Group Medical Visits for Patients With Dyslipidemia

The healthcare system is in crisis. On one hand, the population requires more healthcare services due to aging and the increasing prevalence of chronic diseases. On the other hand, proportionally fewer healthcare professionals are available to meet the demand. Ample evidence suggests that strengthening the primary healthcare system could improve the population's health, particularly among individuals with chronic diseases, including cardiovascular diseases. The introduction of group medical visits (GMVs) is one proposed innovation to revitalize primary healthcare. GMVs are a type of medical appointment offered to a group of patients with similar medical conditions, replacing the traditional one-on-one consultation format. During a GMV, patients can receive a health assessment, education about their condition, including the prevention of complications, as well as prescriptions, lab test requests, or referrals to other healthcare professionals. GMVs have been integrated into primary healthcare systems in other countries (primarily to promote healthy lifestyle modifications) and are associated with clinically significant improvements in patient behaviors and health outcomes. Other studies have also shown that GMVs improve access to primary healthcare, reduce emergency department visits, and enhance quality of life, self-efficacy, and patient satisfaction with care. However, most studies assessing the effectiveness of GMVs focused on patients with diabetes, meaning there is little information on the impact of GMVs on patients with other conditions predisposing to cardiovascular diseases. However, several barriers to implementing GMVs have been identified, including uncertainty about remuneration for the intervention. The government of New Brunswick recently approved a billing code allowing family physicians to be compensated for providing GMVs to patients with specific conditions, including dyslipidemia - which is at the origin of most cases of cardiovascular diseases, and which can be effectively managed with lifestyle interventions. Nevertheless, this code has seen little to no use due to uncertainty surrounding how best to implement GMVs. The main objective is to assess the implementation of GMVs for patients with dyslipidemia in a NB-based primary healthcare clinic serving over 15,000 patients. This is meant to prepare the ground for a large trial.

It is estimated that >4,000 patients at the study clinic have dyslipidemia. A new series of VMGs will be launched every 3-6 months and 20 patients with dyslipidemia will be invited for each series. Simultaneously with the implementation of GMVs, a data collection process will take place to evaluate the quality of implementation using the RE-AIM framework. Through this process, Reach will be represented by the proportion of invited patients who participate in GMVs. Additionally, sociodemographic data from the clinics' electronic medical record (EMR) system will be used to assess whether participating patients are representative of all eligible patients. Effectiveness will be assessed by administering pre- and post-GMV questionnaires to measure changes in patient knowledge, self-efficacy, behavioral change intentions, and actual behaviors (using surveys from the Canadian Health Measures Survey by Statistics Canada). Effectiveness will also be assessed by comparing the clinical outcomes (i.e., lipids, hospitalisation for cardiovascular conditions) of the patients recruited with those of matched controls identified through the EMR. Adoption will be assessed as the proportion of eligible patients invited to GMVs by their primary care providers. Implementation will be evaluated through a modified interactive assessment grid to evaluate which key elements of the initiative were delivered as planned. All challenges encountered and any adaptations made to the implementation plan will also be considered as part of the implementation assessement. Maintenance: physicians and clinic managers will be surveyed about their willingness to continue offering GMVs for patients with dyslipidemia. Additionally, the number of GMVs delivered through every six month period will be monitored to track variations in service delivery.

Inclusion criteria

• Diagnosis of dyslipidemia according to the guidelines of the Canadian Cardiovascular Society, i.e., at a minimum: an intermediate cardiovascular risk according to the Framingham Risk Score (10-19.9%) WITH LDL-C ≥ 3.5 mmol/L or non-HDL-C ≥ 4.2 mmol/L or ApoB ≥ 1.05 g/L

Exclusion criteria

• Patients unable to participate in GMV sessions or to provide informed consent

• Patients with a mental health condition likely to limit their ability to benefit from GMV sessions and discussions (Examples: severe dementia or an acute psychiatric decompensation occurring within the past six months)
• A diagnosis of terminal illness or a life expectancy of less than 12 months