Patient Outcomes from Student-Run Health Services: An Integrative Review

Figures & data

Box 1 Search Terms Used

Tertiary OR student* OR undergraduate* OR graduate* OR volunteer* AND led OR run OR facilitated OR managed OR assisted AND service* or centre* OR center* OR clinic*

Notes: The * (asterisk) here is a truncation symbol added to the end of the root of a word in Boolean searches to search for all forms of a word where this word could have multiple endings. Clinic* thus searched databases for, inter alia, clinic, clinics, and clinical.

Table 1 Eligibility Criteria for Articles

Criterion	Inclusion	Exclusion
Language	English	Non-English
Population	Recipients of health interventions delivered by students at a student-run clinic	Recipients of health interventions delivered by a registered health professional at a student-run clinic
Study design	Comparative analysis between one or more samples, or between one or more time points within a single sample	Descriptive only, cross-sectional analysis (without comparison)
Outcome	Assessed patient clinical outcomes, including anthropometric, medical and functional	Assessed patient satisfaction or experiences of intervention
Source type	Peer-reviewed publications	Conference abstracts and proceedings, dissertations and theses, editorials, commentaries, letters to editor, reviews

Figure 1 PRISMA flow diagram.

Notes: Adapted from: Liberati A, Altman D, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of Clinical Epidemiology. 2009;62(10)e1-e34. Creative Commons.⁹⁵

