Shared medical appointments for the preoperative consultation visit of Mohs micrographic surgery Thomas J. Knackstedt, MD,a and Faramarz H. Samie, MD, PhDa,b Lebanon and Hanover, New Hampshire Background: Shared medical appointments (SMAs) allow patients with similar diagnoses to be simultaneously educated and cared for by 1 provider. SMAs appear well suited for Mohs micrographic surgery because all patients receive similar information about skin cancer pathophysiology, prognosis, prevention, treatment, reconstructive options, and wound care. Objective: We sought to create a SMA for the preoperative consultation visit of Mohs micrographic surgery and to evaluate patient satisfaction with this model. Methods: A pilot SMA was implemented. Patient satisfaction was assessed via a 13-question survey over a 6-month period. Results: In all, 149 patients were seen in our SMAs. The survey response rate was 65.8%. Respondents answered Likert scale questions with a mean value of 4.29 6 0.09 (on a 1-5 scale, where 5 is the best). Patients found the SMA model useful (84.7%) and would attend another SMA in the future (80.6%). Limitations: Limitations include the sample size of the study, relatively homogenous patient population, possible response bias, and a potential selection bias (as all participants in the SMA chose this type of appointment rather than a conventional one). Conclusions: SMA can be successfully used for the Mohs preoperative consultation visit with high patient satisfaction. ( J Am Acad Dermatol 2015;72:340-4.) Key words: dermatologic surgery; Mohs micrographic surgery; outcomes research; patient satisfaction; shared medical appointments; skin cancer.
ver 3.6 million cases of nonmelanoma skin cancer are diagnosed annually.1 The majority are basal cell carcinoma and squamous cell carcinoma. Mohs micrographic surgery may be used to treat nonmelanoma skin cancer. In a survey of the American College of Mohs Surgery members, 67% of respondents reported performing preoperative consultations.2 The benefits of consultation include patient and surgeon familiarity, increased patient education, and improved preoperative planning.3 Shared medical appointments (SMAs) have been used for over 15 years and allow a group of patients
with similar medical conditions to be simultaneously cared for or educated by 1 provider.4 SMAs have been used for patients with diabetes, congestive heart failure, asthma, hypertension, and chronic kidney disease and have demonstrated fewer hospitalizations, decreased emergency department visits, and increased patient satisfaction with their overall care.5,6 For physicians, SMAs reduce daily repetition, decrease downtime, and may increase productivity.7,8 Patient satisfaction with SMAs can be as high as with conventional appointments.9 Within surgical specialties, SMAs for bariatric surgery visits have proven to be a cost-efficient way to provide
From the Section of Dermatology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon,a and Geisel School of Medicine, Dartmouth College, Hanover.b Funding sources: None. Conflicts of interest: None declared. Parts of this research were presented at the American College of Mohs Surgery Annual Meeting on May 1, 2014 in Phoenix, AZ. Accepted for publication October 16, 2014.
Reprint requests: Faramarz H. Samie, MD, PhD, Section of Dermatology, Department of Surgery, Dartmouth-Hitchcock Medical Center, 1 Medical Center Dr, Lebanon, NH 03766. E-mail: [email protected]
Published online November 21, 2014. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.10.022
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completion at home (see below). In the individual care with shorter waiting times and high patient examination rooms, each patient’s medical history satisfaction.8 and pathology were reviewed by the senior physiSMAs are well suited for the Mohs preoperative cian (F. H. S.). A focused physical examination was consultation as patients receive similar information performed and a photograph of the marked surgical about skin cancer pathophysiology, prognosis, presite was taken with the patient’s written consent. vention, treatment, reconstructive options, and Consent for the upcoming surgical visit concluded wound care. We implemented a SMA for the prethe consultation. Fig 1 shows operative visit of Mohs the flow of events in our SMA micrographic surgery and CAPSULE SUMMARY model. evaluated patient satisfaction through a survey. Shared medical appointments are an Outcome measures effective and interactive visit model that Patient satisfaction was METHODS has been successfully used in many assessed via an anonymous SMA design specialties. 13-question survey (Table I) Several unique SMA Shared medical appointments can be given to all patients attending models have been described. successfully used for the perioperative SMAs between August 2013 We combined features of consultation visit of Mohs micrographic and February 2014. Survey Physicals SMA, where the surgery with high patient satisfaction. questions were categorized examination of patients to evaluate the structure, occurs in private as part of a Shared medical appointments should be content, and overall patient routine annual examination considered a viable alternative to the satisfaction. Survey comor subspecialty care, and conventional visit model. pletion was defined per Cooperative Health Care Lenexa.12 In addition, mean Clinics, which use group education with individual counseling, to create our census