Healthcare providers experiences with shared medical appointments for heart failure.

Shared medical appointments (SMAs) offer a means for providing knowledge and skills needed for chronic disease management to patients. However, SMAs require a time and attention investment from health care providers, who must understand the goals and potential benefits of SMAs from the perspective of patients and providers. To better understand how to gain provider engagement and inform future SMA implementation, qualitative inquiry of provider experience based on a knowledge-attitude-practice model was explored. Semi-structured interviews were conducted with 24 health care providers leading SMAs for heart failure at three Veterans Administration Medical Centers. Rapid matrix analysis process techniques including team-based qualitative inquiry followed by stakeholder validation was employed. The interview guide followed a knowledge-attitude-practice model with a priori domains of knowledge of SMA structure and content (understanding of how SMAs were structured), SMA attitude/beliefs (general expectations about SMA use), attitudes regarding how leading SMAs affected patients, and providers. Data regarding the patient referral process (organizational processes for referring patients to SMAs) and suggested improvements were collected to further inform the development of SMA implementation best practices. Providers from all three sites reported similar knowledge, attitude and beliefs of SMAs. In general, providers reported that the multi-disciplinary structure of SMAs was an effective strategy towards improving clinical outcomes for patients. Emergent themes regarding experiences with SMAs included improved self-efficacy gained from real-time collaboration with providers from multiple disciplines, perceived decrease in patient re-hospitalizations, and promotion of self-management skills for patients with HF. Most providers reported that the SMA-setting facilitated patient learning by providing opportunities for the sharing of experiences and knowledge. This was associated with the perception of increased comradery and support among patients. Future research is needed to test suggested improvements and to develop best practices for training additional sites to implement HF SMA.

Introduction

Heart failure (HF) is a major public health problem affecting over 6 million people in the United States with an estimated cost greater than $30 billion each year [1]. Approximately 20% of all patients hospitalized for HF within the Veterans Health Administration (VHA) are re-hospitalized within 30 days, illustrating the burden on patients and the healthcare system [2]. Effective self-management strategies such as a healthy diet, medication adherence, and recognizing when to seek treatment can improve quality of life and reduce hospitalizations for people who are diagnosed with HF, especially when unhealthy behaviors and risk factors are addressed [3]. Yet, HF remains a complex chronic disease where comprehensive patient-centered care that includes supportive and medical care services including dietary, social, pharmacy and rehabilitative services are provided to the patient in coordination with primary and specialty care is difficult to achieve [4].

In a shared medical appointment (SMA) multiple patients with a common chronic illness are seen together by at least two healthcare providers often with expertise in nursing, psychology, medication management, and nutrition in single appointment to provide a forum for patients to learn about self-care from providers and through interactive support from peers [5-10]. Shared medical appointments offer a potential means of reducing rehospitalizations by providing education and support implementing self-management strategies and follow-up care. Session topics are often adapted to meet the current needs of the patient participants.

While this care model has been shown to improve patient experience and clinical outcomes in a variety of settings, the refinement of this model continues to be informed by qualitative, quantitative, and mixed methods studies. Participation in SMAs has been shown to improve patients’ self-management skills [9]. However, few studies have focused on how this care model affects provider experience.

While use of SMAs is growing, further spread is expected to improve outcomes. Designing SMA programs that enhance provider and patient experience could facilitate the spread of SMAs by promoting provider buy-in and improving program sustainability. Most studies of SMAs focus on patient outcomes with few reporting on effects on healthcare providers with those that do reporting mixed results [5-10]. A better understanding of SMAs from the perspective of healthcare providers who refer patients to or lead SMAs could inform better implementation and delivery of the SMA model to ultimately improve better self-management of HF for patients.

A goal of this study was to inform sustainability and scalability of SMAs by exploring the experience of health care providers leading and referring patients to SMAs. This study used a knowledge, attitudes and practice model to explore the experience of health care providers who lead or referred patients to SMAs at three VHA sites. Data were analyzed using a qualitative rapid matrix analysis in order to quickly provide actionable feedback to the providers/respondents [11, 12]. How providers’ SMA-experience can inform future SMA implementation is the focus of this paper.

