Chronic diseases represent the world’s leading cause of death and disability, accounting for 59% of all deaths and 49% of the global disability burden.¹ More than 75% of healthcare costs in the United States are attributed to complications of chronic disease.² Many patients with chronic disease seek and/or require treatment from multiple primary and specialty healthcare practitioners (HCPs). As a result, chronically ill patients may experience inconvenience, confusion, and frustration at needing to see different HCPs in multiple locations.

In a similar fashion, HCPs face a lack of consistent communication with their colleagues because the plan of care for patients with chronic disease involves so many people and is frequently complex. Input from numerous medical specialists may be required to render comprehensive care, which can adversely affect quality of care, patient safety, and overall health outcomes if this care is not well coordinated. Patient satisfaction and HCP satisfaction are compromised under these circumstances.³

Polycystic ovary syndrome (PCOS), a common chronic condition, affects approximately 7% of reproductive-aged women.⁴ In fact, PCOS is the most common endocrine disorder among women in this demographic group.⁴ Many women with PCOS see multiple HCPs—both primary care practitioners and specialists— none of whom takes the lead in overall management.  Likewise, this diverse group of HCPs may have little opportunity to discuss cases and coordinate their efforts.

The PCOS group medical visit (GMV) concept is designed to provide patient care at one location. Primary care practitioners and specialists such as dermatologists and endocrinologists participate in this collaborative endeavor. Patients receive individualized care and counseling, as well as educational information and the opportunity to network with other women dealing with the same problems. Overall objectives are consistency in care and personal empowerment to facilitate symptom management and prevent potential adverse health consequences.

Several medical websites, including PubMed and Google Scholar, were searched for articles related to PCOS. More than 9000 articles on PCOS-related topics such as treatment, diet, infertility, cardiovascular health, insulin resistance (IR), and prevalence in the adolescent population were identified.  The search was then refined to focus on PCOS treatment strategies, which produced more than 4000 articles. The topic was further narrowed to emphasize advances in diagnosis and treatment strategies, yielding 123 articles. These abstracts were reviewed for relevancy and currency.

A search of the American College of Obstetricians and Gynecologists website for information on PCOS yielded 32 citations dealing primarily with topics such as amenorrhea, infertility, and endometrial cancer. A search of Medscape revealed 272 relevant articles; this website was far more user-friendly and relevant than others in that it cited only those publications in English that addressed medical management strategies. As a result, this website was the primary online resource for the PCOS focus of this paper.

Print publications and journals, including Women’s Health Care: A Practical Journal for Nurse Practitioners, The Female Patient, Journal of the American Academy of Nurse Practitioners, and Contraception, were reviewed. Several articles from these publications were used.

Google Scholar and Ovid were used in the search for articles related to GMVs. Search terms included group medical visits, shared medical appointments, chronic disease collaboration, chronic care model, and patient education for chronic disease. More than 10,000 articles were found. When limited to GMVs and chronic disease, the search led to 50 results. Of the 50 articles, 7 were identified as research on interventions such as the GMV or the shared medical appointment. Most studies in the GMV literature search emphasized the importance of communication and teamwork in a collaborative practice setting.

Dorothea Orem’s self-care theory is central to any discussion of the utilization of GMVs for women with PCOS.⁵ In short, Orem’s selfcare framework stresses that individuals inherently want to care for themselves. Once self-care deficits are addressed and overcome, health-seeking behaviors and outcomes are maximized. Many women express feelings of confusion, disempowerment, and vulnerability after they learn that they have PCOS. As they navigate through the healthcare system, many of them have difficulty integrating various plans of care from multiple HCPs, and consequently experience frustration as well. The US healthcare system, in its present state, is inadequate in terms of addressing the complexities of PCOS or, for that matter, any chronic disease that requires management from a variety of medical generalists and specialists.

Crete and Adamshick⁶ utilized the Orem model to conduct a qualitative study of PCOS sufferers. Their research, which addressed quality-of-life issues, suggested a need for patients and HCPs to identify strategies that help patients acquire or maintain a sense of control.

Wagner’s chronic care model (CCM) was developed to help change the delivery of ambulatory care using evidence-based guidelines to improve clinical outcomes.¹ The premise behind the CCM was to design preventive care approaches for chronic disease sufferers so as to decrease the need for acute interventions. Six components were identified as being necessary for the CCM to improve management of chronic illness: (1) organizational support, (2) self-management support, (3) community resources; (4) decision support; (5) clinical information systems; and (6) delivery system design.

Using these theories and frameworks as a guidepost, the authors then searched the literature for articles related to the construct of the GMV for PCOS sufferers. Overall, the literature review points to a lack of coordinated effort among clinicians on behalf of patients with PCOS, resulting in inadequate care, poor adherence to treatment strategies, and increased risk for adverse health consequences, but it also suggests that the GMV has merit for these patients, and deserves more intensive study.

