Overview
This chapter first addresses the costs of group clinic interventions before moving on to more general issues of implementation and feasibility. Using information from studies assessing the costs of group clinics and economic evaluations of interventions, this chapter aims to:
identify key cost elements of group clinic interventions (i.e. where costs might be incurred or saved as part of a group clinic intervention)
identify information relating to the actual costs of these interventions (i.e. the costs of establishing and running a group clinic intervention and the savings attributed to a group clinic intervention).
Costs
Methods
The methods for this section are found in Chapter 2.
Results of the literature search
The results of the three-stage literature search are presented in . The analysis of costs used eight studies.
Results of the literature search: costs
Included and excluded articles
The included articles consisted of one cost-effectiveness analysis,134 four RCTs with costs included58,69,79,86 and three cost–utilisation analyses.62,136,137
The included studies are summarised in . Full details of the data extraction can be found in Appendix 3.
Summary table of cost studies
Overview of studies
Of the eight papers included, seven reported studies undertaken in the USA58,62,69,79,86,136,137 and one reported a study undertaken in Italy.134 The medical conditions for which the group clinics were run were diabetes (five articles), comorbid diabetes with hypertension (one article) and complex behavioural health and medical needs (two articles). The patients in this last group were frequent users of the emergency department. For all of the papers, the perspective was of the health system. The health settings were a diabetes clinic,134 Kaiser Permanente health maintenance organisation,79,137 Puget Sound health maintenance organisation,86 Veterans Affairs Medical Centres,69 university affiliated medical centre58,62 and a hospital.137
What are the key elements in examining the costs of group clinics?
Costs incurred in setting up/running a group clinic
Edelman et al.69 calculated the costs of a group visit using data on staff time to run the GMV and staff time to make follow-up telephone calls. Scott et al.79 estimated costs for CHCC meetings according to the amount of time that providers spent at the meeting and their mean hourly salaries.
Costs saved as a result of the group clinic
Evidence on costs saved as a result of group clinics tended to be related to health service utilisation, for example hospital admissions, urgent care visits, primary care visits, specialty visits and group visits. Clancy et al.62 portioned charges into outpatient visits, emergency department visits and inpatient stays.
What evidence exists for the costs of group clinics?
Costs incurred in setting up/running a group clinic
Edelman et al.69 estimated a cost of US$504 (range US$445–578) to conduct a group visit, with an annual per-patient cost of US$460 (range US$393–554). Crane et al.136 estimated the total annualised direct costs of the programme as US$66,000. Scott et al.79 estimated an average per-patient group cost over 24 months of US$484. Staff salaries constituted 77.4% of the total average cost (US$375).
Bondonio et al.134 undertook a cost-effectiveness analysis of RCTs in type 1 and type 2 diabetes. For type 2 diabetes, they calculated that over the study period (4 years), €119.25 was spent by the Italian health service on each intervention patient, compared with €90.44 for the control group over the same period. For type 1 diabetes, over the study period (3 years), €271.24 per patient was spent on the intervention group and €120.15 per patient was spent on the control group.
Costs saved as a result of the group clinic
One study showed no significant difference in costs between group clinics and usual care.86 There were differences in utilisation, with intervention patients visiting primary care almost one time more than usual care patients, although there were significant reductions in specialty and emergency room visits among intervention patients.
Clancy et al.58 established that total costs were higher for intervention patients than for control patients in terms of outpatient costs (US$1444 vs. US$1099; p = 0.008) and inpatient costs (US$1410 vs. US$365). However, emergency department costs did not differ.
There was no difference in health service utilisation in the study by Levine et al.137 and they found that the difference in total costs between intervention and control patients was not statistically significant (US$8845 vs. US$10,228; p = 0.11).
Edelman et al.69 found a pattern of reduced health service utilisation in the group medical care group compared with the usual care group as follows: emergency care visits (0.9 vs. 1.3 visits per patient-year; p < 0.001), primary care visits (5.3 vs. 6.2 visits per patient-year; p = 0.01).
Crane et al.136 compared patients before and after a DIGMA intervention in terms of emergency department and inpatient charges and also compared DIGMA patients with a control group. The median total costs (emergency department and inpatient charges) prior to the intervention starting was US$1167 and 12 months after the intervention these had fallen to US$230 (p < 0.001). This was as a result of reduced utilisation: per person per month emergency department visits dropped from 0.58 in the 12 months prior to involvement to 0.23 (p < 0.001).