Materials and methods

This qualitative study was a portion of a VHA three-site randomized control trial (RCT) to study outcomes associated with the use of SMAs following hospitalization for HF [13]. The qualitative work included interviews with health care providers involved in the conducting or referring patients to SMAs, the intervention arm of the RCT, and was approved by the Louis Stokes Cleveland Department of Veterans Affairs Medical Center’s (LSCDVAMC) Institutional Review Board (IRB).

Setting

All three sites involved had comparable ongoing HF SMA programs led by multi-disciplinary teams including dieticians, psychologists, physicians, nurses, clinical pharmacists, physician assistants, and nurse practitioners. All programs conducted 90-minute group medical appointments that included an assessment of patient needs, a planned topical self-management education session, and a patient-initiated disease-management discussion. Sessions included individualized attention from a healthcare provider and one site included skills training. Patients were referred to HF SMAs by either a physician, nurse, clinical pharmacist, physician assistant or nurse practitioner that were adapted to include consistent patient education. Further details of the HF SMA self-care topics and appointment protocol have been previously published [13].

Respondents

HF SMA team leads from each site supplied names of providers leading and/or referring patients to the HF SMAs. All 33 individuals included on the list of provided names were invited by email to participate in an in-person or telephone interview regarding their experiences with HF SMAs. Of the contacted providers, 73% (33/24) responded and were interviewed. Twenty-four interviews were completed either in-person (n = 3) or by telephone (n = 21) with physicians (n = 8), pharmacists (n = 4), dieticians (n = 2), clinical psychologists (n = 4), nurse practitioners (n = 2), and registered nurses (n = 4) across three VAMC sites. Participation in this study was voluntary and confidential. Table 1 provides the distribution of respondents among sites and gender.

Table 1

Respondents.

	Site A	Site B	Site C	Total
Referred	19	8	6	33
Interviewed	10	8	6	24
Total Referred Male/Female	5/14	4/4	2/4	11/22
Total Interviewed Male/Female	2/8	4/4	2/4	8/16

Data collection

Consents were mailed by USPS to respondents and included language agreeing to both participation in the interview and allowing the interview to be recorded. After study staff received the signed consent by USPS, interviews were scheduled either in-person or by telephone. A semi-structured interview guide with grounded probes (S1 Appendix Interview Guide) was developed based on a knowledge-attitude-practice (KAP) framework which proposes that knowledge and attitude about a intervention can inform the practice of a public health intervention [14-16]. The KAP was used as a framework to identify domains important to clinician participation in SMAs rather than a predictive model. Neutral domains or data categories without positive or negative assignments were identified for each interview question. Each semi-structured interview was conducted by two of three individuals who identified as female and were experienced in semi-structured interviewing and qualitative analysis (JJ, SB, VM). Interviewees included healthcare team members who led or referred patients to HF SMAs. Each interview was completed by two trained interviewers, one serving as lead interviewer and the other serving as notetaker. All respondents consented to both the interview and allowed the interview to be audio recorded. Transcripts were reviewed with audio to check transcript accuracy. A debrief form was completed immediately following the interview to record the interviewer’s and notetaker’s initial feedback (S2 Appendix Agenda for Debriefing Post Interview Meetings). The three-person interview team met to discuss the interview, consider and discuss potential personal biases, and build consensus on the content of the debrief form. Although all interviewers were from one of the three study sites, the interviewers had no prior relationship with the respondents at the time of the interview but communicated with the clinical teams to feedback aggregate data and obtain validation of results.

Data analysis

Qualitative data analysis was completed in additive steps. Debrief notes and transcripts were analyzed using a team-based qualitative rapid assessment process [17] shown to expeditiously yield high quality review of data in a timely manner allowing for timely feedback to the SMA teams [18]. As an initial step, each interview question was assigned a neutral domain as listed in Table 2 and a summary template was created based on these domains: knowledge of SMA structure, SMA attitude, effect on patients, suggested improvements, experience of providers, patient referrals.

Table 2

Matrix domains and operational definitions.