Polycystic Ovary Syndrome—Articles dating as far back as the mid-1930s have covered the syndrome of polycystic ovaries. Originally referred to as Stein-Leventhal syndrome by the physicians who identified it, PCOS was diagnosed in women with enlarged ovaries who experienced menstrual cycle irregularities, most notably, amenorrhea. For decades, professional medical organizations and societies have attempted to formalize protocols for diagnosis and treatment of patients with PCOS. Several manifestations of the syndrome, including hyperandrogenism and ovulatory dysfunction, have persisted throughout this process.

More recently, the connection between PCOS and two phenomena—IR and the metabolic syndrome (met-S)—has surfaced, potentially broadening diagnostic evaluation and treatment options. To date, however, no sanctioned protocol for diagnosis or treatment of PCOS exists.⁷

Dermatologic manifestations of PCOS may include hirsutism, acne, striae, and alopecia. Because of their chronic anovulation, PCOS sufferers are also at increased risk for certain reproductive cancers and infertility. Just as important, if not more so, is the relatively new relationship that has been established between PCOS and met-S. The prevalence of met-S is 15.6% in US women aged 20-39 years and 37.2% in those aged 40-59 years.8 Possible health consequences of met-S include diabetes, dyslipidemia, and hypertension (HTN), which can result in an enormous personal, social, and economic burden to patients and have a major impact on the healthcare system at large. Prevention strategies designed to identify women at risk for PCOS, as well as early diagnosis and intervention, must be priorities.

Several medical societies have attempted to develop a diagnostic template for PCOS; for example, the 1990 National Institutes of Health criteria included hyperandrogenism and either oligomenorrhea or amenorrhea.9 According to the 2003 Rotterdam Consensus Criteria, women receiving a diagnosis of PCOS needed to meet at least two of three criteria: hyperandrogenism, oligo/amenorrhea, and polycystic ovaries, as confirmed by ultrasonography (USG).¹⁰ The latest set of diagnostic criteria, published by the Androgen Excess Society in 2006, requires hyperandrogenism and either the presence of oligo/amenorrhea or polycystic ovaries on USG.¹¹

In addition to a lack of consensus regarding diagnostic criteria, experts disagree on laboratory assessment and management of patients with PCOS.¹² By tradition, patients have been triaged to multiple HCPs, including dermatologists, endocrinologists, gynecologists, and infertility specialists, in an effort to address symptoms and complications. As examples, menstrual cycle disorders and infertility concerns have been assigned to gynecologists; hirsutism and acne to dermatologists; and IR, obesity, pre-diabetes, dyslipidemia, and HTN to internists and other primary care practitioners. Obesity, sleep apnea, and depression are serious adjuvant co-morbidities commonly seen in women with PCOS, but these problems are frequently omitted in the evaluation and management processes.¹³

Patients with PCOS are typically frustrated by a lack of knowledge about the syndrome, as well as ineffective or inconsistent treatment recommendations and interventions.¹⁴ This lack of knowledge and control can result in anxiety, depression, and a sense of guilt.

Polycystic ovary syndrome is not only complicated and confusing, but also costly. In 2005, Azziz et al¹⁵ estimated the health care-related burden of PCOS to exceed $4 billion. The breakdown of this cost was $93 million for the initial evaluation, $1.3 billion for treatment of abnormal uterine bleeding, $533 million for infertility care, $622 million for treatment of dermatologic disorders, and $1.77 billion for management of diabetes-related outcomes.

Is there a better way to coordinate care for women with PCOS that not only helps them navigate the healthcare system but also manage their disease and perhaps save money in the long run? The GMV may offer promise in this regard.

Group Medical Visits—GMVs egan to surface in the 1990s within large healthcare delivery systems.¹⁶ Initial benefits included minimized patient backlog, improved access to care, lower healthcare costs, improved patient and HCP satisfaction, and increased psychosocial support for patients.¹⁷ The GMV concept, emphasizing collaborative care among a group of HCPs, has become an emerging trend in the nation’s effort to improve the quality and delivery of care to patients. GMVs entail individualized meetings with an HCP, educational programs dealing with the specific disease, and interactive group discussions. These types of visits allow increased time for self-management education, skill building, and HCP–patient interaction.² Many patients gain confidence in their self-care abilities when they witness other group members' successful behavior changes.²

The first HCP to include GMVs was John Scott, MD, in a Kaiser Permanente practice in Colorado.^18,19 Dr Scott gave elderly chronically ill patients the option of seeing him in groups of 15-20 people. In 2004, Dr Scott reported the results of a study in which he compared the effectiveness of group visits (called cooperative health care clinic visits, or CHCC visits) with that of traditional one-on-one patient visits.¹⁹ He found that patients attending CHCC visits, compared with the control group, made fewer emergency department (ED) visits, experienced greater satisfaction, stayed healthier, and incurred lower costs. Since Dr Scott’s first CHCC was founded, more of these types of clinics have been instituted and are effectively and efficiently operating throughout the country.