Table 2 Overview of Articles Selected for Review

Author	Discipline(s)	Study Method	Participants				Assessment and Intervention Characteristics
			N	Age*	Sex (%F:M)	Ethnicity**	Intervention Duration/Description	Outcome Measured	Results
Diabetes
Adams et al. 2015^Citation24	Pharmacy	PP PPS	67I 66C	69y I 68y C	32:68 I 42:58 C	-	Individualised pharmaceutical care plan developed in advance of patient consultation	HbA1c Cholesterol BP mmHg EQ-5D Medication adherence	Potential non-significant improvements across all health indicators – feasibility study so underpowered to detect significance
Gorrindo et al. 2014^Citation27	Medicine	PPCR	45	49y	62:38	33% Hispanic 36% Black 29% White	Routine care, including visits and phone calls, at SRC, over a period of 12 months	HbA1c	Significant improvement in blood glucose levels after 12 months, with trend indicating a correlation between better outcomes and more frequent touchpoints
Janson et al. 2009^Citation28	Medicine Nursing Pharmacy	NRCT	221 I 163 C	65y I 63y C	53:47 I 56:44 C	Intervention: 25% Asian 31% Caucasian 22% African American 20% Other Control: 31% Asian 30% Caucasian 19% African American 19% Other	Individual 30-minute appointments, based on the Improving Chronic Illness Care (ICIC) Model from teams of interprofessional clinical learners, offering education and self-management support, and targeted phone support	HbA1c LDL BP mmHg Vaccinations Prescriptions Hospital utilization	No significant differences between groups post intervention; significantly more frequent screening occurred for the intervention group across all clinical indicators
Kahkoska et al. 2018^Citation29	Medicine Physician assistant Pharmacy	PPCR	8	-	63:37	25% White	Triage, medication reconciliation, brief history, and physical exam, after which patients participated in the 60–90 minute shared medical appointment (SMA)	HbA1c	Improved blood glucose levels in 6 out of 8 participants, although much variability within individuals - study underpowered to detect significance
Laitman et al. 2017^Citation30	Medicine	CCCR PPCR	44	50y	50:50	83% Hispanic	Routine diabetes care at SRC, mostly drug therapy, over a period of 2+ years	HbA1c	Significant improvement in blood glucose levels at 6m, 1y, 2y, and 2y+. It took an average 288 days for participants to achieve an ADA goal of 7.0%
Lee et al. 2016^Citation31	-	PP PPS	22	38–67y range	64:36	-	Attendance at DSME (Diabetes self-management education) course, support at follow up visits and regular check-ins by phone, over a period of 12 months	HbA1c ADA survey results	An average 10.8% improvement in diabetes knowledge in ADA pre- and post- intervention tests. Non-significant cohort improvement in blood glucose - study underpowered to detect significance
Martin et al. 2015^Citation32	Pharmacy	PPCR PPS	48	-	-	American Indian/Alaska Native	Medication audit, assessment of clinical needs, medication management therapy, pre/post phone calls, over a period of 6 months	HbA1c	Improvement in blood glucose levels was non-significant comparing pre-post means but significant comparing pre-post medians
Mehta et al. 2016^Citation33	Medicine	PP	68	47y	46:54	54% African American 31% White 9% Hispanic 6% Other	Patient education prior to expedited referral for routine care at SRC, over a period of 9 months	HbA1c BMI	Significant improvement in blood glucose levels; and a statistical increase in BMI for those attending <2 appointments not evident in those who attended more
Nagelkerk et al. 2018^Citation34	Medicine Physician assistant Pharmacy	PPCR	250	57y	61:38	48% Black 38% White 9% Asian 5% Other	Phone calls, monthly group diabetic classes and medication reconciliation audits	HbA1c BMI BP mmHg LDL and HDL and Triglycerides	Significant improvement in triglycerides and non-significant improvements in lipid ratios and BMI (but most clinical indicators showed no significant improvement). For a sub-sample of higher-risk patients, significant improvements were found in blood glucose levels and cholesterol
Nuffer 2012^Citation35	Pharmacy	PPCR	417	-	-	-	Six 1-hour appointments, which included an initial assessment, self-care education, health education and management strategies, reinforcement and reassessment, over a period of 6 months	HbA1c BP mmHg LDL and HDL and Triglycerides	Significant improvements across all clinical indicators (except HDL levels)
Ryskina et al. 2009^Citation36	Medicine	CCCR	25	49y	40:60	80% Hispanic 12% Black 4% Asian 4% White	Diagnosis + one or more follow up visits at SRC	HbA1c LDL BP mmHg Screening: • Nephropathy • Retinopathy • Foot exam	Comparable or better than averages reported for uninsured populations in blood glucose levels, cholesterol, blood pressure and screening rates