Domains	Definition
Knowledge: SMA structure and content	Respondents’ understanding of how SMA were structured at their site impact of SMAs
Knowledge: Patient referrals	Organizational processes for referring patients to SMAs
Attitude: Effect on patients	Influence of SMAs specific to patients
Attitude: Experience of providers	How leading SMA affected provider
Practice: Suggested improvements	Respondents’ suggestions for improvements

Each qualitative analyst applied the summary template to the same three transcripts and then met to reach consensus on operational definitions of each summary template domain. Once consensus was reached each transcript was assigned to an individual team member for summary completion. Team members individually reviewed debrief forms for each interview before completing corresponding summaries. Representative quotes were noted during the rapid analysis process on the summary templates. Upon completion and consensus from all analysts, summaries were compiled into a single matrix organized by site and provider type for comparison. Analysts met regularly until consensus on the entire matrix was reached.

These consensus meetings resulted in a final matrix that was condensed to five domains as all items first coded as SMA attitudes were duplicative of other domains. These five domains were arranged in columns with data from each interview summarized by row allowing for a quick assessment of domains across sites. For each site, data summaries including descriptions of SMAs were compiled and shared with the respective respondents.

Results

Data aggregated by each of the three sites are summarized in Table 3 illustrating the many similarities and the few differences between sites. Respondents found HF SMAs to be an effective care model that offer benefits for providers and patients. Most respondents leading HF SMAs in this study found their participation as beneficial for themselves and Veterans. Respondents felt SMAs were beneficial due to knowledge gained from other providers suggesting potential improvements in collaborative and coordinated patient care. However, from the provider perspective, challenges were noted such as labor-intensive preparation and setup. On the other hand, this model was noted to offer potential improvements in clinical outcomes for patients.

Table 3

Matrix for all sites.

Summaries	Site A	Site B	Site C
SMA structure & content	• Content adjusted based on group interest and need	• Structure is adaptable.	• Multi-disciplinary
	• Interactive	• Set curriculum	• Individual and group attention
	• Multidisciplinary	• Taught like classes, but opportunity for interaction	• 4 sessions, 1.5 hour
	• Resources provided to patients	• Multidisciplinary;	• Need 4–5 patients to be effective
	• Individualized care	• Informational handouts distributed
	• Group setting, 8–10 patients	• Patients get brief exam.
	• Patients learn skills.	• Four different sessions; 1/week
	• 2-hour comprehensive & less fragmented appointment	• Cardiologist oversight
	• Provides education for medications & diet	• Critical for pharmacist to lead
	• Skills of leader are critical.
Effect on patients	• Benefit from sharing knowledge & experiences.	• learning from each other	• Patient-to-patient sharing/support
	• Learn self-management	• Develop community	• Most successful SMA patient has support at home and is not a substance abuser or mentally ill/demented
	• Develop comradery with other patients.	• Receiving HF education helps with lifestyle change and self-management.	• Good for newly diagnosed patients
	• Convenient	• Helps with medication adherence	• Efficient use of provider/patient time
	• Holistic care	• Helps with emotional response to HF
	• Patients become proactive.	• Validates patient’s experience
	• Better care continuity	• Some patients don’t like groups.
	• Perceived decrease in hospital and/or emergency department visits	• Some patients need more individualized attention.
	• Earlier appointments	• Travel can be a barrier.
		• Easy access to providers
		• Not for very ill patients
		• Study will see how well it works
Suggested improvements	• Increase number of SMAs	• Increase number of sessions	• Add exercise component
	• Add more providers such as nurse practitioners	• Add an exercise physiologist	• Refresher sessions would be helpful to patients
	• More ‘new’ resources: physical therapist/social worker/	• Offer SMAs at outpatient clinics	• Need good communication between providers
	exercise physiologist	• Offer a support group	• Better for success when SMAs are endorsed by VA administration and/or by cardiology department heads
	• Offer more SMAs at outpatient clinics (especially rural)	• Add an advanced class
	Longer duration
	• Encourage caregiver of patients with cognitive issues to attend
	• Add cooking class
Experience of providers	• Inter-disciplinary knowledge sharing	• Providers learn from each other.	• Able to treat patients more holistically through SMAs
	• Efficient sessions	• Address issues providers don’t have time for	• A lot of work for provider but great for patients
	• Better job satisfaction	• Not helpful to providers	• Saves providers time
	• Learn from patient to patient interactions	• Reduces redundancy for providers	• A lot of work
	• Able to be more holistic with care
	• Provides opportunity for more communication between SMA providers and primary care provider (PCP)s
Patient referrals	• Patients with new onset, existing, acute chronic symptoms or based on chart review are referred.	• HF inpatients are referred by nurse	• HF nurse approaches inpatients for immediate consent & scheduling
	• Nurse Practitioner (NP) or PCP refers.	• All HF hospitalized patients referred	• Recruitment is an issue if cardiology department isn’t on-board
	• HF NP is SMA gatekeeper	• All HF Consults referred to SMA	• No direct consult for SMAs
	• Don’t refer patients who don’t like groups or have severe behavioral or violence issues.	• PCPs and pharmacist refer
	• More direction needed for referrals	• PCPs can refer patients to specific SMA session
	• Distribute more information to patient on SMA pros and cons prior to visit	• SMA provider is added as signer
		• number of referrals up since new chief
		• Streamline referral process

