Group Clinic for Chemoprevention of Squamous Cell Carcinoma: A Pilot Study
Topical 5-fluorouracil (5-FU) is a valuable treatment of actinic keratosis (AK), but its use is limited by bothersome side effects. To evaluate patient satisfaction with a regimen of 5-FU for AK in group clinics, we offered participation in shared medical appointments (SMAs) to dermatology clinic patients diagnosed with AK at the Providence VA Medical Center in Rhode Island. Approximately 3 to 4 patients attended each pair of sessions spaced 2 weeks apart. At each visit, photographs and feedback were obtained; at the second visit, clinicians graded the patients’ reactions to 5-FU according to a validated numeric scale. Of the 14 study patients who attended the second SMA, 10 stated that they completed 2 weeks of 5-FU therapy, and the other 4 stated that they completed at least 11 days. The validated scale used during the second visit to grade the patients’ 5-FU reactions confirmed that all 14 patients demonstrated at least 1 expected adverse skin reaction. Feedback about the group setting was uniformly positive, with specific appreciation for the educational aspects, normalization of the treatment process, and opportunities to ask questions. The group clinic setting for 5-FU was well received and is a promising model for delivering this important treatment.
Practice Points
- Shared medical appointments (SMAs) enhance patient experience with topical 5-fluorouracil (5-FU) treatment of actinic keratosis (AK).
- Dermatologists should consider utilizing the SMA model for their patients being treated with 5-FU, as patients demonstrated a positive emotional response to 5-FU therapy in the group clinic setting.
Comment
Shared medical appointments promote treatment adherence in patients with chronic heart failure and diabetes mellitus through efficient resource use, improvement of access to care, and promotion of behavioral change through group support.7-13 Within the dermatology literature, SMAs are more profitable than regular clinic appointments.15 In SMAs designed to improve patient education for preoperative consultations for Mohs micrographic surgery, patient satisfaction reported in postvisit surveys was high, with 84.7% of 149 patients reporting they found the session useful, highlighting how SMAs have potential as practical alternatives to regular medical appointments.16 Similarly, the feedback about the group setting from our patients who completed both appointments was uniformly positive, with specific appreciation for the normalization of the treatment process and opportunity to ask questions with their peers.
The group setting—where patients were interacting with peers undergoing the same treatment—provided an encouraging environment during the course of 5-FU therapy, resulting in a positive treatment experience. Additionally, at the conclusion of the second visit, patients reported an increased understanding of their condition and the importance of future sun-protective behaviors, further demonstrating the impact of this pilot initiative.
The Veterans Affairs’ Current Procedural Terminology code for a group clinic is 99078. Veterans Affairs medical centers and private practices have different approaches to billing and compensation. As more accountable care organizations are formed, there may be a different mixture of ways for handling these SMAs.
,Limitations
Our study is limited by the small sample size, selection bias, and self-reported measure of adherence. Adherence to 5-FU is excellent without group support, and without a control group, it is unclear how beneficial the group setting was for adherence.17 The presence of the expected skin reactions at the 2-week return visit cannot account for adherence during the interval between the visits, and this close follow-up may be responsible for the high adherence in this group setting. The major side effects with 5-FU are short-term. Nonetheless, longer-term follow-up would be helpful and a worthy future endeavor.
Veterans share a common bond of military service that may not be shared in a typical private practice setting, which may have facilitated success of this pilot study. We recommend group clinics be evaluated independently in private practices and other systems. However, despite these limitations, the patients in the SMAs demonstrated positive reactions to 5-FU therapy, suggesting the potential for utilizing group clinics as a practical alternative to regular medical appointments.
Conclusion
Our pilot group clinics for AK treatment and chemoprevention of SCC with 5-FU suggest that this model is well received. The group format, which demonstrated uniformly positive reactions to 5-FU therapy, shows promise in battling an epidemic of skin cancer that demands cost-effective interventions.
