of GV, comparator(s), 

participation, and attrition

• Content delivered 

1. Self-management education (SME)—disease-specific 

education and self-management skills to cope with symptoms

2. Didactic education (DE)—informational only (lectures)

3. Experiential education (EE)—instruction via demonstrations

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Evidence-based Synthesis Program 

(ESP)

Methods (3)

• Focused on distal health outcomes measuring 

quality of life and functional status—likely to be 

important to patients and could conceivably be 

impacted by the interventions examined

• Also focused on intermediate outcomes such as 

self-efficacy

• Self-efficacy: personal beliefs in one’s ability to succeed in 

self-managing illness 

• Quality assessment (good, fair, poor)

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Evidence-based Synthesis Program 

(ESP)

Results

• Search yielded 3,450 citations; 599 were selected 

for full-text review

• 87 publications reporting on 81 group visit trials 

o Diabetes interventions (29)

o Arthritis/falls interventions (22)

o Asthma/COPD (10)

o Hypertension/CHF (12)

o Chronic pain (4)

o Multiple chronic conditions (4)

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Evidence-based Synthesis Program 

(ESP)

Results (2)

By Key Question 

• Key Question 1: 

o Short- and medium-term improvements in self-efficacy

o Little evidence that interventions improved quality of life, 

functional status, or utilization outcomes

o Modest short-term improvements in HbA1c

• Key Question 2:

o Little difference according to patient demographic and SES

• Key Question 3:

o In 5 studies, SME group visits may be more effective than DE

o Mixed results for individual vs. group visits 20
Evidence-based Synthesis Program 

(ESP)

Results (3)

By Clinical Area

• Arthritis 

o 18 studies from the US, Europe, and Australia

o Wide variation in intervention structure, content, and duration

o Moderately strong body of evidence for short and medium term 

self efficacy improvements

o Little effect on quality of life or utilization

• Falls 

o 4 studies from the US, Canada, and Australia

o Didactic falls prevention + experiential exercise training may 

improve self-efficacy and reduce the risk of falls

o Strength of evidence is low 21
Evidence-based Synthesis Program 

(ESP)

Results (4)

By Clinical Area

• Asthma 

o 5 studies from the US, and Australia

o Little effect on quality of life or utilization

• COPD 

o 5 studies from Northern Ireland, the UK, the Netherlands, France, 

and a VA Medical Center in the US

o Small body of fair-to-good quality evidence suggests didactic + 

experiential training may be associated with small improvements 

exercise capacity and symptoms

o Clinical significance of these findings is unclear

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Evidence-based Synthesis Program 

(ESP)

Results (5)

By Clinical Area

• Hypertension, CHF, CAD 

o 3 fair-quality studies in 4 publications from the US and the 

Netherlands for patients with CHF or CAD

o 7 studies in patients with hypertension from the US and other 

international settings

o Few studies among CHF patients—findings on self-efficacy, 

quality of life, and biophysical measures were largely neutral

o Improvements in blood pressure control for patients with 

hypertension in short-term and long-term studies

 

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Evidence-based Synthesis Program 

(ESP)

Results (6)

By Clinical Area

• Diabetes Mellitus 

o 30 studies from the US, Europe, and other international settings

o 5 studies found improvements in self-efficacy 

o Little evidence of improved quality of life over short- or long-term

o 11 studies compared a group visit intervention to one or more 

active intervention arms

 3 found greater improvements in HbA1c control for self-management 

vs than didactic (additional differences between intervention arms)

 2 studies compared group to individual education: 1 fair-quality 

study found a telephone-based self-management program 

performed similarly to an in-person self-management group visit

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Evidence-based Synthesis Program 

(ESP)

Results (7) 

 

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Figure 1. 

Effect of group visits 

compared to usual care 

on HbA1C at ≤6 month 

follow-up, by duration 

of intervention 
Evidence-based Synthesis Program 

(ESP)

Results (8)

 

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Figure 2. 

Effect of group visits 

compared to usual care 

on HbA1C at 7-12 

month follow-up, by 

duration of intervention
Evidence-based Synthesis Program 

(ESP)

Results (9)

By Clinical Area

• Chronic Pain 

o 4 studies from the US, and Europe

o Very small body of literature suggests group-based selfmanagement education interventions may improve pain coping 

skills over the short-term

o Strength of this evidence is low

 Few small and moderately sized trials 

 Methodological quality of one of the studies finding benefit 

was poor

 

27
Evidence-based Synthesis Program 

(ESP)

Results (10)

By Clinical Area

• Multiple chronic conditions 

o 4 studies evaluating the Chronic Disease Self-Management 

Program in the US, China, and the Netherlands

o The peer-led, community-based program is associated with 

medium-term improvements in self-efficacy, health status, and 

health care utilization which may persist long-term

o Moderately strong evidence from two large US trials, though 

findings were not replicated in other countries

o Findings likely apply most to patients engaged enough in care to 

agree to attend a multi-week course.

 

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Evidence-based Synthesis Program 

(ESP)

Discussion

• Group visits can improve short-term self-efficacy 

• Little effect on quality of life, functional status

• Peer-led community-based self-management program 

may improve health and utilization among patients 

with multiple chronic illnesses

• No evidence of harms

 Group visits may be a reasonable alternative for 

educating patients with chronic illness

 Low overall participation and retention rates suggest 

they may not be a viable option for many patients and 

should not be the sole alternative

 29
Evidence-based Synthesis Program 

(ESP)

Limitations

• Comparability of studies 

• Participation rates, ranged from 13-100 percent

• Relatively few comparative intervention studies

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Evidence-based Synthesis Program 

(ESP)

Future Research

Patients/populations: 

• Few good quality studies in patients with asthma, COPD, CHF, 

chronic pain, and multiple chronic conditions

 More trials in these populations

Interventions:

• Lack of clarity about intervention components associated 

with improvements

 More head-to-head comparative trials

Comparator:

• Relatively few studies with active comparison groups

 Comparative effectiveness trials 31
Evidence-based Synthesis Program 

(ESP)

Future Research (2)

Outcomes: 

• Heterogeneity in outcomes (uncertain validity)

 Standardized approach to outcome measurement/validated scales

Timing:

• Lack of studies examining long-term outcomes

 Trials with longer follow-up

• Few trials assessed booster session effects

 Trials evaluating booster sessions

Setting:

• Few trials in community and rural settings

 Test telehealth trials located in community settings 32
Evidence-based Synthesis Program 

(ESP)

Discussants:

Sharon Watts, DNP, RN-BC, CDE (Cleveland VA)

1. From a practitioner’s perspective, are there any outstanding gaps that 

you think would be valuable to day-to-day practice?

2. Are these findings surprising?

3. Does the group visits report convey any information that would 

influences your teamlet practice? 

Susan Kirsch, MD (PACT Coordinating Center)

1. Are there any implications for VA PACT-level rollout decisions?

2. Implications for funding research to better inform PACT rollout 

decisions?

3. Are there implications for collaboration between HSR&D/QUERI and 

ONS in future work on this topic? 33
Evidence-based Synthesis Program 

(ESP)

Questions?

If you have further questions, 

feel free to contact:

Ana Quiñones, Ph.D.

503.494.5889 

quinones@ohsu.edu

Ana.Quinones@VA.gov

The full report and cyberseminar presentation is available on the ESP website: 

http://www.hsrd.research.va.gov/publications/esp/

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