Smith et al. 2014^Citation37	Medicine	CCCR PPCR	182	53y	59:41	75% Latino 15% Caucasian 4% Asian 3% African American 3% Other	Routine care at SRC over mean period of 2.6 years	HbA1c LDL and HDL and Triglycerides BP Creatinine Screening: • Ophthalmology exam	Significant improvement in blood glucose levels, cholesterol and blood pressure, rates generally compare favourably to uninsured in other settings
Stroup et al. 2003^Citation38	Pharmacy	RCT	30 I 40 C	52y I 59y C	42:58 I 67:33 C	-	Monthly 1-hour appointments, via home visit or phone, for 2 years duration. Visits included review of pharmacological treatment, clinical monitoring and management, discussion of diabetes related complications and responding to patient questions	HbA1c Weight BP LDL and HDL and Triglycerides Diabetes related ED admissions Hospital visits	No significant difference in clinical indicators after 2 years; non-significant reduction in diabetes related ED admissions and hospital visits in the intervention group
Wilcox 2020^Citation39	-	PPCR	56 I 53 C	52y I 56y C	50:50 I 49:51 C	Intervention: 48% White 46% Hispanic 4% Black 2% Asian/ Pacific Islander Control: not provided	Impact of quality improvement intervention (flow sheet) on routine diabetes care provided at clinic	HbA1c Screening: • Urine protein • Foot exam • Eye exam	Patients who received care in 1y post flow sheet introduction were more likely to receive at least two HbA1c tests (53%), a microalbumin test (46%), and a foot exam (46%) compared to those receiving care before the flow sheet was introduced (28%, 2%, and 25%, respectively), with no difference in eye exam rates
Hypertension
Atkinson et al. 2018^Citation40	Medicine	CCCR PPCR	97	56y	62:38	70% Hispanic 8% White 8% Black 13% Other	>2 visits for routine care of patients with hypertension at primary care SRC	BP mmHg (initial vs follow-up and compared to national average)	Clinically significant decreases in BP post intervention and controlled BP rates similar to national averages for insured/uninsured
Berman et al. 2012^Citation41	Medicine	PP	17	-	-	-	Routine care of patients with hypertension at primary care SRC	BP mmHg	76% of patients with previously uncontrolled BP had controlled BP
Leung et al. 2012^Citation42	Medicine Nursing Pharmacy	PP	25	54y (med)	40:60	53% Latino 24% Black 24% White	Two clinic visits and 6×20 minute phone calls, focused on medication review and goal setting, over a period of 3–6 months	Medication adherence BP mmHg	Significant improvements in medication adherence
Smith et al. 2017^Citation43	Medicine	PPCR	496	51y	-	71% Hispanic	Routine care of patients with hypertension at primary care SRC, over a period of 1 year	BP mmHg	Significant reduction in BP over time
Taylor et al. 2015^Citation44	Medicine	CCCR PPCR	65	53y	60:40	55% Hispanic 29% Black 5% Asian 3% White	>2 visits for routine care of patients with hypertension at primary care SRC	BP mmHg	Clinically significant decreases in BP post intervention and controlled BP rates similar to State-wide averages in other care settings
Wahle et al. 2017^Citation45	Medicine Pharmacy	CCCR PPCR	64	55y	52:48	-	Routine care of patients with hypertension at primary care SRC	BP mmHg	Hypertension control rates similar to national averages
Functional health/quality of life
Arkin 2003^Citation46	Various (including non-health)	PP	24	79y	67:33	-	Students led clients with Alzheimer’s in 16–20 exercise sessions and 10 group activity sessions per semester, for 2 to 8 semesters	Six-minute walk test Duration of aerobic exercise (mins) Upper body strength (lbs) Lower body strength (lbs)	Highly significant fitness gains were achieved in the six-minute walk test, upper and lower body strength, and duration of aerobic exercise
Doherty et al. 2020^Citation47	Occupational therapy	PP	26	52 y	50:50	58% African American/Black 39% Caucasian/ White	Treatment activities centered on client-chosen goals that emphasized occupational Performance and participation in functional tasks, 45–60 mins weekly, over a period of 12–14 weeks	MCID in: COPM ACS ARAT PROMIS MoCA BBS PHQ-9	A small effect of treatment was found on all outcome measures, with statistically significant MCID change scores found for COPM and ARAT
Lavelle et al. 2001^Citation26	Occupational therapy	PPCR	85	66y	32:68	-	Students led clients who had had cerebrovascular accident (stroke) 6+mo previous in 12 (mean) 1-hour occupational therapy sessions	Patient-selected rehabilitation goals	All except one patient in the sample made progress towards rehabilitation goals, group mean goal progress score indicate significant overall gains
O’Brien et al. 2017^Citation48	Physical therapy	PPCR	71	62y	45:55	-	Students led physical therapy, once weekly, for 60 minutes, over a period of 10–11 weeks	“Minimum detectable change” (MDC) in at least one of 19 objective measurement tools	MDC achieved in approximately 70% of cases, and success was shown to be impacted by number of visits
