Patient Perspectives on Lifestyle Medicine Virtual Group Visits

Abstract

Lifestyle Medicine Virtual Group Visits (LMVGVs) have potential for providing effective lifestyle education and counseling to patients who have or are at risk for chronic disease. The purpose of this study was to assess primary care patients’ motivations for participation in and preferences for future engagement with LMVGVs. This was a cross-sectional survey conducted in an academic community-based clinic. A total of 111 patients who signed up for LMVGVs between September 2020 and August 2021 completed the survey between February and April 2022. Patient demographics and LMVGV attendance data were collected from the medical record. The most common reported reasons for signing up for LMVGVs were to focus on lifestyle changes and to lower chronic disease risk. The most common reasons for attending subsequent LMVGVs were the focus on healthy lifestyle changes and the positive focus of the groups. Almost all (98%) respondents who attended ≥5 LMVGVs indicated they would recommend LMVGVs to family or friends. Most respondents preferred monthly LMVGVs, including 71% of those who attended ≥5 LMVGVs. These findings inform efforts to develop LMVGVs that are feasible and acceptable to patients, contributing to the promotion of lifestyle behaviors that aid in the prevention and treatment of chronic disease.

“Respondents were motivated to join both initial and subsequent LMVGVs to modify lifestyle factors and to reduce chronic disease risk. Respondents also returned to LMVGVs in large part due to the positive group experience.

Purpose

Group medical visits, also called shared medical appointments, have expanded over the past two decades due to the unique benefits they confer to patients with chronic medical conditions. ¹ A group medical visit allows for several patients with common medical conditions to meet together with a clinician (e.g., physician or nurse practitioner) who can provide both general education about chronic disease care as well as patient-specific guidance. These visits are longer in duration than most individual medical visits, typically lasting 60 minutes or more, and may involve multidisciplinary teams of providers (e.g., physicians, nutritionists, and/or health and wellness coaches). In group medical visits, patients can also voice their questions and share their personal experiences of chronic disease to the benefit of other patients. ²

Clinical improvements associated with group medical visits have been demonstrated in a wide range of settings.^3-7 In addition, prior studies have also identified that patient and provider satisfaction is consistently high in a variety of group medical visit programs, with patients expressing interest in attending additional groups.^2,4,8-11 Contributing factors to patient satisfaction include accessibility, peer support and collective problem solving, time and attention from clinicians, motivation for self-management, and a positive emphasis on health promotion and disease management.^2,8,10-13 Group medical visits have been shown to ease physician workload, ¹² help overcome “repetition fatigue” associated with individual visits, ⁸ and increase overall productivity. ¹¹ Group medical visits have also been shown to be more efficient and cost-effective than individual outpatient appointments, leading to improved access and reduced acute health care service utilization in emergency departments and specialist visits.^2,4,8,13,14

To date, most group medical visits have been conducted in person. In response to the COVID-19 pandemic, however, virtual group medical visits have been conducted on telehealth video platforms.^1,15,16 Early research on virtual group visits demonstrated feasibility and acceptability, ¹ and virtual group visits have been studied in patients with type 2 diabetes mellitus, obesity, and vitiligo.^17-19

Lifestyle Medicine Virtual Group Visits (LMVGVs) are virtual group medical visits that focus on evidence-based behavior changes such as healthy eating, physical activity, and stress reduction. LMVGVs in primary care are emerging as a novel approach to help manage and prevent chronic diseases.^20-22 A growing body of literature indicates that LMVGVs aid in addressing important barriers to accessing outpatient care, including time constraints and transportation costs, that disproportionately impact high-risk patient populations. ²⁰ Conducting visits using a virtual platform also facilitates patient access to a wider variety of lifestyle medicine resources, such as culinary skill teaching, and offers opportunities for family member involvement. ²¹ Findings from a recent single arm pilot study suggest that LMVGVs may have clinical benefits for hypertension, leading to reductions in both blood pressure and antihypertensive medication dosing. ²³ Patient reported outcomes of participation in LMVGVs are also promising. In a recent cross-sectional survey of 111 primary care patients participating in LMVGVs, respondents reported improvements in healthy eating, physical activity, weight loss, stress levels, blood pressure, blood sugar, and sleep. ²²

