Wednesday, 13 July 2016

ClinicSpeak: group clinics for MSers

What is your risk of falling and sustaining a fracture? What can you do about it? #ClinicSpeak #MSBlog 

"I have mentioned many times before that I think the current healthcare model in relation to MS diagnosis and management in the NHS is broken. It is based on a synchronous model of one-to-one consultations typically in specialised centres. MSers have to travel long-distances, to get a cursory examination and very short amount of time with their HCP. At Barts-MS we are trying to disrupt this model, but are having difficulty getting funding for new initiatives. We tested our first falls and bone health group clinic yesterday with 12 patients with MS who are at high risk of falling. The clinic was moderated by a person with MS and included a multidisciplinary team with a neuro-physiotherapist (Claire Townsend), a MS clinical nurse specialist (Freya Edwards), a content designer (Alison Thomson) and myself. I was filling in for our registrars who had done all the leg-work and heavy lifting in terms of designing and implementing the clinic. Verbal feedback from the patients yesterday was overwhelmingly positive; it is clear patients got much more out of a 3-hour clinic than they would do out of a 15 minute one-to-one consultation. We will now use this experience to improve the clinic and hopefully use the data we collect to support a grant application to study this form of service development formally. You can see from the systemic review below there is an unmet need in relation to group clinics in MS. However, to get group clinics accepted and adopted we will have to collect data to prove that they are cost-effective (save the NHS money), prevent falls and fractures (reduce healthcare utilisation), improved patient quality of life and are an improvement on what we offer at present (staff and patient satisfaction). We plan to put all of our group clinic material online so that other MSers could access the material and use it themselves for self-management. Alison will be posting on this topic in much more detail."

BACKGROUND:  Group clinics are a form of delivering specialist-led care in groups rather than in individual consultations.

OBJECTIVE: To examine the evidence for the use of group clinics for patients with chronic health conditions.

DESIGN: A systematic review of evidence from randomised controlled trials (RCTs) supplemented by qualitative studies, cost studies and UK initiatives.

DATA SOURCES: We searched MEDLINE, EMBASE, The Cochrane Library, Web of Science and Cumulative Index to Nursing and Allied Health Literature from 1999 to 2014. Systematic reviews and RCTs were eligible for inclusion. Additional searches were performed to identify qualitative studies, studies reporting costs and evidence specific to UK settings.

REVIEW METHODS: Data were extracted for all included systematic reviews, RCTs and qualitative studies using a standardised form. Quality assessment was performed for systematic reviews, RCTs and qualitative studies. UK studies were included regardless of the quality or level of reporting. Tabulation of the extracted data informed a narrative synthesis. We did not attempt to synthesise quantitative data through formal meta-analysis. However, given the predominance of studies of group clinics for diabetes, using common biomedical outcomes, this subset was subject to quantitative analysis.

RESULTS: Thirteen systematic reviews and 22 RCT studies met the inclusion criteria. These were supplemented by 12 qualitative papers (10 studies), four surveys and eight papers examining costs. Thirteen papers reported on 12 UK initiatives. With 82 papers covering 69 different studies, this constituted the most comprehensive coverage of the evidence base to date. Disease-specific outcomes – the large majority of RCTs examined group clinic approaches to diabetes. Other conditions included hypertension/heart failure and neuromuscular conditions. The most commonly measured outcomes for diabetes were glycated haemoglobin A1c (HbA1c), blood pressure and cholesterol. Group clinic approaches improved HbA1c and improved systolic blood pressure but did not improve low-density lipoprotein cholesterol. A significant effect was found for disease-specific quality of life in a few studies. No other outcome measure showed a consistent effect in favour of group clinics. Recent RCTs largely confirm previous findings. Health services outcomes – the evidence on costs and feasibility was equivocal. No rigorous evaluation of group clinics has been conducted in a UK setting. A good-quality qualitative study from the UK highlighted factors such as the physical space and a flexible appointment system as being important to patients. The views and attitudes of those who dislike group clinic provision are poorly represented. Little attention has been directed at the needs of people from ethnic minorities. The review team identified significant weaknesses in the included research. Potential selection bias limits the generalisability of the results. Many patients who could potentially be included do not consent to the group approach. Attendance is often interpreted liberally.

LIMITATIONS: This telescoped review, conducted within half the time period of a conventional systematic review, sought breadth in covering feasibility, appropriateness and meaningfulness in addition to effectiveness and cost-effectiveness and utilised several rapid-review methods. It focused on the contribution of recently published evidence from RCTs to the existing evidence base. It did not reanalyse trials covered in previous reviews. Following rapid review methods, we did not perform independent double data extraction and quality assessment.

CONCLUSIONS: Although there is consistent and promising evidence for an effect of group clinics for some biomedical measures, this effect does not extend across all outcomes. Much of the evidence was derived from the USA. It is important to engage with UK stakeholders to identify NHS considerations relating to the implementation of group clinic approaches.

FUTURE WORK: The review team identified three research priorities: (1) more UK-centred evaluations using rigorous research designs and economic models with robust components; (2) clearer delineation of individual components within different models of group clinic delivery; and (3) clarification of the circumstances under which group clinics present an appropriate alternative to an individual consultation.

FUNDING: The National Institute for Health Research Health Services and Delivery Research programme.


  1. Having fallen myself I can tell you it is really a frightening and LIMITING experience. While I've made gains against my MS my gait is still a bit of a wreck. Once one has fallen one has it in ones head, thats good and bad. Good in that one is more aware of hazards. Bad in that one may see hazards where they do not exist and by being too cautious go for a ride to the ground.

    I know several others that have fallen as well.

    It would be WONDERFUL if these clinics could be put into video for other MS'ers around the globe. We'd be delighted to put them into incoming traffic on our site.

  2. Great idea - patients learn a lot from other patients - as well from healthcare professionals. We are all experts in our own disease and often other patients can convey things in laymen's terms quite well. Hope the results prove interesting!

  3. Well done in getting the falls and bone clinic up and running. I was very lucky to be involved in the testing for this clinic before it was made available to people who attend MS clinics at the Rotal London Hospital. During the testing and evakuation I learnt so much on the physiotherapy and balance side. I am a frequent faller and I am well aware how much a fall can reduce self confidence. I have to use a walkig aid all the time.

    If the falls clinic is a success how about doing one for people who have bladder and bowel problems. An increase in the awareness of your limitations and what is available to improve quality of life through a face to face clinic is invaluable. It is so much more effective than reading a pamphlet that attempts to answer all the questions to all the problems.


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