Stickler 2016^Citation49	Physical therapy	PPCR	28	20–69y range	54:46	-	Attendance at student PT clinic (average 3 visits)	Functional quality of life scores in: NPRS QOL VAS SF-8 BP mmHg	Significant improvement in NPRS pain scale and physical component of SF-8
Walcott 2018^Citation25	Nursing	NRCT	43 I 55 C	46y I 37y C	79:21 I 64:36 C	-	8x weekly home visits by nursing students (needs assessment and personalised care plan)	Health related quality of life scores in SF-12	Intervention group demonstrated improvement in the physical component and physical function domain of SF-12 compared to control group
Zylstra et al. 2020^Citation50	Occupational therapy	PPCR	56	6y (paediatric) 63y (adults)	-	-	Student-designed interventions to address identified needs for adult and paediatric groups, sessions were held twice weekly, attended 7 (or more) sessions	COPM	For both age-groups there was a statistically significant improvement in perceived performance and satisfaction with participation in meaningful occupations, and a clinically significant improvement in satisfaction
Depression
Liberman et al. 2011^Citation51	Medicine	CCCR	49	61% 18–44y 29% 45–64y 4% 65y+	78:22	82% Hispanic 8% Black 4% Caucasian 4% Other 2% Unknown	Routine depression treatment at primary care SRC	Number of visits post diagnosis Medication adherence	Quality of depression treatment meets or exceeds that of insured populations in city (New York) and state (New York)
Mann et al. 2019^Citation52	Medicine	CCCR	79	-	-	71% Hispanic	Routine depression treatment at primary care SRC	Medication adherence	Adherence rates generally lower than for New York State Medicaid or New York State commercially insured
Soltani et al. 2015^Citation53	Medicine	PPCR	215	49y	80:20	99% Latino 2% Non-latino	Depression screening and treatment following implementation of universal screening, diagnosis, and management program	PHQ-2 PHQ-9	Depression screening resulted in an increase in diagnoses made; clinically significant improvements in depression reported
Hospital utilization
Kramer et al. 2015^Citation54	Medicine	CCS	245	41y	53:47	60% African American 26% Caucasian	Routine care at SRC	ER visits	Number of ER visits significantly decreased compared to those newly enrolled
Thakkar et al. 2019^Citation55	Medicine	PPCR	796	18–65+ range	52:48	64% White 13% Black 9% Hispanic 7% Asian 7% Other	Routine primary care at SRC	ER visits	Per-patient ER utilisation significantly decreased
Trumbo et al. 2018^Citation56	Medicine Nursing Pharmacy	PPCR	262	45y (med)	64:36	58% African American or Hispanic or Minority	Routine primary care at SRC	ER visits Hospital admissions	May reduce hospital admissions
Szkiladz et al. 2013^Citation57	Medicine Pharmacy	NRCT	86 I 94 C	70y I 72y C	56:44 C 48:52 C	-	Student-delivered counselling upon discharge	Hospital readmissions	No difference observed in readmission rates
Substance use
Der et al. 2001^Citation58	Medicine	PPS	88	42y	58:42	89% White	Smoking cessation programme including counselling, follow-up contact and pharmacologic treatment	Tobacco use	Follow-up data from 44 (of 88) patients at 6mo found an 18% abstinence rate, comparable to other treatment programmes
Lough et al. 2011^Citation59	Medicine	PP	257	42y	45:55	88% White 4% Native American 4% African American 2% Hispanic	Smoking cessation intervention, over a period of 12 weeks	Tobacco use	Reductions in tobacco use were achieved
Myers Virtue et al. 2018^Citation60	Dentistry Pharmacy	NRCT	25 I 25 C	48y I 48y C	64:36	Intervention: 36% White 60% Black 4% Other Control: 20% White 72% Black 8% Other	Tobacco cessation intervention at student dental clinic	Tobacco use	Education was delivered successfully and increased knowledge, but had no apparent impact on quit attempts
Spector et al. 2007^Citation61	Medicine	PP	11	41y	18:82	-	Smoking cessation intervention for homeless subjects (cognitive behavior therapy or unstructured support), 9-session protocol	Tobacco use	For 6 of 11 participants completing programme, decreases in self-reported mean number of cigarettes smoked daily (19 to 9) and carbon monoxide mean level (28.0 to 20.2), pilot study underpowered to detect significance
Stuhlmiller et al. 2018^Citation23	-	CCCR	2068	26y	52:48	75% Aboriginal or Torres Strait Islander	Smoking cessation programme and alcohol harm education; comparison between patients seen <12 months vs >12 months prior	Tobacco use Alcohol use	Slight reduction in relative risk of smoking and drinking alcohol
Weight
Brown et al. 2015^Citation62	Medicine Nursing Health professions	NRCT	25 I 21 C	-	96:4 I 95:5 C	Intervention: 24% White 68% Black 4% Hispanic Control: 24% White 86% Black 14% Hispanic	Student vs professional led weight management intervention, over a period of 10 weeks	Weight (kg) BMI	Patients in both student-led and professional-led) programs lost a statistically and clinically significant amount of weight. No difference between student and professional led interventions