levels and patients per provider hour combined group and individual visit pilot SMA.10,11 were calculated for SMAs and compared with conventional appointments. Only patients with a biopsy-proven basal cell carcinoma or squamous cell carcinoma were eligible. Patients who previously had been treated RESULTS with Mohs micrographic surgery with the senior In all, 149 patients, average age 70.9 (range author (F. H. S.) were ineligible for the SMA. Patients 32-94) were seen in 20 SMAs in the 6-month period who had prior Mohs micrographic surgery outside of (Table II). SMA attendance averaged 7 to 8 our institution remained eligible for the SMA. patients (mean 7.1; range 5-10) per 90-minute Schedulers described the structure and goals of the period. For the same time period, 6 patients are SMA and patients chose either the SMA or a convenscheduled in the conventional appointment tional individual appointment. Patients were invited format. Sessions were attended by 82 (55.0%) to bring family members or caregivers to the SMA. men and 67 (45.0%) women with 159 skin cancers. A total of 123 (77.4%) basal cell carcinoma Visit structure and 36 (22.6%) squamous cell carcinoma were We surmised that the optimal clinic flow would seen. result from a group education visit followed by In all, 98 patients completed and returned individual examinations. Ninety minutes were the mail-in survey, resulting in a 65.8% response allocated for the completion of the appointments. rate. In all surveys returned, over 80% of the The first part of the visit was spent in a dedicated questions were answered, resulting in a complete SMA room. A 20-minute PowerPoint presentation survey response. Overall, survey respondents (Microsoft, Redmond, WA) developed by the senior answered the Likert scale questions with a mean physician (F. H. S.) and nursing staff covered value of 4.29 6 0.09 (on a scale of 1-5, where 1 is the the etiology, prognosis, risk factors, treatments, worst and 5 is the best). Table III summarizes reconstructive options, postoperative wound care the overall mean responses for individual Likert instructions, and an overview of the day of surgery. scale questions. A total of 56 (87.7%) respondents Dedicated time for questions followed, although strongly agreed or agreed that they had patients were also encouraged to ask questions adequate time with the provider and received throughout the lecture. Before completing this thorough care (88.8%). Patients strongly agreed segment, a 1-page satisfaction survey was given to or agreed that they were informed about their the patient together with a postmarked envelope for diagnosis (84.7%) and treatment options (84.7%). d
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Fig 1. Structure and flow of the shared medical appointment.
Table I. Patient satisfaction survey questions Part 1: Yes-no-undecided Was the SMA useful? Do you prefer the SMA style? Do you feel prepared for your procedure? Would you opt to attend another SMA? Were issues addressed that you did not anticipate? Part 2: 5-Point Likert scale Please rate your satisfaction with following: Amount of time spent with the provider Thoroughness of care Information about diagnosis Information about treatment options Clarity and number of questions answered Degree of involvement in decision-making Comfort level in the SMA Part 3: Open-ended question Do you have any additional comments? SMA, Shared medical appointment.
Furthermore, 76.5% of respondents report that issues were addressed that they did not anticipate. Most patients (84.7%) found the SMA to be useful, felt prepared for the upcoming procedure (95.9%), and even preferred the SMA over a conventional visit (71.4%). Of the respondents, 80.6% would opt to attend a SMA in the future. See Figs 2-4 for detailed response rates.
DISCUSSION A SMA for the preoperative consultation visit of Mohs micrographic surgery was developed and a survey was designed to capture patient satisfaction with the structure, content, and overall SMA experience. Demographics of our SMA attendees are consistent with previous data.13,14
Table II. Characteristics of shared medical appointment attendees Average SMA attendance Attendees Age, y Male Female Tumors Basal cell carcinoma Squamous cell carcinoma
7.1 (range 5-10) 149 70.9 (range 32-94) 82 (55.0%) 67 (45.0%) 159 123 (77.4%) 36 (22.6%)
SMA, Shared medical appointment.
Table III. Likert scale questions: average response rates with SD Question:
Amount of time spent with the provider Thoroughness of care Information about the diagnosis Information about the treatment options Clarity and number of questions answered Degree of involvement in decision-making Comfort level in the SMA Overall
Average response rate (SD)
4.27 4.4 4.26 4.32 4.43 4.16 4.23 4.29
(0.99) (0.90) (0.98) (0.98) (0.87) (1.09) (1.00) (0.09)
SMA, Shared medical appointment.
Patient satisfaction for SMAs can be high. Overall, survey respondents answered the Likert scale survey questions with a mean value of 4.29 on a 5-point scale. One of the primary goals of the SMA was to improve patient education. The majority of survey respondents strongly agreed that the SMA educated them on the diagnosis and potential treatment options of their condition. As in other educational ventures, the group dynamics of SMA sessions can be unique. Recognizing this variability, it is reassuring
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Fig 2. Patient satisfaction with the flow and design of the shared medical appointment.