The following provides the results organized by the neutral domains with representative quotations from respondents.

SMA structure and content

SMAs from all sites shared commonalities in SMA structure and content. Respondents from each of the three sites reported that SMAs were conducted as consecutive multi-disciplinary interactive weekly group sessions with each session lasting approximately 90 minutes in duration. While each session included pre-determined instruction on issues such as diet and medication, each session was also adapted to correspond with the needs and requests of the patient attendees. Respondents from all sites described how a portion of each session was devoted to providing patients individualized one-on-one medical care. One site included skills training and that was the only noted content and structure related difference between the three sites.

Each respondent described the multidisciplinary nature of the SMAs. Respondents from all three sites commented on how both patients and providers learn from SMA leaders with a range of skills and knowledge.

“I think they’re [SMA] excellent. I think they’re a great way for people to have access to all the different team members without having to come in for many different appointments and it’s also good for the team [SMA] they learn from each other.” Site B

“I think they’re really helpful. They meet a need that no one else had been able to do in the sense of these are patients that kind of need a little bit of everything in order to support them through what I think is a far harder process than I think people give credit for in terms of managing heart failure. I think it’s efficient…” Site A

Effect on patients

Most respondents emphasized how the SMA setting efficiently provided patients the opportunity to share experiences and gain knowledge from fellow participants. Respondents noted that comradery and support were fostered as patients became familiar with one another as they attended multiple consecutive sessions together. Respondents felt feedback from fellow SMA attendees helped validate patients’ emotional experiences with chronic disease management in addition to promoting better self-management for patients.

“when you see the sharing and empowering that is, goes on between patients by setting their worries at ease and that’s something extremely valuable and maybe not be addressed in the individual setting because patients often don’t know or not aware of other patients feel the same way about their illness.” Site B

“I think it would be very helpful for them [the Veterans], mainly because they don’t feel—there’s all these underlying processes that occur in a group, and one is that they don’t feel alone. That a medical condition is normalized. There’s a lot of support that occurs…” Site C

Some respondents cautioned that SMAs weren’t for all patients such as those who were uncomfortable in a group setting or were at an advanced stage of their chronic illness.

“I wouldn’t refer psychiatric patients or those who really don’t like group appointments, very private people. Newly diagnosed people would be good for SMAs.” Site A

“I think from previous experiences patients who are very sick do not do well here because they are recently discharged from the hospital … they do not do well because first of all they are not that interactive with the group and they probably want all of the attention to self because they do not feel right and therefore I don’t think the shared medical appointment will work if the patient is not really eager to learn or interact because they are so bogged down by their illness.” Site B

Suggested improvements

All sites provided suggestions to increase access to SMAs for Veterans who currently participate and to make it easier for more Veterans to participate. Some suggested adding more sessions in general while others specifically requested the addition of a class with an exercise focus. The inclusion of a refresher support group and/or follow-up sessions were also suggested. Sites felt that providers from other disciplines could participate such as an exercise physiologist. Communication between providers and support from their local cardiology chief or national leadership were noted as important to continued promotion of the service. One site stressed the importance of encouraging attendance by patients’ caregivers.

