John Dixon

THROUGHOUT history, healers have used the clinical process of one-on-one consulting — “expert” advising “patient”.

This has served humanity well for the infections, injury and odd case of demonic possession that have dominated health. However, the increase in chronic diseases has dramatically altered the landscape.

No longer is a medicament, advice or surgery sufficient or necessarily appropriate to manage what can amount to complex, lifetime metabolic, cardiovascular, respiratory or carcinogenic disorders.

Recognition of this led to changes to the Medicare Benefits Schedule (MBS), originally conceived in the 1970s. Changes were made to the MBS in 1999 and 2005 in respect to patients with complex or chronic problems, to include primary care item numbers for patient management plans and team care arrangements with allied health professionals.

Support for group diabetes education, with an expert leader and small group of patients (ie, 1:10‒20) followed. Still, the march of chronic disease goes on.

In dealing with chronic disease, it appears too much is expected of the individual medical practitioner in the 1:1 clinical role and too little in the 1:10 educational role

But a compromise is in the wings.

Shared medical appointments (SMAs), according to their US-based initiator De Edward Noffsinger, are “a series of consecutive individual medical visits in a supportive group setting where all can listen, interact, and learn”. In other words, an SMA is a comprehensive medical visit, which fits between a single clinical consultation and a group education session.

The process, as developed in the US and now trialled in several countries, has particular relevance for lifestyle-related chronic diseases. It has been described by one US clinic, in which SMAs were introduced 10 years ago, as “an innovative, interactive approach to healthcare that brings patients with common needs together with one or more healthcare providers. While an individual appointment typically lasts 15 to 30 minutes, a shared appointment is 90 minutes long, allowing participants to spend more time with the healthcare team”.

The effectiveness of SMAs has been demonstrated with a range of health problems, but MBS funding rules in Australia are perceived as having limited the initiative here.

For example, item 23 of the MBS states a service must be “provided in the course of a personal attendance by a single medical practitioner on a single patient on a single occasion”. This has been interpreted as excluding group treatments. However, SMAs are not group treatments but individual treatments in front of a group.

With preliminary funding from the Royal Australian College of General Practitioners, we are currently finishing an assessment of patient and clinician acceptance of 24 SMAs for type 2 diabetes in eight Australian primary care centres involving about 200 patient visits. The assessment is not designed at this stage to measure clinical outcomes.

To date, the assessment has found both clinicians and patients are overwhelmingly in favour of the process with 100% of those patients attending saying they would come back to an SMA, and the majority stating they preferred this to a single consultation. A recent US study which included 921 SMA patients and 921 usual care patients had similar results.

The process has been particularly popular with marginal groups such as lower socioeconomic status bulk-billed patients, those in rural and remote areas, the elderly, and Indigenous men. In our research many of these patients claim they are heard more and learn more from SMAs than in a usual care consultation. The most common statement is: “It’s good to hear from others with similar problems”.

Most importantly, clinicians involved claim to relish the opportunity to use their skills in an interactive group atmosphere.

Although our current study is not focused on clinical outcomes, published data suggest outcomes equal or exceed those from the usual care approach.

While SMAs are not intended to replace the single consult, the findings from our early work reinforce an application made  last year to the Medical Services Advisory Committee by the Australian Lifestyle Medicine Association for the introduction of an MBS item number for SMAs.

The next steps for SMAs are to ensure quality control, to identify the chronic diseases where they are likely to be most effective, and to evaluate medium- to long-term outcomes.
 

Professor John Dixon is a NHMRC Senior Research Fellow with the Baker IDI Heart and Diabetes Institute, Melbourne. Professor Garry Egger is adjunct professor of health and applied sciences at Southern Cross University, and at the Centre for Health Promotion and Research, NSW.

Appreciation is expressed to Dr John Stevens for his contribution to this work.

COI:
Garry Egger: The Australian Lifestyle Medicine Association may develop training for clinicians in running SMAs in the future.
John Dixon: I have no conflicts to declare.