Background

Chronic pain is estimated to affect at least 20% of adults in the United States, with 7% of adults suffering from high-impact chronic pain that hinders their daily life and activities [1]. The societal toll of chronic pain is immense, contributing not only to large economic costs, but also to the suffering of individuals, families and communities [2, 3]. Chronic pain is also associated with significant comorbidities, opioid abuse, and poorer overall health. Groups with low socioeconomic status and racial/ethnic minorities are disproportionately affected by and undertreated for chronic pain [4,5,6,7,8]. The latest guidelines for chronic pain management recommend a biopsychosocial approach to care that is multi- or interdisciplinary, includes evidence-based nonpharmacological approaches, pain self-management support, and a trusting patient-clinician relationship [3, 9,10,11,12,13]. Despite the critical need for comprehensive and effective chronic pain care, the delivery of such care remains challenging. Comprehensive nonpharmacological approaches to pain management are resource intensive, involving multiple visits over time [3, 10,11,12, 14, 15].

Group medical visits (GMVs) offer an innovative and efficient model for providing comprehensive care for patients with chronic pain [16]. ‘Group medical visit’ and ‘shared medical appointment’ are broad terms used to describe multiple models of care that include a) care from one or more licensed clinicians, b) peer support, and c) health education. GMVs have the potential to meet the goals of the Quintuple Aim for healthcare quality improvement by 1) improving patient experiences (extended time with the provider, peer support, and engagement in care); 2) improving population health (improved pain managemenet); 3) lowering health care costs (more efficient care delivery); 4) improving provider experience, (increased job satisfaction); and 5) improving health equity (increasing access to guideline-concordant pain care for underserved communities) [17,18,19,20,21,22,23,24,25,26]. To achieve these goals, GMVs for treatment of chronic pain need to be more widely implemented and sustained.

Previous systematic reviews of GMVs have not focused specifically on chronic pain alone or looked specially at determinants of implementation for this innovation [27,28,29,30,31]. In this systematic review, we explored how GMVs for patients with chronic pain are implemented into clinical settings and identified factors that may determine when implementation is or is not successful. We utilized the updated Consolidated Framework for Implementation Research (CFIR), a widely-used implementation framework, to provide structure in identifying factors that determine successful implementation of innovations in multiple domains [32].

The goal of this review is to set the stage for development of implementation strategies to promote the widespread uptake of GMVs for chronic pain into clinical care. As well as informing clinical practice, the findings from this review may help identify important directions for future implementation research.

Methods

Study design

This mixed methods systematic review followed PRISMA guidelines, which are considered the gold standard for reporting [33, 34]. A review protocol in accordance with the PROSPERO guidelines for systematic reviews outlined the procedure to be adhered to during the review [35]. The protocol ensured that appropriate databases, key words and search terms were included. Experts in GMVs and implementation science reviewed the relevance of the search terms. The final systematic review protocol was established thorough an iterative process and was submitted to PROSPERO for registration (PROSPERO 2021 CRD42021231310) [36].

Search methods

The review included peer-reviewed studies that reported findings on the implementation of GMVs for chronic pain. Pubmed, EMBASE, Web of Science, and Cochrane Library were searched on October 10th, 2022. Search terms included “chronic pain,” “fibromyalgia,” “diabetic neuropathies,” “low back pain,” “headache disorders, “sickle cell anemia,” “arthritis,” “neurogenic pain” and “shared medical appointments” or “group medical visit,” as well as permutations of all terms using Boolean logic. For a detailed search strategy, see Appendix A.

Quantitative, qualitative, and mixed methods study designs, inclusive of experimental and observational study designs, were included. Opinion papers, protocol papers, systematic reviews (and other reviews such as scoping or narrative reviews), and editorials were excluded. Only full-length publications were included; conference abstracts were excluded. English language studies regardless of country where research was conducted were included.

Studies of GMVs (alternatively referred to as shared medical appointments or medical group visits) that focused on management of chronic pain conditions were included. For the purposes of this review, chronic pain is defined as pain that lasts more than three months.

GMVs are defined for the purposes of this review as:

  • Care is provided to multiple patients in the same room or telehealth meeting.