“Maybe access. Being offered more in the rural areas. Some of these Veterans come from a long distance.” Site A

“It would be nice if it can be offered on more days of the week and at different times because I know that transportation can be potentially an issue.” Site B

“better ways to communicate about the program, getting the word out there” Site C

Experience of providers

Most session leaders reported gaining knowledge by observing providers from other disciplines deliver care and gaining a better understanding of patients by observation of patient-patient interactions during the SMAs. These respondents added that SMAs could be an efficient use of the providers’ time and could contribute to improved job satisfaction.

“Excellent, and they’re helpful to me in a very similar way as they are to the patients. You know, where you’re involved in a group you learn all the different ways all the providers contribute, so just being involved in that I’ve learned all about medication for heart failure, and diet for heart failure, and symptom management for heart failure than I would have being just a sole psychologist on a team.” Site A

“… what we found out was that not only were we as the practitioners experts, but the patients in the room are also experts, and they were able to collaborate and share their experiences and their ideas with each other, which in my experience, has been way more impactful than just us telling them again and again what they should do or need to do, so that has really been insightful for myself, being involved with the shared medical appointments.” Site C

However, two respondents, each from different sites, felt that sessions required lot of work including scheduling.

“So, it’s possible that the scheduling could be more streamlined, or user-friendly.” Site B

“I think it’s a ton of behind-the-scenes work for the staff who are putting everything together.” Site C

Patient referrals

Nurses played a key role in the referral process at all sites. Overall, all sites expressed a need for improvement in the referral processes. Identifying specific guidelines for the type of patient best suited for SMAs and developing informational materials specifically directed toward potential patients was recommended.

“I am thinking that right now the referral process is not easy. Basically, we need to copy the people who are running the shared medical appointments, so they know patients that want to get a shared medical appointment. So, in the future probably something that is like a consult is needed.” Site B

Discussion

This qualitative study expands upon other studies examining providers’ experiences with SMAs [19, 20] and focuses on providers’ knowledge of structure, attitudes about effectiveness, and ideas on how to improve the practice of SMAs. The findings support other work highlighting the importance of a collaborative multi-disciplinary team to a successful SMA program [5, 21–24] and more recently discussed by Thompon-Lastad and Gardiner [25]. These data highlight how the SMA environment facilitates provider learning about multidisciplinary patient care through direct observation of providers during the SMA sessions [24]. Additionally, this study illustrates how this environment can support better care by enhancing opportunities for communication and care coordination among providers similar to other studies [19-21]. While in this study providers differed in their opinion on whether SMAs are an efficient use of providers’ time all respondents noted the unique knowledge gained by observations of patient-patient and patient-provider interactions.

Having good communication between team members from multiple disciplines was noted in this and other studies [20, 21] to be elemental to a successful SMA program. This setting may promote communication among participants [22] the SMA team members and with primary care providers. In addition to the report of better provider-to-provider communication, this study supports other work suggesting that the inclusion of a designated team member skilled at facilitating group discussions could promote focused group sharing and learning among patients [26].

Opportunities to improve the SMA have focused on patient education [27] experience [20] with one study noting that some patients found the information provided to be overwhelming [7]. In contrast, data presented here suggest a need to expand awareness SMAs to both patients and providers and to increase patient access to SMAs and increase use of SMAs by providers. Although numerous studies have reported the benefits of SMAs to patients not all patients have the opportunity to participate. The burden of attending repeated SMAs could be alleviate by offering SMAs at more locations closer to where patients live and at a wider range of times.

Conclusions

Even though numerous studies have highlighted the benefits of participation in SMAs to patients with chronic illnesses such as heart failure, diabetes and blood pressure [7–10, 19–27] there is room for further spread of this type of care delivery model. These findings illustrate the provider experience and further detailing the patient experience could inform facilitation and implementation strategies to encourage providers to lead and/or refer patients to SMAs. Further research is warranted to investigate the implementation of SMAs for HF at new sites.

Practice implications

These findings highlight benefits for providers in participating and leading the HF SMAs and present some strategies for improving SMAs and the presentation of the benefits of SMAs to new clinical teams.

Interview guide.

(DOCX)

Click here for additional data file.

Agenda for debriefing post interview meetings.

(DOCX)

Click here for additional data file.