Scott et al.79 found that the intervention (CHCC) group had lower health service utilisation [admissions χ2 = 5.8 (p = 0.012); emergency department visits χ2 = 9.8 (p = 0.008); and professional services χ2 = 7.5 (p = 0.005)]. However, in other aspects of utilisation there was no significant difference between the groups. Intervention group costs associated with emergency department visits were significantly lower for intervention than control patients; although there were no other significant differences, costs were lower for health service utilisation in the intervention group. The overall cost saving was US$41.80 per member per month.
Group clinic patients in the study by Clancy et al.62 found reduced emergency department (49.1% lower) and total (30.2% lower) charges but higher outpatient charges (34.7% higher) when comparing patients in the intervention group with those in the usual care group. However, controlling for endogeneity (the potential for unobserved patient characteristics to influence adherence), group clinics significantly reduced outpatient visit charges through a reduction in specialty visits (for which group clinics were found to substitute).
Cost-effectiveness analysis
Bondonio et al.134 undertook a cost-effectiveness analysis. For type 2 diabetes group care patients, using Diabetes Quality of Life questionnaire (modified) score as a proxy outcome, the cost-effectiveness ratio was €2.28 and for type 1 diabetes group care, it was €19.46. The authors stated that they were not able to calculate a quality-adjusted life-year outcome.
Discussion
Group care is more expensive to set up and run, and although not many studies have actually calculated these increased costs, they have reported increased use of physician time, increased educational resources, increased frequency of appointments per patient and the existence of one-to-one appointments for patients on group care, all of which will increase costs when compared with usual care. The lack of information relating to the costs of the intervention in the studies we examined means that it is challenging to draw conclusions about the cost of group clinics. From the data from the RCTs, we can understand more about the key cost elements of group clinics. However, this information would need to be considered in a full economic analysis in order to be meaningful.
From the studies we examined, we can make better judgements on the cost savings as a result of patient participation in group clinic interventions. The majority of studies examined addressed the changes in utilisation and the subsequent changes in costs. There was a mixed pattern of changes in utilisation, with some studies reporting that intervention patients used fewer health services overall while others reported an increase in some areas (primary care, inpatient and outpatient). This mixed pattern was repeated in the assessment of changes in costs; understandably, in studies where utilisation decreased, there was a decrease in costs. With this mixed set of results, it would not be meaningful to cluster studies together in terms of utilisation and cost changes.
It would have been informative to identify whether or not the savings identified are realised over a longer period of time. We found evidence to suggest that the US health-care system reimbursement process means that these interventions will always be delivered in a standard way to ensure that insurance claims are reimbursed, thereby making costs across interventions (although not cost savings) more uniform. It may be possible to hypothesise that as group clinics become more widespread, staff costs will decrease as more staff become trained (training being a major part of establishing a group clinic, as identified in the main review).
Clancy et al.58 aimed to determine why costs were higher for intervention patients than for control patients. In addition to small sample sizes, they note that participating in an intervention such as a group clinic might ‘activate’ patients who had previously missed care to catch up with the care that they had missed, thereby increasing health service utilisation. In addition, the length of study is important: improved self-care (which is often an outcome of group clinic interventions) may have a time lag, and so for a shorter study 6 months is not sufficient time to demonstrate a decrease in utilisation and, therefore, to observe a decrease in costs.
Summary of included studies
Our assessment of costs and feasibility across a heterogeneous set of studies has showed mixed effects of group clinic interventions on costs and savings. A full economic analysis of group clinics, along with the robust collection of costs data alongside group clinic interventions, is recommended. A full economic analysis could allow for data included in RCTs, such as the type of clinician delivering the intervention and how long each group clinic lasts, to be costed in order to get a more complete picture of the costs of group clinic. Primary research assembling information on the running of group clinics and the costs that are saved specifically within a NHS setting would be essential to inform decisions about group clinic provision in a UK context.
Feasibility
Overview
Feasibility conflates many issues, such as acceptability to patients and providers, practicality in terms of required procedures (whether alongside or as a substitute for existing practice) and affordability, in terms of financial considerations and available equipment and premises. The evidence to be mapped against this domain is drawn from qualitative studies of provider and patient attitudes, implementation studies not otherwise included in this review and an overall picture of likely cost-effectiveness, as has emerged from Chapter 4. Feasibility includes general issues to be considered within any context for implementation of group clinics and specific issues relating to implementation within a NHS context.
What are the key considerations regarding feasibility?
Key to a consideration of feasibility in this context is affordability. Although claims are made of cost savings these are based on either (1) US studies of limited geographical or temporal relevance or (2) a simplistic argument of more patients seen by a clinician per hour. In particular, there is limited evidence of cost implications in a UK study. Indeed, although the insights from group acupuncture clinics are informative in terms of the group interactions and dynamics within a UK context, the actual assessment of costs would be potentially misleading. As will be explained later in this report the achievements of the group acupuncture clinics are located within a ‘work smarter’ treatment delivery model. These otherwise promising achievements have, therefore, limited relevance to the monitoring model that is fundamental to group clinic provision.