  • A licensed clinician documents the medical encounter (provider bills insurance using relevant ICD-10 codes and documents in the medical record).

  • Patients interact with each other during the group session.

Studies of individual medical appointments (not groups) for chronic pain were excluded. Studies of group therapy where no medical codes were billed and no medical provider was present were excluded, as group therapy with no medical component is a distinct intervention from GMVs.

Data extraction and synthesis

Two reviewers independently screened titles and abstracts using the inclusion and exclusion criteria. When disagreement occurred, two reviewers independently assessed full texts and came to an agreement.

Two reviewers extracted data from each article using a structured tool to extract key features of the included studies related to method, sampling approach, sample size, and characteristics of the study sample, innovation, and setting. Data related to implementation determinants (i.e., barriers and facilitators) were extracted from throughout the body of the manuscripts, as relevant information on contextual factors influencing implementation may be included throughout the body of the text. The data source and context within the text were extracted for each determinant. Reviewers compared extractions and reconciled differences.

Data synthesis was guided by the Consolidated Framework for Implementation Research (CFIR) [32], a comprehensive framework of determinants related to implementation. CFIR contains five domains (Innovation Characteristics, Inner Setting, Outer Setting, Characteristics of Individuals, and Process) and constructs within each domain. Determinants data were compiled and grouped by category by two reviewers independently and then sorted into CFIR domains.

To assess the quality of each article, two reviewers independently extracted data and assessed risk of bias using the Mixed Methods Appraisal Tool version 2018 [37]. Quality was assessed to determine the risk of bias in the findings presented in the included manuscripts. The Mixed Methods Appraisal Tool allowed for the assessment of bias across a broad range of study types. The tool provides distinct checklists of criteria to evaluate qualitative, quantitative, or mixed methods studies. Discrepancies were resolved by referral to the original studies and occasionally through arbitration by a third reviewer.

Results

Description of included studies

Thirty-three articles from 25 studies met criteria for inclusion (see Fig. 1). Most studies were conducted in the United States (n = 20). Twenty studies focused on patient populations with heterogenous chronic pain. The remaining five studies focused on patients with chronic non-cancer pain, chronic neuromuscular disorders, chronic pelvic pain, chronic back pain, and rheumatoid arthritis (see Table 1).

Fig. 1
figure 1

PRISMA diagram

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Table 1 Manuscript details
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Quality assessment

Eight manuscripts were qualitative, six were quantitative randomized controlled trials, nine were quantitative non-randomized, three were quantitative descriptive, and seven were mixed methods (see Tables 2, 3, 4, 5 and 6). Quality assessment ratings for articles ranged from 0 to 100%. The four studies that received ratings of 0 failed to do one or more of the following: present clear research questions, collect data that allowed them to answer their research questions, or provide adequate rationale for using a mixed methods design. On average, manuscripts with qualitative methods held the highest ratings, indicating high quality and low risk of bias, and manuscripts with quantitative, non-randomized methods held the lowest. The largest contributors to lower MMAT ratings included incomplete outcome data, failure to account for confounding variables in study design and analysis, nonresponse bias, and participants not being representative of the target population.

Table 2 MMAT bias assessment. Bias assessment for qualitative studies (n = 8)
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Table 3 MMAT bias assessment. Bias assessment for quantitative (randomized controlled trial) studies (n = 6)
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Table 4 MMAT bias assessment. Bias assessment for quantitative (non-randomized) studies (n = 9)
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Table 5 MMAT bias assessment. Bias assessment for quantitative (descriptive) studies (n = 3)
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Table 6 MMAT bias assessment. Bias assessment for mixed methods studies (n = 7)
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Description of participants involved

Articles included data from patients (n = 23), clinicians/staff (n = 2), or both patients and clinicians/staff (n = 2) (see Table 7). The mean age of participants ranged from 40 to 62 years old. In most studies, females comprised the large majority of participants (75% on average). Twenty articles included the racial or ethnic makeup of their participants. The participants in these articles, on average, were 41% non-Hispanic white, 24% Black or African American, 30% Hispanic, 1% Asian American or Pacific Islander, 5% Native American, and 9% other or unknown. Several studies explicitly focused on reaching racially and ethnically under-represented patient populations [40, 46, 48, 71].