7 May 2021

PONE-D-21-04750

Healthcare providers experiences with shared medical appointments for heart failure

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Reviewer #1: April, 2021

Dear Editor,

Thank you for the invitation to review this manuscript which reports the results of a qualitative study exploring the Shared Medical Appointments (SMAs) experience from healthcare providers’ perspectives. The topic is interesting and of contemporary importance. However, the paper lacks important standards of rigorous scientific research. Kindly find my comments below:

1. Introduction:

- Line 57: suggest to define patient self-management in heart failure and its relationship to SMAs.

- Line 60: provide a reference at the end of statement and elaborate more on comprehensive patient care and how to deliver such care.

- Line 61: SMAs are the focus of the paper, yet I was not able to find a clear definition of the concept SMA. How often is SMA applied? At what disease states is it more helpful? Is it a novel concept or has it been long applied in clinical practice? Need to clarify the context where SMAs are most helpful to get the reader to better understand the concept especially if they are not familiar with this kind of shared patient care.

- Line 66: need to add a reference proving that active engagement in SMAs was associated with improved patient self-management.

- Line 81: was this really the focus of the paper? I didn’t appreciate any future direction for establishing new SAMs, yet most of the discussion was related to insights for improving already established SMAs. Need to refine aims to better align with the actual reported information.

2. Materials and Methods: overall, the methods section was poorly constructed and it failed to describe important information that are needed to replicate the study. I am listing major comments below:

- Line 83: the number of included sites must be listed at the very beginning of the section (i.e. under the setting part line 91), however, I wasn’t able to find it until line 106.

- Line 85: “patients were randomized to either SMA or usual care”. This is kind of vague; how often were the SMAs sessions held and how often were HF patients seen (in usual care) post hospital discharge? Did you conduct the SMA interviews with providers right after patients were seen, why did you report patient randomization? Need to clarify.

- Lines 95 and 96: patients were referred to SMAs by physicians, nurses, clinical RPhs, PAs, NPs while in line 105 dieticians and clinical psychologists were also listed; does this imply that those (i.e. dieticians and psychologists) were SMA leaders rather than SMAs referral points? Need to clarify.

- Lines 100-101: Convenience sampling while all provided names included? Does this imply that there were other providers’ names supplied but not included in SMA interviews? Or did you mean using convenience sampling to collect the providers’ names or sites? Need to clarify as this is confusing.

- Line 104: helpful to provide response rate (out of 33 invited, 24 accepted and were interviewed, ~ 73%).

- Line 108: Table 1 could have included more informative data related to sites (or even demographics of SMA leaders at different sites); years of providing SMA, hospital bed size, number of providers involved in SMAs, total number of HF seen throughout the study period vs those referred to SMA among others. This could have been even used in sub-analysis of facilitators and barriers as listed as aims of the present study in line 75.

- Line 110: were signed consents collected even from those who were interviewed over the phone? Need to clarify how written consents were obtained. Regarding consents, each participant was asked to provide two consents: one written and another audio taped as consent to record the interview, right? Clarify.

- Line 112: need to elaborate more on KAP framework, provide a reference and define context specific KAP.

- Line 113: clarify neutral domain.

- Line 114-116: how did you ensure consistency in interviewing process among three interviewers? Line 114 reported that 3 interviewers conducted the interviews while 116 noted that 2 trained interviewers conducted the interview; kind of confusing, were the three interviewers SMA interview leaders and note-takers at the same time or were they only leaders and you had 2 others to conduct the actual interview and take notes?

- Line 122: was this a condition for conducting the interview? Did you ensure lack of bias through assigning each interviewer to conduct the interview at a different site form interviewers’ affiliation? If not need to highlight.

- Line 128: team-based analysis; were those the same 3 interviewers together? Or a new team? Revise used terms, define as needed, and make sure to be consistent (team-based vs interviewers vs analysists?)

- Line 134: piloting? How was this done, this was not mentioned earlier? Was the study referenced in 7 (Cohen et al, 2017) the pilot study? Clarify as some information in the current paper and that published by Cohen are contradictory and lack accuracy (check my note related to S1 below for further clarifications).

- Line 146: Table 2 legend included the word “initial” which gives the impression that the listed domains are those of the primary template (i.e the 6 domains) while it actually listed the final domains retained after final matrix analysis excluding SMA attitude, please modify the legend accordingly.