Fig 3. Patient satisfaction with the educational component of the shared medical appointment.
that patients felt comfortable or very comfortable in the SMA in 82.2% of cases and would opt to attend another SMA (80.6%). Nevertheless, it should be noted that although patient satisfaction can be high, SMAs are likely suitable for most but not all patients. In addition to the responses to our postvisit survey, individual patient comments were very encouraging. Patients found the appointment ‘‘very helpful and informative’’ and believed that it ‘‘makes [them] more relaxed.’’ Furthermore, patients stated that ‘‘this [SMA] is an efficient use of everyone’s time’’ and asked to ‘‘please continue this program.’’ Our SMA model facilitated focused patient visits and decreased provider repetition. Costs associated with the implementation of a SMA have previously been attributed to increased administrative support, social workers, or other facilitators for group visits.7,15 Implementing the SMA had no associated cost in our experience. No changes to our administrative staff,
nursing, or provider number were required. In addition, the in-depth education allows for increased contact time between patient and provider and may result in an improved patient-physician relationship. Selecting the optimal number of patients for a group visit is challenging. SMA attendance in our series ranged from 5 to 10 patients and 8 patients seemed to be the optimal number. Potential limitations of our study include its sample size and response rate, potential for a response bias, and a homogenous patient population from an academic referral center. All participants in the SMA chose this appointment model over a conventional one. As there was no randomization of patients to different appointment models a selection bias was possible. This survey was anonymous to obtain the most accurate survey responses. Consequently, precise characterization of nonresponders and their preferences for SMA versus conventional appointments was not possible.
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Fig 4. Patient satisfaction with the overall shared medical appointment (SMA) experience.
Conclusion A successfully implemented SMA for the Mohs micrographic surgery preoperative consultation visit can result in high patient satisfaction. Patients are educated about their disease and treatment options while benefitting from the questions and concerns raised by others. Patients are involved in the decision-making and feel prepared for the upcoming procedure. SMAs can be viable model for the delivery of patient-focused care. REFERENCES 1. Rogers HW, Weinstock MA, Harris AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol. 2010;146:283-287. 2. Campbell RM, Perlis CS, Malik MK, Dufresne RG Jr. Characteristics of Mohs practices in the United States: a recall survey of ACMS surgeons. Dermatol Surg. 2007;33:1413-1418. 3. Sharon VR, Armstrong AW, Jim On SC, Ibrahimi OA, Eisen DB. Separate- versus same-day preoperative consultation in dermatologic surgery: a patient-centered investigation in an academic practice. Dermatol Surg. 2013;39:240-247. 4. Beck A, Scott J, Williams P, et al. A randomized trial of group outpatient visits for chronically ill older HMO members: the Cooperative Health Care Clinic. J Am Geriatr Soc. 1997;45:543-549. 5. Edelman D, McDuffie JR, Oddone E, Gierisch JM, Nagi A, Williams JW. VA evidence-based synthesis program reports. Shared medical appointments for chronic medical conditions: a systematic review. Washington (DC): Department of Veterans Affairs; 2012. 6. Scott JC, Conner DA, Venohr I, et al. Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic. J Am Geriatr Soc. 2004;52: 1463-1470.
7. Sidorsky T, Huang Z, Dinulos JG. A business case for shared medical appointments in dermatology: improving access and the bottom line. Arch Dermatol. 2010;146: 374-381. 8. Seager MJ, Egan RJ, Meredith HE, Bates SE, Norton SA, Morgan JD. Shared medical appointments for bariatric surgery follow-up: a patient satisfaction questionnaire. Obes Surg. 2012;22:641-645. 9. Page C, Reid A, Hoagland E, Leonard SB. WellBabies: mothers’ perspectives on an innovative model of group well-child care. Fam Med. 2010;42:202-207. 10. Noffsinger EB. Running group visits in your practice. 1st ed. New York: Springer; 1999. 11. Millermaier E, Neuwirth Z, Noffsinger E, Prescott D. Shared medical appointments: a proven health care delivery model. In: Massachusetts Medical Society Conference Proceedings. November 6, 2009. Available at: http://www.massmed.org/ Continuing-Education-and-Events/Conference-ProceedingArchive/Shared-Medical-Appointments/#.VGZ-bPnF841. Accessed November 14, 2014. 12. Lenexa KS. American Association for Public Opinion Research. (2011). Standard Definitions: Final dispositions of case codes and outcome rates for surveys (7th ed). Available at: http://aapor.org/ Content/NavigationMenu/AboutAAPOR/StandardsampEthics/ StandardDefinitions/StandardDefinitions2011.pdf. Accessed November 14, 2014. 13. Gray DT, Suman VJ, Su WP, Clay RP, Harmsen WS, Roenigk RK. Trends in the population-based incidence of squamous cell carcinoma of the skin first diagnosed between 1984 and 1992. Arch Dermatol. 1997;133:735-740. 14. Harris RB, Griffith K, Moon TE. Trends in the incidence of nonmelanoma skin cancers in southeastern Arizona, 1985-1996. J Am Acad Dermatol. 2001;45:528-536. 15. Griffin BL, Burkiewicz JS, Peppers LR, Warholak TL. International normalized ratio values in group versus individual appointments in a pharmacist-managed anticoagulation clinic. Am J Health Syst Pharm. 2009;66:1218-1223.