Table 7 Participant demographics
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Characteristics of GMV innovations

Most studies evaluated group visit models with a pre-specified number of sessions (as opposed to some group visit models which conduct meetings indefinitely) (See Table 8). Studies reported on group visits delivered in English, Spanish, Dutch, Chinese, and Korean. Physicians facilitated the GMV in 21 studies, often in collaboration with physical therapists, nurses, physician assistants/nurse practitioners, and complementary and integrative practitioners. Eleven studies mentioned that group visits were billed fee-for-service via ICD-10 codes. Six studies describe specific health insurance coverage.

Table 8 Characteristics of group medical visit design and delivery
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Determinants of GMV innovations

Below, we present findings on determinants of GMV implementation, within each of the five CFIR domains (see Fig. 2). Only qualitative data on determinants of implementation was extracted, no included studies measured barriers and facilitators to implementation quantitatively. A summary of themes and selected illustrative quotes and data sources within the original manuscripts is presented in Table 9. A full accounting of source quotes and data sources within the original manuscripts is presented in Appendix B.

Table 9 CFIR determinants by domain
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Fig. 2
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Themes from the updated consolidated framework for implementation research

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Innovation characteristics

Relative advantage

Thirteen studies described the relative advantage of providing GMVs compared to other forms of chronic pain care [40, 44, 51, 53, 56, 57, 60, 61, 63, 64, 66, 68, 69]. Eight studies present survey data, interview data, or ethnographic observations in the “Results” section and five studies discussed relative advantages in the “Discussion” section. Patients (innovation recipients) and providers (innovation deliverers) described how their experience receiving or delivering care was improved in GMVs. Groups allowed providers to spend more time with their patients (typically GMVs are one to three hours long), provided access to complementary and integrative therapies, and improved patient-provider relationships.

One article also discussed the benefits of GMVs “over other types of group encounters,” including having groups facilitated by a billing provider who can document the visit in the electronic health record, and provide care coordination with other providers [57]. Another study described how the innovation “outperformed provider education,” suggesting its relative advantage over another commonly used innovation [63].

Cost to innovation recipients and health system

Four studies specifically discuss the cost of the innovation; either to the organization where group medical visits are implemented, or the patients who are receiving care [48, 51, 60, 62]. Two manuscripts mention that the GMV programs are either “financially self-sustaining [48]” or “broke even financially [51].” Two articles provided supporting cost data [51, 60]. Two articles discussed contextual information regarding cost in the “Discussion” section [48, 62]. Only one article included a cost-effectiveness analysis, which concluded that the group medical visit program “was more cost-effective than an individual appointment when a group size of more than 6 patients was maintained [60].” Another article addressed the issue of overbooking groups to minimize the financial impact of patients not attending [62].

Several studies reported on measures related to cost, including emergency room utilization [45, 49, 64], healthcare utilization [39, 54, 55], and wait times for appointments [62], all noting that GMVs reduced high-cost healthcare use and improved access to appointments.

Design and adaptability: population served

Two manuscripts described how the relative homogeneity or heterogeneity of the patients impacted the success of the innovation [52, 54]. The manuscripts come to differing conclusions about whether having an ethnically diverse population of innovation recipients is beneficial or not for the success of the innovation, with patients reporting that diversity was a benefit in one study [52], and the authors conjecturing that a mixed ethnicity setting may be challenging in the other study [54].

Inner setting

Tension for change: opportunities for treatment options

Two manuscripts reference the pressure of the opioid crisis leading to changes in clinic policy that created an opportunity for changing clinical treatment of chronic pain [55, 67]. Internal clinic policies created consistency and increased cohesiveness among staff [55], or may have provided an opportunity to offer new forms of clinical care [67].

Relational connections, communications, and culture: group recruitment and referral systems

Seven studies reported on the importance of referral networks and recruitment strategies within the clinical environment, though only two presented data to support this assertion [46, 48, 54, 55, 58, 63, 65]. Staffing to make reminder calls, physicians giving personal referrals to the group visit program, email reminders, and distributing lists of eligible patients to providers were all mentioned as important strategies for supporting innovation recipient recruitment.