3. Results:

- Lines 164-167: very long and hard to follow.

- Line: 203: confusing, need to revise.

4. Discussion: very concise and lack comprehensive comparison to other published studies; suggest to better align with the results of the study. Some of the results need to be discussed at length.

5. Conclusion: It is important to make sure that conclusions are grounded on the study findings.

6. S1: it is very important to clarify the association between the present study and that listed as reference 7; similarities and differences. When I tried to refer to the published paper by Cohen et al, 2017, most information were contradictory. I was not able to comprehend if that study was more of a pilot study to the current one or were they the same. Examples of contradictory information include: number of questions included in the S1, number of research assistants conducting the interviews, number of interviewed providers…..

I hope you find some of the provided insights useful in improving the scientific content of the paper. Besides, the paper needs extensive copy-editing to improve the flow of information.

Kind regards,

Yours sincerely,

Rawand A. Khasawneh

Assistant Professor of Clinical Pharmacy

Faculty of Pharmacy

Jordan University of Science and Technology

Irbid- Jordan

**********

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Reviewer #1: No

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9 Jul 2021

The following includes edits to our manuscript addressing each concerned raised by the reviewer:

1. Introduction:

- Line 57: suggest to define patient self-management in heart failure and its relationship to SMAs.

This definition has been added.

- Line 60: provide a reference at the end of statement and elaborate more on comprehensive patient care and how to deliver such care.

Reference and explanation included.

- Line 61: SMAs are the focus of the paper, yet I was not able to find a clear definition of the concept SMA. How often is SMA applied? At what disease states is it more helpful? Is it a novel concept or has it been long applied in clinical practice? Need to clarify the context where SMAs are most helpful to get the reader to better understand the concept especially if they are not familiar with this kind of shared patient care.

The definition and studies involving are now introduced in more detail in paragraph 2,3 and 4 of the introduction.

- Line 66: need to add a reference proving that active engagement in SMAs was associated with improved patient self-management.

Dickman et al., 2012 has been added as a reference showing self-reported improvements in management of a chronic illness. Specifically, participation in SMAs over four months increased exercise time and patient’s success at reaching measurable goals.

- Line 81: was this really the focus of the paper? I didn’t appreciate any future direction for establishing new SAMs, yet most of the discussion was related to insights for improving already established SMAs. Need to refine aims to better align with the actual reported information.

The introduction has been edited to reflect the main goal of this paper which is to describe provders’ experience leading and referring patients to SMAs.

2. Materials and Methods: overall, the methods section was poorly constructed and it failed to describe important information that are needed to replicate the study. I am listing major comments below:

- Line 83: the number of included sites must be listed at the very beginning of the section (i.e. under the setting part line 91), however, I wasn’t able to find it until line 106.

Added to the first line of the Materials and methods section.

- Line 85: “patients were randomized to either SMA or usual care”. This is kind of vague; how often were the SMAs sessions held and how often were HF patients seen (in usual care) post hospital discharge? Did you conduct the SMA interviews with providers right after patients were seen, why did you report patient randomization? Need to clarify.

This information has been removed as it is not relevant to this qualitative work.

- Lines 95 and 96: patients were referred to SMAs by physicians, nurses, clinical RPhs, PAs, NPs while in line 105 dieticians and clinical psychologists were also listed; does this imply that those (i.e. dieticians and psychologists) were SMA leaders rather than SMAs referral points? Need to clarify.

This has been clarified.

- Lines 100-101: Convenience sampling while all provided names included? Does this imply that there were other providers’ names supplied but not included in SMA interviews? Or did you mean using convenience sampling to collect the providers’ names or sites? Need to clarify as this is confusing.

- Line 104: helpful to provide response rate (out of 33 invited, 24 accepted and were interviewed, ~ 73%).

Reference to convenience sampling has been removed. All provider whose names were supplied were contacted.

- Line 108: Table 1 could have included more informative data related to sites (or even demographics of SMA leaders at different sites); years of providing SMA, hospital bed size, number of providers involved in SMAs, total number of HF seen throughout the study period vs those referred to SMA among others. This could have been even used in sub-analysis of facilitators and barriers as listed as aims of the present study in line 75.