While measures of patient satisfaction regarding virtual group medical visits are high,^24-26 little is known about patients’ motivations for participating in LMVGVs. Improving knowledge about patients’ experiences with LMVGVs can inform the development and scaling of LMVGVs that are responsive to patient needs and interests, increase patient engagement, and potentially contribute to improvement of chronic disease control. The goal of the current study was to assess patients’ motivations for participating in LMVGVs and preferences for future engagement with a LMVGV program. We hypothesized that patients were motivated to join LMVGV programming and attend subsequent LMVGVs primarily because of an interest in making healthy lifestyle changes to prevent and treat chronic conditions.

Methods

Methods for this survey study are previously reported. ²² Briefly, this study was a cross-sectional survey of adult (i.e., 18 years and older) primary care patients at a community health clinic who signed up to participate in ≥1 LMVGV in the Massachusetts General Hospital’s Healthy Lifestyle Program (HLP) between September 1, 2020 and August 31, 2021. Three physicians individually led 60-minute LMVGVs on hypertension (4-part series), diabetes and prediabetes (4-part series), nutrition (rotating monthly topics), stress reduction (rotating monthly topics), and insomnia (2-part series). There were approximately 2-3 LMVGVs offered each week. Patients were encouraged to sign up for additional LMVGVs after completing a LMVGV session or series. Health and wellness coaches were integrated into each LMVGV and offered up to 6 months of one-on-one virtual coaching visits free of charge to all patients. Records for one-on-one health and wellness coaching were not available for this study.

Participants were surveyed after their participation in the LMVGVs. Surveys were mailed to patients’ homes between February 7, 2022 and March 23, 2022, and they could be completed on paper or online. The study protocol included up to 3 reminder phone calls by research staff to remind the patient to complete the survey. Two waves of surveys were sent out and each wave included up to 3 phone calls. The development of survey questions was informed by literature review of studies regarding patient participation in LMVGVs as well as the clinical observations of the investigators.^3-7 Survey items were then developed, and content validity of the survey was established by an interactive process of review by content experts, including physicians with experience conducting LMVGVs. After revision of the survey items based on expert feedback, the survey instrument was deployed for data collection. The complete survey is included in the Appendix.

As previously reported, 261 patients were contacted to complete the survey, and 124 patients (48%) completed the survey. There were 13 respondents who were excluded from study analysis because of discrepancies between their survey responses and attendance data. ²² 111 participants completed the survey and were included in this analysis. Survey respondents were predominantly female (73%) and non-Hispanic White (83%) with a mean age (SD) of 60.6 (12.5) years. There were 49 patients (44%) who reported attending college or more education, 41 (37%) who reported “excellent” or “very good” overall health, and 8 (7%) who reported “often” experiencing loneliness. There were 12 respondents who attended 0 LMVGVs, 51 respondents attended 1-4 LMVGVs, and 48 respondents attended ≥5 LMVGVs (Figure 1).

Figure 1.

Reason for signing up for initial LMVGV (N = 111). Survey respondents signed up to participate in ≥1 LMVGV between September 1, 2020 and August 31, 2020. Surveys were mailed to patient’s homes between February 7, 2020 and March 23, 2020. Respondents were able to check all responses that applied.

In addition to previously reported demographic, socioeconomic, and health measures from the survey, respondents were asked why they signed up for their first LMVGV. They were provided a list of options and were asked to “check all that apply,” including wanting to make lifestyle changes, lower disease risk, reduce medications, and spend more time with their doctor. Respondents who indicated that they attended ≥1 LMVGV were asked to indicate all the reasons they attended subsequent LMVGVs. Respondents were asked to “check all that apply” for the following options: liking the positive focus, enjoying being part of a group of people with similar health goals, enjoying engaging with the doctor in a group setting, focusing on healthy lifestyle changes, and not needing to come to the doctor’s office for the visit (i.e., having a virtual rather than in-person visit). All respondents who attended ≥1 LMVGV were asked how their experiences compared to their expectations and whether they would recommend LMVGVs to family or friends. Additional demographic characteristics, including patient age, sex, race, and ethnicity were obtained from the EHR along with the LMVGV dates for which the patient signed up and the attendance outcome of each visit. The study was reviewed and deemed exempt by the Mass General Brigham Institutional Review Board on November 29, 2021.