Bergeson and Dean³ aimed to address the issues of fragmented care, dissatisfied and poorly managed patients, and frustrated HCPs. They recommended identification of a care coordinator or case manager who could consolidate information, provide consistency in care, promote a sense of continuity, and serve as a resource for patients. Favorable outcomes associated with this type of plan include decreases in overprescribing or in overlapping prescriptions, fewer adverse drug interactions, and lower treatment costs.²⁰

Jaber et al² pointed out that GMVs improve HCP productivity, which results in HCP satisfaction. Noffsinger and Atkins²¹ reported a provider productivity level increase of 256.4%; in this 4-physician setting, the number of patients seen in the traditional manner was 16.3, vs 41.8 in the GMV format. Increased participation by patients in a primary care delivery system produces an economic advantage and decreased hospital/ED use.¹⁹ In an environment where medical costs and deliverables are being scrutinized, new and cost-effective ways of delivering care are needed. GMVs may be an innovative way to accomplish this goal.

The GMV concept has obvious benefits for both patients and HCPs. Since 1995, healthcare leaders have been attempting to implement group visits into primary and specialty care clinics. Multidisciplinary teams are required to make GMVs in CHCCs successful. As the US healthcare delivery system evolves, innovations such as GMVs could improve consumer satisfaction while increasing revenue and decreasing HCP burnout.

The GMV has some downsides. Unless appropriate consent forms are developed and utilized, GMVs may generate Health Insurance Portability and Accountability Act concerns. In addition, some HCPs prefer one-on-one encounters over group discussions. Scott et al¹⁹ cautioned that some frail elderly patients who participated in GMVs did not improve in terms of functional impairment, disease outcomes, or independent living.

Watts et al¹⁷ evaluated the nurse practitioners’ chronic care model (CCM) as it affects patient education. In particular, the authors monitored each patient’s participation in the group, assessing changes in self-care and empowerment skills. The analysis showed that participation in the CCM resulted in improved decision making and self-management. In addition, the CCM was credited as having an effective delivery system design.

Another study assessed the effect of GMVs for patients with congestive heart failure.²² The authors theorized that patients would learn more about the disease process by communicating with other patients and HCPs in a group setting. They concluded that patients developed increased confidence from the GMVs. They surmised that peer support results in increased motivation to achieve favorable health outcomes.

Shared medical appointments have been successful in dealing with complex, chronic conditions. Greer and Hill²³ evaluated the utility of the GMV in a small group of patients with met-S.  They assessed three outcomes: body mass index (BMI), weight, and waist circumference. After the intervention, only the decrease in waist circumference was statistically significant. However, peer support, self-management, and continuity were cited as important factors affecting behavioral changes necessary to improve outcomes.

Group medical visits typically incorporate patient education, peer support, and patient-to-patient mentorship. Bergeson and Dean³ confirmed that the self-management skills acquired through group education can improve self-efficacy, promote behavior change, and improve patient outcomes. To further address this concept, the Institute of Medicine (IOM) has recommended that all HCPs be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.²⁴

A CHCC utilizing GMVs could help a team of HCPs address a common objective—comprehensive care for patients with PCOS. This care would follow evidence-based guidelines and would be provided at a central location. Objectives for this CHCC would include: (1) increasing patient and HCP satisfaction; (2) implementing an educational module to educate patients about PCOS; (3) educating patients regarding options in care (empowerment); and (4) assisting patients in developing strategies to improve their own health and decrease the risk for adverse consequences of PCOS.

The PCOS clinic would provide consolidated, collaborative care by multiple HCPs, including, but not limited to gynecologists, internists, dermatologists, psychiatrists, endocrinologists, dieticians, exercise physiologists, and aestheticians—all in one location. Time would be allocated for patient education, peer/provider interaction, and the GMVs. A  flow chart for visits has been developed to make maximum use of time and provide as much individualized care to each patient as possible (Table).

A study conducted by Colwell et al¹⁴ provided intensive education to PCOS patients over 13 months. The study validated that patient education and individualized treatment plans were necessary to motivate patients to prevent adverse disease outcomes. Furthermore, the authors concluded that structured education and follow-up would stimulate health-promoting lifestyle changes.

A collaborative PCOS clinic utilizing GMVs would aim to achieve the objectives of the CCM and of Orem’s theory of self-help and empowerment. Foci of this clinic would include collaboration among HCPs (healthcare organization), provision of effective patient education (clinical information systems), promotion of empowerment (self-management support), and implementation of a change from individual visits to shared medical appointments (delivery system design). Through educational support, patients would increase their understanding of the evidence-based guidelines to be able to become engaged participants in the plan of care.

Additional research is needed in the arena of chronic disease management. Studies evaluating unique, cost-effective options in health care that are both patient and HCP friendly must be designed. Supporting this concept, Harris et al²⁵ have suggested that focus on teamwork among HCPs and resources for patient empowerment be implemented on a broad scale.

Because of the prevalence of PCOS in the United States, additional innovative approaches to management of this syndrome must be a priority. Patient education programs must be initiated and evaluated. Obesity, diabetes, and heart disease are health consequences directly related to late identification and intervention for women with PCOS. Early, evidence-based health strategies can help prevent or limit these common disease outcomes. The GMV concept is one option to improve delivery of effective, efficient, high-quality health care. DNP programs must display a leadership role in designing new and cutting-edge strategies to improve patient outcomes in the evolving world of 21st-century health care.