Available resources: previous culture supporting groups

Seven studies discussed the importance of previous GMV programs in the organization [40, 42, 45, 48, 58, 63, 66]. Four manuscripts discussed GMVs for chronic pain that developed out of the same research group at Boston Medical Center and discussed how existing GMV programs helped to pave the way for additional research and iterations of GMVs for patients with chronic pain [40, 42, 43, 45]. An additional three manuscripts discussed how the presence of GMVs for other conditions at the clinical site, including obesity, diabetes, and group prenatal care, helped to lower the initial investment and reduce barriers to implementing chronic pain groups [48, 63, 66]. One manuscript presented data supporting showing how the lack of a previous culture supporting GMVs, and the lack of familiarity of the clinic’s providers and staff with the GMV model was a barrier to be overcome in successfully implementing groups [58].

Outer setting

Financing; policies and laws

Five studies reported on issues pertaining to financing and insurance reimbursement of GMVs, with three presenting qualitative data related to perceived financing challenges from the perspectives of clinicians and staff [55, 56, 65, 68, 69]. Group visit programs billed as group therapy or typical primary care visits, for instance, may not match the reimbursement providers receive for more complex pain consultation services [55]. One manuscript discussed the financial risk providers take by running group visit programs, as reimbursement is dependent on the number of patients enrolled [69]. One manuscript described successful billing practices [56], while another discussed insurance reimbursement as a barrier to GMVs and medical care in general [68].

Other financial barriers to group implementation concerned the burden participation in group visits placed on individual patients. One manuscript described how clinical staff expressed confusion over how to serve patients with high co-pays, the frequency of billing, and who was responsible for billing patients who participated in group programs [65].

One study referenced the challenges associated with compensating providers of nonpharmacological pain management services (e.g. acupuncturists), particularly because these services are not generally reimbursed by Medicare or Medicaid [65, 67].

Critical incidents and external pressure: opioid crisis and COVID-19 pandemic

Two studies mention challenges with implementation of GMVs pertaining to the ongoing opioid epidemic [51, 55]. Both studies describe challenges with enrolling or retaining patients in GMVs whose expectations around receiving opioid treatment did not match the policies of the clinic. Two studies briefly mentioned the COVID-19 pandemic, noting that both planning activities and GMVs could be conducted via telehealth due to the pandemic [58, 64].

Policies and laws: reimbursement of complementary and integrative health (CIH) practitioners

Two studies discuss challenges related to staffing GMVs with staff who are trained in complementary and integrative health (CIH) modalities [58, 65]. Thompson-Lastad [67] discussed how staff trained in a CIH modality such as acupuncture or yoga typically played multiple roles in their workplaces, primarily due to the lack of reimbursement to provide CIH services in individual visits.

Characteristics of individual

Innovation recipients: need

Ten studies reported on how group medical visits improved the innovation recipient’s quality of life, including improvements in self-efficacy, satisfaction, function, and improvements in physical and mental health [38, 42, 49, 50, 57, 61, 64, 65, 68, 70]. These improvements in well-being and personal fulfillment were attributed to the benefits of the innovation. One manuscript reported on innovation recipient’s negative expectations around group visits, including “fear the experience will be detrimental to their wellbeing due to possible contagion [62].”

Innovation recipients: opportunity

Ten manuscripts reported that patients had encountered logistical challenges in attending group medical visits. For in-person groups, barriers were largely related to transportation, scheduling, and health challenges making it difficult to attend. For telehealth groups, there were some challenges accessing technology and scheduling remained a challenge for some. Thus, innovation recipients (patients with chronic pain), lacked the opportunity or availability to fulfill their role in receiving the GMV.

Out of twenty five studies, eight mentioned that confidentiality was addressed within the group, six mentioned no concerns with confidentiality, seventeen did not document, and two manuscripts described intended innovation recipients who had concerns about privacy [61, 68], or feeling vulnerable or anxious in a group setting [52, 68].