Patient characteristics were summarized using means with standard deviations for continuous variables and frequencies with percentages for categorical variables. Based on the distribution, we categorized number of LMVGVs attended into 3 categories: 0, 1-4, and ≥5 attended. ²² All analyses were conducted using SAS version 9.4 (SAS Institute, Cary, NC).

Results

The most common reasons that patients signed up for their first LMVGV, regardless of subsequent attendance, were to focus on lifestyle changes (50% who attended 0 LMVGVs, 69% who attended 1-4 LMVGVs, and 85% who attended ≥5 LMVGVs) and to lower risk of chronic disease such as heart disease or diabetes (67% who attended 0 LMVGVs, 59% who attended 1-4 LMVGVs, and 71% who attended ≥5 LMVGVs) (Figure 1). Other less frequently reported reasons for respondents signing up included a desire to reduce medications and to spend more time with their doctor.

Among all patients attending ≥1 LMVGV (N = 77), the most frequent reasons for attending subsequent LMVGVs included the focus on healthy lifestyle changes (70%) and the positive focus of the groups (68%). Other common reasons included being in a group with patients who had similar health goals (57%), being with the doctor who led the group (56%), and not having to commute to the doctor’s clinic (52%) (Figure 2).

Figure 2.

Reason for attending subsequent LMVGVs for survey respondents who reported attending more than one visit (N = 77). Survey respondents signed up to participate in ≥1 LMVGV between September 1, 2020 and August 31, 2020. Surveys were mailed to patient’s homes between February 7, 2020 and March 23, 2020. Respondents were able to check all responses that applied.

Most patients (65%) who attended ≥1 LMVGV reported that their LMVGV experience was better than their expectations, including 88% of respondents who attended ≥5 LMVGVs and 43% of those who attended 1-4 LMVGVs (Table 1). A total of 93% of respondents indicated that they would recommend an LMVGV to family or friends, including 98% of patients who attended ≥5 LMVGVs.

Table 1.

LMVGV Experience for Survey Respondents Who Attended at Least One Visit (N = 99).

LMVGVs Attended	Total	1-4	5+
	N = 99	N = 51	N = 48
Patient perspectives, N (%)
How did LMVGV compare to expectations?
Worse	6 (6.1)	5 (9.8)	1 (2.1)
Same	26 (26.3)	22 (43.1)	4 (8.3)
Better	64 (64.6)	22 (43.1)	42 (87.5)
Recommend LMVGV to family or friends?
No	4 (4.0)	3 (5.9)	1 (2.1)
Yes	92 (92.9)	45 (88.2)	47 (97.9)

LMVGVs = Lifestyle Medicine Virtual Group Visits. Survey respondents signed up to participate in ≥1 LMVGV between September 1, 2020 and August 31, 2021. Surveys were mailed to patients’ homes between February 7, 2022 and March 23, 2022. 3 of the respondents did not answer these questions.

Most respondents (57%) preferred monthly LMVGVs, including 71% of those who attended ≥5 LMVGVs. Preferences for the time of day for LMVGVs were divided between morning (35%), afternoon (32%), and evening (30%) (Table 2). At the time of the survey (Spring 2022), most respondents preferred virtual groups (48%), although 23% expressed an interest in attending in-person groups and 26% expressed an interest in attending hybrid groups when the COVID-19 infection risk was lower.

Table 2.

Patient Preferences for LMVGV Scheduling (N = 111).