More information regarding each site was not obtained.

- Line 110: were signed consents collected even from those who were interviewed over the phone? Need to clarify how written consents were obtained. Regarding consents, each participant was asked to provide two consents: one written and another audio taped as consent to record the interview, right? Clarify.

The process of collecting consents has been clarified.

- Line 112: need to elaborate more on KAP framework, provide a reference and define context specific KAP.

An explanation of how the KAP framework was to organize the qualitative data has been included.

- Line 113: clarify neutral domain.

Neutral domains are qualitative data categories without positive or negative attributes; this is now included in the manuscript.

- Line 114-116: how did you ensure consistency in interviewing process among three interviewers? Line 114 reported that 3 interviewers conducted the interviews while 116 noted that 2 trained interviewers conducted the interview; kind of confusing, were the three interviewers SMA interview leaders and note-takers at the same time or were they only leaders and you had 2 others to conduct the actual interview and take notes?

More details have been added to clarify how interviewers and analysts worked together.

- Line 122: was this a condition for conducting the interview? Did you ensure lack of bias through assigning each interviewer to conduct the interview at a different site form interviewers’ affiliation? If not need to highlight.

The fact that interviewers and analysts had no prior relationship with respondents at any of the three sites is now included.

- Line 128: team-based analysis; were those the same 3 interviewers together? Or a new team? Revise used terms, define as needed, and make sure to be consistent (team-based vs interviewers vs analysists?)

More details have been added to clarify how interviewers and analysts worked together.

- Line 134: piloting? How was this done, this was not mentioned earlier? Was the study referenced in 7 (Cohen et al, 2017) the pilot study? Clarify as some information in the current paper and that published by Cohen are contradictory and lack accuracy (check my note related to S1 below for further clarifications).

The word piloting was misleading and has been removed.

- Line 146: Table 2 legend included the word “initial” which gives the impression that the listed domains are those of the primary template (i.e the 6 domains) while it actually listed the final domains retained after final matrix analysis excluding SMA attitude, please modify the legend accordingly.

The legend has been modified.

3. Results:

- Lines 164-167: very long and hard to follow.

- Line: 203: confusing, need to revise.

The results section has been edited extensively.

4. Discussion: very concise and lack comprehensive comparison to other published studies; suggest to better align with the results of the study. Some of the results need to be discussed at length.

The discussion section has been expanded.

5. Conclusion: It is important to make sure that conclusions are grounded on the study findings.

The conclusions have been edited to align with the findings.

6. S1: it is very important to clarify the association between the present study and that listed as reference 7; similarities and differences. When I tried to refer to the published paper by Cohen et al, 2017, most information were contradictory. I was not able to comprehend if that study was more of a pilot study to the current one or were they the same. Examples of contradictory information include: number of questions included in the S1, number of research assistants conducting the interviews, number of interviewed providers…..

The Cohen et al. 2017 is a completely separate study.

Besides, the paper needs extensive copy-editing to improve the flow of information.

Extensive edits have been made throughout the manuscript.

Thank you for your consideration of this revised manuscript.

Respectfully,

Sherry L Ball, PhD

Submitted filename: response to Reviewers 0708.pdf

Click here for additional data file.

21 Jan 2022

Healthcare providers experiences with shared medical appointments for heart failure

PONE-D-21-04750R1

Dear Dr. Ball,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Tareq Mukattash

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

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Reviewer #1: All comments have been addressed

**********

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Reviewer #1: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

**********

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The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

**********

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Reviewer #1: I believe the authors did a good job addressing all points addressed from my side.

- The introduction was further expanded to include relevant suggested information.

- The methods section was greatly improved to make it possible to duplicate the study in the future.

- Conclusions are presented in appropriate way and are congruent with the study findings. The authors reconstructed this section based on the results as suggested by the reviewer.

- The authors copyedited the paper to improve the flow of information.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

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Reviewer #1: No

Submitted filename: PLOS ONE R2.docx

Click here for additional data file.

28 Jan 2022

PONE-D-21-04750R1

Healthcare providers experiences with shared medical appointments for heart failure

Dear Dr. Ball:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

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on behalf of

Dr. Tareq Mukattash

Academic Editor

PLOS ONE