Innovation recipients: motivation

Two studies discussed out-of-pocket costs from the patient perspective [52, 63]. When asked, patients were very opposed to paying a co-pay for a GMV, noting that they “perceived the group as a support group, noted that no other support groups cost money [52].” In another GMV, where innovation recipients were offered the overdose-reversing drug Nalaxone at a discount, the authors noted that the out-of-pocket cost was not a barrier for innovation recipients, and that they were all motivated to participate [63].

Opportunity for mid-level leaders and implementation leads: allocating administrative support

Two studies emphasized the importance of “adequate staffing and institutional support for patient recruitment [65].” The authors pointed out that identifying “patients was time consuming [69],” and thus required input from office staff and assistants. Depending on the clinical context, the individual making the decision to allocate staff time to supporting GMVs might be a mid-level leader or an implementation lead.

Innovation deliverers: capability and motivation

Twelve studies described the capabilities of the innovation deliverers as being essential to the success of the group visit programs. Some manuscripts emphasized the cultural expertise of the innovation deliverer, such as speaking the native language of innovation recipients [40] or sharing demographic characteristics with the recipients [54, 66] Others emphasized the skill and training of the innovation deliverers [48, 51, 52, 54, 66, 69, 70]. Some emphasized the importance of innovation deliverers being able to “step back while providing care in group visits [66]” and recipients described that “they came down on our level [44].”

Motivation, or ‘buy-in’ was also mentioned in two manuscripts as a particularly salient factor for innovation deliverers who provided integrative GMVs [58, 67]. The “openness” and “commitment” of innovation deliverers (clinicians delivering GMVs) to provide this unique type of care facilitated implementation.

Process

Assessing the needs of innovation recipients and innovation deliverers

Two studies discussed an assessment of the eligibility of patients to participate in the innovation, as well as the process of deciding what the eligibility criteria to participate in the GMVs should be [67, 69]. Some of the decisions over the inclusion criteria were based on “individual clinicians’ comfort with mental health conditions [67]” and providers’ assessment of which patients were suited to participating in groups.

Teaming, assessing context, and planning

One article discussed the importance of including administrative billing staff in the process of planning the implementation of a GMV program, particularly as it related to billing and financing of the program [55].

Discussion

While only five of the studies included in this systematic review [38, 58, 65, 68, 69] explicitly set out to evaluate barriers and facilitators to implementation of GMVs for patients with chronic pain, the studies included point to consistent implementation determinants for this healthcare innovation. The relative advantage of GMVs for chronic pain when compared with other available models for treating chronic pain was mentioned in almost half of the manuscripts included in this review. Other commonly mentioned determinants included the capability and motivation of individual innovation deliverers (clinicians), the cost of the innovation to recipients and the health system including reductions in healthcare utilization, the need and opportunity of innovation recipients (patients), the availability of resources and any previous culture supporting groups within the inner setting (clinic), the relational connections supporting recruitment and referral to group visits within the inner setting, and financing and policies within the outer setting. Some less commonly mentioned determinants included policies within the outer setting related to reimbursement of complementary and integrative health practitioners, the pressures of the opioid crisis both within the outer setting and subsequent tension for change within the inner setting, the motivation of innovation recipients, the adaptability and design of the innovation for differing populations, opportunity for implementation leads to allocate administrative support, and the process of assessing needs, assessing context, teaming, and planning. Collectively, the determinants point to substantial opportunities related to the ongoing opioid and chronic pain epidemics and need for non-opioid treatment options, as well as specific challenges related to implementing GMVs for chronic pain.

The overall quality of manuscripts included in this review as assessed using the Mixed Methods Appraisal Tool was mixed, with the highest quality ratings obtained by qualitative studies. Although the focus of this systematic review was not on quantitative outcomes, it is noteworthy that there was a range of risk of bias in the manuscripts included, including incomplete data reported, and few randomized controlled trials. This suggests an opportunity for more rigorously designed controlled trials to be conducted on GMVs for chronic pain.