LMVGVs Attended	Total N = 111	0 N = 12	1-4 N = 51	5+ N = 48
Patient preferences, N (%)
Time
Morning	39 (35.1)	6 (50.0)	19 (37.3)	14 (29.2)
Afternoon	36 (32.4)	4 (33.3)	14 (27.5)	18 (37.5)
Evening	33 (29.7)	2 (16.7)	15 (29.4)	16 (33.3)
Prefer not to answer	3 (2.7)	0 (0.0)	3 (5.9)	0 (0.0)
Frequency
Weekly	36 (32.4)	7 (58.3)	16 (31.4)	13 (27.1)
Monthly	63 (56.8)	4 (33.3)	25 (49.0)	34 (70.8)
Yearly	7 (6.3)	1 (8.3)	6 (11.8)	0 (0.0)
Prefer not to answer	5 (4.5)	0 (0.0)	4 (7.8)	1 (2.1)
Method for learning about future groups
Patient portal	64 (57.7)	6 (50.0)	26 (51.0)	32 (66.7)
Email	23 (20.7)	2 (16.7)	12 (23.5)	9 (18.8)
Phone call	9 (8.1)	2 (16.7)	2 (3.9)	5 (10.4)
Mailing	7 (6.3)	1 (8.3)	5 (9.8)	1 (2.1)
Flyer	4 (3.6)	1 (8.3)	3 (5.9)	0 (0.0)
Prefer not to answer	4 (3.6)	0 (0.0)	3 (5.9)	1 (2.1)
Method for signing up for future groups
Patient portal	68 (61.3)	8 (66.7)	27 (52.9)	33 (68.8)
Email	28 (25.2)	2 (16.7)	14 (27.5)	12 (25)
Phone call	7 (6.3)	1 (8.3)	4 (7.8)	2 (4.2)
Mailing	4 (3.6)	1 (8.3)	2 (3.9)	1 (2.1)
In clinic	1 (0.9)	0 (0.0)	1 (2.0)	0 (0.0)
Prefer not to answer	3 (2.7)	0 (0.0)	3 (5.9)	0 (0.0)
Prefer for visit type after Covid?
In-person	25 (22.5)	6 (50.0)	11 (21.6)	8 (16.7)
Virtual	53 (47.7)	3 (25.0)	25 (49.0)	25 (52.1)
Hybrid	29 (26.1)	3 (25.0)	11 (21.6)	15 (31.3)
Prefer not to answer	4 (3.6)	0 (0.0)	4 (7.8)	0 (0.0)

LMVGVs = Lifestyle Medicine Virtual Group Visits. Survey respondents signed up to participate in ≥1 LMVGV between September 1, 2020 and August 31, 2021. Surveys were mailed to patients’ homes between February 7, 2022 and March 23, 2022.

Discussion

The results of this study describe patients’ experiences of and preferences for LMVGVs. Nearly half of survey respondents attended 5 or more LMVGVs, demonstrating a willingness to spend time focused on lifestyle medicine in a virtual group setting. Respondents were motivated to join both initial and subsequent LMVGVs to modify lifestyle factors and to reduce chronic disease risk. Respondents also returned to LMVGVs in large part due to the positive group experience. Respondents reported high satisfaction with the LMVGV programming, including more than half of respondents who endorsed a better-than-expected experience.

Previous research has suggested patient preferences for group care as compared with individual visits. ¹⁰ Findings from this study are similar to what has previously been reported for in-person group medical visits, in which both clinicians and patients have reported positive experiences.^{2,4,8-11,14,27} Participants in in-person group medical visits have rated their care as more accessible and sensitive to their needs as compared with patients attending traditional, one-on-one medical visits. ¹⁰ Previous research has demonstrated high rates of participant interest in attending additional group medical visits in the future ¹¹ and demonstrated higher levels of satisfaction among patients who attend multiple group medical visits. ¹⁰ The findings of this study suggest that these benefits translate to the virtual group medical visit setting. In addition, virtual group medical visits may further promote the accessibility of these visits by eliminating logistical barriers such as transportation.

