Evidence from the first Shared Medical Appointments (SMAs) randomised controlled trial in India: SMAs increase the satisfaction, knowledge, and medication compliance of patients with glaucoma.

In Shared Medical Appointments (SMAs), patients with similar conditions meet the physician together and each receives one-on-one attention. SMAs can improve outcomes and physician productivity. Yet privacy concerns have stymied adoption. In physician-deprived nations, patients' utility from improved access may outweigh their disutility from loss of privacy. Ours is to our knowledge the first SMA trial for any disease, in India, where doctors are scarce. In a 1,000-patient, single-site, randomized controlled trial at Aravind Eye Hospital, Pondicherry, we compared SMAs and one-on-one appointments, over four successive visits, for patients with glaucoma. We examined patients' satisfaction, knowledge, intention-to-follow-up, follow-up rates, and medication compliance rates (primary outcomes) using intention-to-treat analysis. Of 1,034 patients invited between July 12, 2016 -July 19, 2018, 1,000 (96.7%) consented to participate, and were randomly assigned to either SMAs (NSMA = 500) or one-on-one appointments (N1-1 = 500). Patients who received SMAs showed higher satisfaction (MeanSMA = 4.955 (SD 0.241), Mean1-1 = 4.920 (SD 0.326); difference in means 0.035; 95% CI, 0.017-0.054, p = 0.0002) and knowledge (MeanSMA = 3.416 (SD 1.340), Mean1-1 = 3.267 (SD 1.492); difference in means 0.149; 95% CI, 0.057-0.241, p = 0.002) than patients who received one-on-one appointments. Across conditions, there was no difference in patients' intention-to-follow-up (MeanSMA = 4.989 (SD 0.118), Mean1-1 = 4.986 (SD 0.149); difference in means 0.003; 95% CI, -0.006-0.012, p = 0.481) and actual follow-up rates (MeanSMA = 87.5% (SD 0.372), Mean1-1 = 88.7% (SD 0.338); difference in means -0.012; 95% CI, -0.039-0.015, p = 0.377). Patients who received SMAs exhibited higher medication compliance rates (MeanSMA = 97.0% (SD 0.180), Mean1-1 = 94.9% (SD 0.238); difference in means 0.020; 95% CI, 0.004-0.036, p = 0.013). SMAs improved satisfaction, learning, and medication compliance, without compromising follow-up rates or measured clinical outcomes. Peer interruptions were negatively correlated with patient satisfaction in early-trial SMAs and positively correlated with patient satisfaction in later-trial SMAs. Trial registration: The trial was registered with Clinical Trials Registry of India (https://ctri.nic.in/) with reference no. REF/2016/11/012659 and registration no. CTRI/2018/02/011998.

PROCESS AND SYSTEMS: A systems approach to embedding group consultations in the NHS.

Group consultations are an important care option that is -starting to gain traction in the USA and Australia. This review summarises the likely benefits accruing from a systems -approach to implementing group consultations widely in the NHS and other socialised healthcare systems. Existing evidence is mapped to five distinct systems approaches: (1) development; (2) different age groups; (3) patient-centred pathway of care; (4) NHS system changes; and (5) education. Implications are discussed for patients and staff, who both benefit from group consultations once embedded; ranging from improved access and efficiency to more enjoyable multidisciplinary team working, improved resource management, and maintained/better outcomes. Moreover, even patients who don't attend group consultations can benefit from system effects of long-term implementation. Changing behaviour and health systems is challenging, but change requires systematic experimentation and documentation of evidence. We conclude that group consultations have unique potential for delivering system-wide benefits across the NHS.