By David Kiefer, MD, Editor
Clinical Assistant Professor, Department of Family Medicine, University of Wisconsin; Clinical Assistant Professor of Medicine, Arizona Center for Integrative Medicine, University of Arizona, Tucson
Dr. Kiefer reports no financial relationships relevant to this field of study.
- In Boston, 19 people with chronic pain and whose first language was Spanish were enrolled in a nine-week, once weekly, group medical visit.
- A variety of topics were covered during the nine weeks, including meditation, nutrition, and depression.
- Eleven people finished the entire series; benefits were seen in pain, fatigue, and depression, but not in anxiety, perceived stress, or physical functioning.
A nine-session group medical visit for Spanish speakers with chronic pain led to statistically significant improvements in pain, fatigue, and depression.
Cornelio-Flores O, Lestoguoy AS, Abdallah S, et al. The Latino Integrative Medical Group Visit as a model for pain reduction in underserved Spanish speakers. J Alt Comp Med 2018;24:125-131.
Originally a spinoff from well-child checks, group medical visits (GMVs) have been used for a variety of medical conditions, and are particularly well-suited for chronic illnesses.1 GMVs usually include both a private component with the healthcare provider (which differentiates this from a support group or class) and a group aspect during which patients participate in a didactic and/or interactive activity with other patients who have received the same diagnosis or are interested in the topic. GMVs may involve just one “class” or a series of meetings over time to address the relevant content. Seen as a way to increase time with patients, encourage social support, promote clinic profitability, improve many outcome measures, and also reduce the tedium that some providers feel by discussing the same information repeatedly,1-3 GMVs are becoming a popular model with widespread applicability.3,4
Along the lines of increasing the use of GMVs, Cornelio-Flores et al examined the efficacy in chronic pain and in Spanish-speaking Latinos, a demographic group that experiences disparity in the treatment of chronic pain. The research group adapted the GMV model to be more “integrative” by using elements of mindfulness-based stress reduction (MBSR) and integrative medicine. There were nine classes (one per week for nine weeks) in this GMV curriculum. They covered such topics as stress, sleep, nutrition, activity, breathing techniques, approaches to lessen inflammation, meditation, acupressure, and integrative approaches to depression.
The researchers enrolled patients who spoke Spanish as their first language and who had musculoskeletal pain for at least 12 weeks and rated their pain at least a four out of 10 (on a 0-10 scale). Patients were excluded if they were pregnant or planning pregnancy soon or had severe mental illness, current substance use, severe medical conditions that would affect their GMV participation, or prior GMV participation. Nineteen patients were enrolled in the study, all of whom attended the first GMV. Only 11 patients completed the nine-session GMV curriculum.
The researchers collected both quantitative and qualitative information. For quantitative data, various scales were used to analyze pain, stress, depression, and sleep; these all had been validated in Spanish. (See Table 1.) Comparisons were made between the values in these scales before and after the GMV. Qualitative data were gleaned from focus groups during the last week, when patients were asked about what they learned, their overall experience, and challenges in participating in the groups.
Table 1: Quantitative Measures and Relevant Scales
|
Scale
|
Parameters Measured
|
Notes
|
|
Brief Pain Inventory
|
Pain (0-10)
|
“during the last week”
|
|
PROMIS-29
|
Pain interference, sleep, anxiety, depression
|
|
|
PHQ-8
|
Depression
|
|
|
PSS-10
|
Perceived stress scale
|
|
Almost 90% of patients were female, with a mean age of 51.6 years. The mean pain score at baseline was 6.9 (out of 10), which dropped 1.7 points by the end of the GMV series (P = 0.03). Comparing the beginning to the end of the GMV, the PROMIS-29 showed improvements in fatigue (P = 0.01) and depression (P = 0.01), but not physical function (P = 0.36) nor anxiety (P = 0.10). In addition, the PHQ-8 score dropped a borderline statistically significant 2.89 points (P = 0.05), whereas perceived stress dropped insignificantly by 0.56 points (P = 0.83).
In the focus groups, patients were satisfied with the GMVs, and noted that they learned from the other patients, that the interactions felt “collaborative,” and that there was more perceived time with the healthcare provider. Other comments mentioned improved pain control, better nutrition, and contentment over the fact that the GMVs were in Spanish.
COMMENTARY
For the 11 people who completed this GMV series, obvious benefits surfaced, including reduction of pain, fatigue, and depression. It was clearly “feasible,” as the authors stated, to use GMVs to reach this demographic and address the difficult-to-treat condition of chronic pain. Obviously, this is a small study (even the authors refer to it as a pilot study), and it needs to be repeated with a control group to be able to say that the results seen were because of the intervention and not some other factor(s). That said, the results corroborate interesting benefits from GMVs for many chronic conditions,1-4 and these benefits cross the boundaries between mind, body, emotions, and spirit. The researchers’ use of a variety of quantitative scales shows this variety of outcome, which, it could be argued (and is supported by the literature), is partly the result of the social support and interaction that comes from patients learning from each other about their common condition.
There is little reason not to consider GMVs for addressing chronic medical conditions in both primary care and medical specialties. However, those planning GMVs have found patient recruitment to be a challenge.2 There certainly is the need to invest time in creating the curriculum and arranging for visit logistics, charting, and billing. Also, as the researchers did here, it seems like a good idea to be mindful of which patients might not be appropriate for a GMV. The exclusions of serious mental health diagnoses or medical conditions that would preclude group participation and continuity make sense as clinicians seek to optimize the patient experience in this format.
On the positive side, it is exciting to see an intervention geared toward a demographic that may fall short of receiving quality care for chronic pain. As our society increasingly diversifies, looking for creative ways to meet the needs of patients from a variety of backgrounds will be even more important. Perhaps GMVs are just the approach necessary to increase time with patients in a fiscally sustainable, provider- and patient-friendly way.
REFERENCES
- Jaber R, Braksmajer A, Trilling JS. Group visits: A qualitative review of current research. J Am Board Fam Med 2006;19:276-290.
- Jones KR, Kaewluang N, Lekhak N. Group visits for chronic illness management: Implementation challenges and recommendations. Nurs Econ 2014;32:118-134.
- Quiñones AR, Richardson J, Freeman M, et al. Educational group visits for the management of chronic health conditions: A systematic review. Patient Educ Couns 2014;95:3-29.
- Housden LM, Wong ST. Using group medical visits with those who have diabetes: Examining the evidence. Curr Diab Rep 2016;16:134.