In addition to the emphasis on lifestyle changes, many respondents cited the positive focus of the program as the reason they returned for subsequent LMVGVs. The uniquely positive focus on health promotion in LMVGVs, and lifestyle medicine in general, contrasts with the often negative perceptions of standard health care in the United States. ²⁸ Outside of group medical visits, the ability of positive psychology to improve lifestyle factors has been well-studied. For example, positive psychological constructs such as optimism and gratitude are associated with healthy eating patterns, and an intervention focused on positive psychology was shown to increase physical activity in the community setting.^29-31

In this study, survey respondents expressed similar preferences for morning, afternoon, and evening LMVGVs. These findings suggest that offering LMVGVs at a variety of times of day could promote the accessibility of visits for a diverse patient population. More than half of survey respondents reported that they preferred monthly LMVGVs, a response that was most pronounced among those who attended ≥5 visits. This indicates that LMVGV programs will need to find the optimal balance between the time commitment of attending recurring visits and the support offered by frequent meetings. At the time of this survey in Spring 2022, most respondents reported that they preferred virtual group visits, but a significant number reported that they would prefer hybrid or in-person group visits when the risk of COVID-19 was lower. These findings underscore the value of telehealth platforms for promoting continued access to care during the COVID-19 pandemic and suggest that patient preferences regarding group visit platforms may evolve with the changing status of public health risk.

Because our study did not include the perspectives of patients who did not sign up for or attend LMVGVs, we were not able to directly assess patient perspectives on barriers to attending LMVGVs. Given the wide range of patient preferences related to time of day for LMVGVs and overall preference for in-person or hybrid groups, logistical factors may have influenced patient participation. Previous studies have also highlighted other potential barriers to LMVGV participation such as patient hesitancy to participate in novel forms of care delivery and insufficient motivation for engaging in health behavior change. ⁸ Future research will be needed to fully contextualize the patient LMVGV experience and to understand barriers to accessing care. These studies may benefit from the use of qualitative methods to further elucidate the factors that shape patient participation in LMVGVs.

Based on the findings of this study, several changes have been made to the operations of the HLP. First, based on patient motivations for chronic disease prevention, additional programming has been added that focuses on hyperlipidemia and obesity management through healthy lifestyle changes. Second, in response to the strong endorsement of the positive nature of LMVGVs, HLP programming has enhanced the focus on positive psychology to improve behavior change. Finally, LMVGV time offerings have been extended to span from morning to early evening to accommodate the wide range of patient preferences identified here.

Overall, this is a descriptive study of a convenience sample of patients who had signed up to participate in the LMVGVs at a health center located in a low-income urban community near Boston, MA. While findings may not be generalizable to all settings, LMVGVs are a relatively new model for helping patients make lifestyle changes, and there is little research about the characteristics and experiences of patients who self-select to participate in these programs. There were several additional limitations of this study. First, LMVGVs were only offered in English. Most respondents were White and female with a mean age of 61, limiting the generalizability of these findings to other demographic groups. Also, survey respondents self-selected to participate in LMVGVs, and there was no comparison group of patients who participated in one-on-one lifestyle medicine appointments available. Patients were able to sign up for LMVGVs at any time during the study period, meaning that some patients were surveyed before completing subsequent LMVGVs. Because surveys were distributed after the conclusion of the LMVGVs, patients completed the survey at different time points in their relation to their participation. Resultantly, recall bias may be an additional limitation of this study. Finally, uncertainty about telemedicine and health and wellness coaching reimbursements might impact the financial viability of future LMVGV programming in some health care systems.

In conclusion, many patients who attended LMVGVs were motivated by the desire to make healthy lifestyle changes and had positive experiences in the LMVGVs. Respondents who attended LMVGVs most frequently had higher program satisfaction compared to respondents who attended less frequently, suggesting that longitudinal participation in LMVGVs could be associated with better outcomes. Findings from this study support the need for more research to examine health and behavioral outcomes resulting from LMVGV participation.

ORCID iDs

Dana Vigue https://orcid.org/0000-0002-3512-1983

Jacob Mirsky https://orcid.org/0000-0001-9353-7226