Linda “Charley” Yang, BS, Stanford Health Care; Maria G. Juarez Reyes, MD PhD, Stanford School of Medicine
Evaluate the feasibility, acceptability and preliminary effectiveness of medical group visits for stress management in an academic onsite health center.
Work has consistently ranked as one of the top two stressors for Americans. (1) Persistent high stress in the workplace negatively impacts productivity. Burnout, low productivity, absenteeism, low job satisfaction and higher turnover are related to high stress in the workplace. (2) While 33% of US employers with more than 5000 employees have on-site clinics, not all of these clinics provide behavioral health services to help manage employee stress.(3)
Virtual Medical Group Visits (MGVs) for stress management are effective in primary care patients.4,5 However there is sparse data on virtual medical group visits for stress reduction in employer-based clinics. The goal of this project was to evaluate the feasibility, acceptability and preliminary effectiveness of an employer-based virtual medical group visit for stress management.
Study design was an observational pre-post study. Recruitment was by open enrollment to all employees at no cost, co-pays for video visits at the health center were waived. Participants self-referred or were referred by their health center provider. Inclusion criteria included adults 18+ years old, English speaking that could attend at least 4 of the 6 weekly group sessions.
Feasibility was determined as percent of patients completing 4 of 6 session greater than 80% of those registered. Acceptability was determined using mean ≥4 on the Satisfaction Survey responses for each of the 6 sessions. As stress is strongly associated with both depression and anxiety (6), we measured anxiety and depression scores to evaluate effectiveness at week 1 and 6 using the Generalized Anxiety Disorder-7 (GAD-7)7 and Patient Health Questionnaire (PHQ-9).(8)
The satisfaction questionnaire administered at week 6 consists of a 5 point Likert scored questionnaire asking participants to rank each of the 6 individual sessions from “not very” to “very” useful, and to indicate how likely they were to recommend the program to others from “very unlikely” to “very likely.” Participants were also invited to add general comments on the program’s strengths and areas that could be improved. Analysis was descriptive with calculations of means and standard deviations.
Program Format: One physician facilitated each MGV via video conference. Patients verbally consented to participate in the program at session 1. The sessions began with a short 3-5 min 1:1 check-in between the provider and each patient within the group setting. Patients were asked to discuss their prior week’s stress management and meditative practice. After conducting these check-ins, the group meeting followed the format below (Figure 1). MGVs were shortened to 90 minutes from the original format to accommodate employee schedules.
Three cohorts were conducted between August 2020 and December 2020 with 6-8 participants in each. 19/22 (86%) completed their pre- and post-session GAD7 and PHQ9 assessments, 14/22 (64%) completed the patient satisfaction survey and were included in analysis
24 total participants enrolled with 22 completing the program (92% of enrollees).
Feedback from respondents was universally positive with 100% of patients stating they were “likely” or “very likely” to recommend the program to others. On average, participants rated the usefulness of all sessions 4.56 out of 5 (standard deviation 0.22), (Figure 2). Specific to this setting-participants requested additional “homework” such as diaries and articles to read between sessions (Figure 3). Preliminary Effectiveness: Baseline GAD7 Score was 7.95, (standard deviation 6.35). Baseline PHQ9 Score was 5.21 (standard deviation 4). On average, GAD-7 scores decreased by 4.7 (58.9%) and PHQ-9 scores decreased by 2.1 points (39.4%). Participants also reported increased frequency of meditation practice at home, with all participants reporting meditating at least once a week, and 77% meditating more than once per week (Figure 4 and 5).
The intervention was found to be feasible with 92% of participants completing >4 group sessions, and acceptable with 100% of participants reporting they were “likely” or “very likely” to recommend the program to others. While preliminary, the intervention showed reductions anxiety and depression scores, consistent with prior findings.4 The context of an on-site health center offers several potential benefits and unique constraints. For example, participants may share similar stressors and have access to similar resources such as Employee Assistance Programs, and Employee Resource Groups to facilitate ongoing support. A potential limitation is that employees who have concerns about confidentiality may not feel comfortable participating in MGVs with their colleagues. While this was not mentioned in the Satisfaction Survey it is possible that employees with this concern may choose not to enroll. Future studies would benefit from larger sample size to establish effectiveness in reducing anxiety and depression, and to further evaluate the benefits and constraints of MGVs for stress management in an on-site medical clinic.
The 6-week medical group stress management program was found to be feasible and highly acceptable when offered through an on-site employer-based clinic. Larger studies are needed to establish size of clinical impact on anxiety and depression, and to evaluate cost effectiveness.