Of note, the participants in the studies included in this review included a high proportion of Black or African American participants and Hispanic participants. Some of the studies focused specifically on clinical settings serving underserved or minority populations, which is consistent with the use of GMVs as a strategy to promote health equity.

Our review is the first to focus on GMVs for chronic pain, and to include substantial data on barriers to broader implementation of GMVs. Recent systematic reviews of GMVs have assessed program components and barriers and facilitators of GMVs for chronic conditions [27, 30, 31], the use of GMVs for buprenorphine therapy [72], and GMVs for women’s health conditions [28]. A systematic review of patient-centered experience in GMVs/shared medical appointments for a wide range of conditions found many benefits to GMVs over individual care, including extended time, higher levels of patient satisfaction overall and with patient-clinician relationships, benefits of peer support, and high levels of engagement among patient participants [73]. Recently, a systematic review evaluating the potential of GMVs to address the Triple Aim of healthcare improvement found evidence of benefits of GMVs in all three aims [29].

While there is significant need from patients with chronic pain and healthcare organizations looking to implement guideline-concordant pain management, this review suggests that there remains a need for further study of determinants of GMV implementation for chronic pain. Our findings suggest that factors in the inner setting and the motivation of key decision-makers have a substantive impact on implementation. Environments with previous experience with GMVs, where leaders and innovation deliverers are motivated and have buy-in, and where referral and recruitment networks have been activated, are primary drivers of implementation. Similarly, the needs and opportunities of patients with chronic pain (such as access to transportation, technology, available time, or other chronic conditions that may impact group attendance) may impact implementation of groups. In communities where there is limited opportunity to attend group visits, including particularly acute transportation or technology barriers, attendance at group meetings may be difficult. However, the needs of patients and the relative advantages of GMVs may help to overcome barriers to attendance. Recent studies of GMVs for patients with chronic conditions conducted during the COVID-19 pandemic have found that conducting GMVs via telehealth is feasible and may have benefits for patients with chronic conditions, particularly to avoid contracting respiratory illnesses [74, 75].

The cost and financing of implementing GMVs are key implementation determinants, but there have been few evaluations of the cost of implementing GMVs or evaluations of financing policies to date. Research evaluating the potential for GMVs to reduce emergency department utilization suggests potential cost savings to health systems. Future evaluation of the cost effectiveness of GMVs for chronic pain as well as changes to financing and policies relevant to the implementation of GMVs (such as licensing of CIH professionals or including GMVs in bundled payments) could help to address some major barriers to implementation.

Limitations

The implementation of GMVs for chronic pain is a topic that has generally been under-researched. With only five manuscripts explicitly focused on evaluating implementation determinants, this systematic review may be missing substantial context. Though other manuscripts included mention of implementation determinants in both their results and through contextual information incorporated into the body of manuscripts, these findings are limited in that these studies were not specifically designed to look at implementation issues.

Further, the majority of manuscripts included in this review are about studies conducted in the US. It is possible that there are alternative terms used in countries outside the US to describe comparable interventions to GMVs that the authors were not aware of. In the US, GMVs are often used as a strategy to overcome reimbursement barriers to guideline concordant chronic pain care. Although not conclusive, this may point to disproportionate use of GMVs for chronic pain care within the US context.

Innovation

Although several systematic reviews have been conducted related to GMVs, this is the first systematic review to look specifically at implementation determinants for chronic pain GMVs. Use of the updated CFIR may enhance the ability to generalize and compare the findings presented here to other evaluations of implementation determinants. With thorough understanding of implementation determinants, there is potential to develop implementation strategies and increase access to GMVs, to understand if and how GMVs meet the Quintuple Aim for healthcare improvement [17].

Conclusion

Group medical visits represent a potential innovation to improve access to guideline-concordant care for patients with chronic pain. There is urgency to implementing these innovations in the context of the ongoing opioid, chronic pain, and lingering COVID-19 pandemics. This review suggests that key determinants of implementation include the relative advantage of GMVs over other forms of chronic pain care, the motivation and capability of clinicians who will deliver GMVs, and the cost of GMVs to the healthcare system. Future research is needed to develop and test implementation strategies that address these determinants to promote the scale-up of GMVs for patients with chronic pain.