Shared Medical Appointments:
Promoting Weight Loss in a Clinical Setting
SUMMARY:
Shared medical appointments (SMAs) are group appointments for patients with similar medical complaints. SMAs include components of a traditional office visit, but provide further emphasis on health education. We sought to investigate the effectiveness of shared medical appointments versus individual appointments on weight loss, within a single-physician practice at the Palo Alto Medical Foundation.
BACKGROUND:
During the two-year study period (November 2006–October 2008), 34 weight loss SMAs were conducted at the Palo Alto Medical Foundation (PAMF, Los Altos clinic) by an Internal Medicine physician. SMAs were offered by the physician on a biweekly basis. Approximately 6-12 patients attended each SMA. Each SMA lasted for a total of 90 minutes, with approximately 60 minutes devoted to addressing the individual health concerns of the patients in the group, and the remaining time spent discussing health-related topics. The SMA was billed as a regular office visit, with appropriate documentation of the individual components of the visit. The medical assistant and behaviorist (Licensed Clinical Social Worker) present at each SMA session were compensated as per usual clinic operating costs.
At each SMA, patients were provided with publicly available, printed lifestyle intervention materials adapted from the Diabetes Prevention Program (DPP).1 The SMA meeting room was equipped with a laptop computer connected to the EpicCare electronic health record (EHR) system, allowing the physician to immediately access and update patient health records as needed. The EHR has been in use at all PAMF clinics since 2000.
PARTICIPANTS:
PAMF Patients with a BMI greater than 25 kg/m2 were identified and personally invited by their primary care physician to attend the weight loss SMA led by an Internal Medicine physician. Invited patients were able to sign up for an appointment and join at any time. The scheduling process was identical to that of a traditional office visit. During the two year study period (2006-2008), a total of 80 unique patients participated in the weight loss SMA.
For comparison, electronic health records (EHR) were used to create a group with similar characteristics (sex, age, BMI, weight) that may have received similar advice and instructions on weight loss from their primary care physician during an individual office visit. The comparison group consisted of 384 patients from the SMA physician’s patient panel who had arrived for an office visit during the study period (November 2006 - October 2008).
SMA MATERIALS:
The weight loss SMA incorporated the lifestyle intervention materials from the DPP, a clinical research study which demonstrated that high-risk individuals could delay or avoid developing type 2 diabetes by losing weight through regular physical activity and a diet low in fat and calories.2 The standard DPP Lifestyle Balance program consists of a 16-lesson curriculum providing training in diet, physical activity, and behavior modification. The intensive curriculum is taught on an individualized basis by case managers and is both flexible and culturally sensitive.
The weight loss SMA adapted the publicly available DPP materials.1 The standard DPP curriculum was condensed to 12 lessons, allowing for one lesson topic (e.g., getting started losing weight, healthy eating, ways to stay motivated) to be covered over the course of two biweekly SMA visits (one topic for each month). At the start of each SMA, new patients were provided with the DPP Lifestyle Balance materials and Fat Counter to help with tracking the amount of food, fat, and calories consumed daily. All new and returning SMA patients received printouts of the DPP lesson topic and were provided with homework handouts at the end of each SMA.
PROCEDURE:
Upon arrival to the clinic for the SMA, patients checked in, had their weight recorded, and were then directed to the SMA meeting room. A medical assistant and behaviorist greeted each patient and distributed the printed materials for the SMA along with a confidentiality form to sign. Patients were provided with time to briefly review the materials and sign the confidentiality form. In signing the confidentiality form, patients agreed to protect the privacy of others and maintain privacy of the information revealed during the SMA visit. Signed confidentiality forms were returned to the medical assistant prior to the start of the SMA.
At the beginning of the weight loss SMA, the physician leader provided a brief introduction and used a flip chart to introduce the SMA and explain the confidentiality and insurance policies to all patients. The physician also talked about the use of DPP materials in the SMA. After the introduction, the physician asked each patient to introduce themselves to the group and discuss their reasons for attending the SMA, weight loss strategies, current diet and exercise goals, as well as any other health concerns. The physician addressed these topics with each patient and documented the encounter within the EHR. If necessary, the physician was able to access the patient’s EHR to order a new prescription, procedure, or lab test. As each patient spoke, the behaviorist recorded the patient’s weight loss goals on a goal sheet for the patient to take home at the end of the SMA. In order to encourage attendance, the behaviorist also wrote a reminder for the next scheduled SMA on the patient’s goal sheet if the patient expressed interest in attending another SMA. A copy of the goal sheet was also provided to the medical assistant and physician, to record in the patient’s EHR. Throughout the SMA, patients were encouraged to share their own stories and provide support for other patients.
During the teaching portion of the SMA, the physician focused on one specific DPP lesson topic (e.g., getting started losing weight, healthy eating, ways to stay motivated). As a part of the DPP, patients learned skills such as including lifestyle activity throughout the day (e.g., parking the car further away from the store), staying away from food cue (e.g., popcorn at the movies), and preventing stress (e.g., practice saying “no”). The physician would discuss the lesson handouts and address any questions about the materials. If patients expressed similar problems or concerns during the SMA, the physician would then lead a group brainstorming session to address the problems or provide a short, educational lecture on a particular topic (e.g., hypertension). Although the SMA did not include a formal exercise program, patients were encouraged to exercise for a total of 150 minutes a week. At the close of each SMA, the physician encouraged patients to track their daily food intake and weight loss progress in their personal log.
REFERENCES:
- Diabetes Prevention Program. DPP Lifestyle Balance Program Materials. 1996; http://www.bsc.gwu.edu/dpp/lifestyle/dpp_part.html. Accessed October 27, 2009.
- Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. Feb 7 2002;346(6):393-403.