A further concern relates to acceptability. Our clinical advisers point out that there is a strong expectation in the NHS of being seen by a specialist clinician within an individual consultation. Even if group clinic provision were to become the default position, a sizeable proportion of the population would still require access to the more traditional model, perhaps because of the complexity or severity of their condition or because they would demand it through exercising patient choice. Such preference may be affirmed on commencement of treatment or, as illustrated by UK group acupuncture clinic qualitative data, may emerge following patients’ experience of the group clinic provision. In particular, the willingness of patients to try a new modality of service provision should not be interpreted as those patients’ commitment to that service modality on a long-term basis.
Practical issues relate to the requirement to be able to access all patient records and results in advance of a single SMA. This may place a burden on diagnostic services but may also prove problematic for the individual specialist, who would have to make time for review of the notes. The latter factor is examined in a US context of uncompensated clinician time.132
Other feasibility concerns relate to the need for clinician training, particularly in group facilitation, and the need for suitable premises. Within the wider picture of feasibility it would be worth exploring whether or not the individual components considered essential to the group clinic approach could be delivered in an alternative format. For example, in some circumstances the socialisation or the interaction with a group facilitator could be offered virtually, offering the opportunity for the clinical team to identify those needing particular help.
What evidence exists on the feasibility of group clinics?
Little evidence exists on the feasibility of group clinics, even though much of the literature suggests how they might be introduced. Particularly noticeable is a shortage of data from the UK. The wider non-NHS-specific literature informs such aspects as implementation and confidentiality. A feasibility study104 revealed such positive aspects of GMVs as personalised attention (77%), self-care education (69%), access to medication refills and examinations (69%) and advice from peers (62%). Negative aspects included insufficient personal attention (23%), logistical barriers (8%) and loss of confidentiality.104
Kirsh et al.27 have explored implementation issues relating to SMAs. They identified such important promoting factors as the formation of a core team committed to quality and improvement with strong support for the clinic leadership from other team members. Notably, tailoring had to take into account such ‘key innovation-hindering factors’ as limited resources (such as space), potential to alter longstanding patient–provider relationships, and organisational silos (disconnected groups) with core team members reporting to different supervisors. The last point emphasises that group clinics should be seen not in isolation but as a potential vehicle towards interprofessional team working, with all of the associated culture changes that this might necessitate.
Concerns relating to confidentiality were raised consistently in the reviewed literature. This issue was examined specifically in a study by Wong et al.107 This study aptly highlights that GMVs can impact on the clinician–patient relationship as patients are ‘able to draw upon more informational resources and social support from attendees and often feel more empowered to pose questions to their providers than they might otherwise in individual encounters’.107 However, providers reported that ‘the most common reason for not attending a GMV was patients’ concerns about confidentiality and hence a preference for individual visits’.107 Nevertheless, one overall finding from the study was that patients who did attend a GMV consciously selected which information they were comfortable sharing in a group situation.107 Although it could be perceived as a drawback that patients filtered the information they felt able to share, some interventions included a discussion of confidentiality with practical examples as a component of the initial group clinic sessions.
Discussion
The review team has identified specific concerns relating to the interpretation of predominantly US data within a specific UK context. In particular, many of the interventions have been delivered within the context of health-care financing that determines the exact configuration of approved packages of group clinic provision and, for example, requires guaranteed access to an individual consultation if requested. Advice from our clinical advisers suggests that a model in which an increasing amount of the content of the previous individual consultation is assumed in a group context, facilitated perhaps by a member of staff who is not the specialist clinician, may be an alternative form of substitution. This might facilitate shorter individual consultations, although this issue remains to be investigated. Importantly, however, such provision would need to be in a context where group education is seen as more central to the chronic disease management process and not as an optional extra.
Summary of included studies
Although the evidence from the USA and that from a UK group acupuncture clinic context does inform a discussion of feasibility, a specific need remains for further investigation of the monitoring model of group clinics within a UK context. This research requirement sits naturally alongside the suggestion made in the previous chapter for a full UK-centric economic evaluation and the need for qualitative exploration of the attitudes of NHS patients, providers and caregivers towards group clinic provision. In addition, there is a requirement to explore the feasibility of ‘substitution’ of specific functions from the individual consultation with a corresponding group-based provision, along with any training and role development issues this might occasion.