Burrows et al. 2013^Citation22	Dietetic	PPCR	26	56y	58:42	-	Student-delivered dietetic weight loss program, within a period of 12 months	Weight (kg) BMI	Significant decreases in weight were reported
Cusumano et al. 2017^Citation63	Physician assistant	PPCR	28	-	-	-	Student-delivered motivational interviewing and counselling intervention	Weight (kg) BMI	A significant decrease in weight was achieved, and maintained 3 and 6 months post intervention
Health screening/vaccination
Abuelenen et al. 2020^Citation64	Medicine	CCCR	236	>18y	-	62% Hispanic or Latino 3% Black/African American 2% Asian 5% White 5% Bi-racial 24% Did not specify	Vaccination initiative in a SRC offering primary care	Vaccination rates	Vaccination rates at a SRC were comparable to or exceeded national averages
Butala et al. 2012^Citation65	Medicine	CCCR	114	35y	49:51	90% Hispanic 8% African American	Screening rates	Screening: • HIV • Diabetes • Cholesterol • Cervical cancer	Screening rates were lower than national averages, but exceeded national uninsured average
Khalil et al. 2020^Citation66	Medicine	CCCR	194	40–75y range	100:0	79% Hispanic	Screening rates	Screening: • Breast cancer	Screening rates for women aged 45+ exceeded national insured and uninsured averages
Price et al. 2020^Citation67	Medicine	CCCR	239	21–64y range	100:0	85% Hispanic	Screening rates	Screening • Cervical cancer	Screening rates exceeded national insured and uninsured averages
Zucker et al. 2013^Citation68	Medicine	CCCR	119	3% <18y 47% 18–49y 44% 50–64y 6% >65y	55:45	60% African American 29% Hispanic 4% Asian 3% Caucasian 4% Other/Unknown	Routine primary care at SRC: Smoking cessation Screening rates Vaccination rates	Screening: • Alcohol abuse • Colon cancer (50y+) • Breast cancer (40y+) • Cervical cancer (21y+) • Pneumococcal (65y+) • Influenza	Met or exceeded state and national smoking cessation counselling and alcohol abuse screening rates and state colonoscopy rate, but not mammography, pap smear, pneumococcal or influenza vaccination rates
Other
Burger et al. 2020^Citation69	Medicine	PPCR CCCR	134–334 (range of n’s across groups)	53–58y (range of means across groups)	-	-	Impact of quality improvement intervention which included patient education, provider education on preventative measures and correct technique for BP measurement, and introduction to EMR	HbA1c BP Screening: • Urine protein • Eye exam • Colon cancer • Breast cancer	Intervention improved screening rates for breast and colon cancer, urine protein screening but did not improve control of diabetes or hypertension or eye exam screening. Most preventive measures exceeded national averages
Felder-Heim et al. 2020^Citation70	Medicine Physician assistant Dental Pharmacy Psychology Physical therapy	CCCR	30 (diabetes) 75 (hypertension)	23% 19–44y 56% 45–64y 13% 65–74y 5% 75–84y 3% 85y+	60:40	-	Routine primary care of patients diagnosed with diabetes or hypertension	HbA1c BP Screening: • Diabetes • Nephropathy • Retinopathy	Diabetes care standards were approximately the same, but hypertension care standards lower, than comparator safety-net providers (local community health center, local federally qualified health center, and Colorado State Medicaid)
Peluso et al. 2014^Citation71	Medicine Physician assistant Nursing	CCCR	39	34y	44:56	92% Latino/a 5% Black 3% Asian	Latent tuberculosis infection treatment (isoniazid regimen), over a period of 9 months	Medication adherence	Isoniazid adherence rates were comparable to other reported programs
Rojas et al. 2015^Citation72	Medicine	PPCR	96	50y	52:48	54% Hispanic 34% Caucasian 5% Black	Routine primary care of patients diagnosed with hyperlipidemia, followed up after a period of 5.5 months	LDL mg/dL	LDL levels decreased among cohort, exceeding national care standards

Notes: *Mean, unless otherwise stated (med=median); **Rounded to the nearest whole number.

Abbreviations: I, intervention; C, control; ED, emergency department; EMR, electronic medical records; HIV, human immunodeficiency virus; mg/dL, milligrams per decilitre; N, number; PT, physical therapy. Health outcomes abbreviations: ACS, Activities Card Sort; ADA, American Diabetes Association; ARAT, Action Research Arm Test; BBS, Berg Balance Scale; BMI, body mass index; BP, blood pressure; BP mmHg, blood pressure, millimetres of mercury; HbA1c, glycated haemoglobin (blood glucose level); COPM, Canadian Occupational Performance Measure; EQ-5D, EQ-5D self-rated quality of life scale; Weight (kg), weight in kilograms; LDL, low-density lipoproteins (cholesterol); HDL, high-density lipoproteins (cholesterol); MCID, minimum clinically important difference; MoCA, Montreal Cognitive Assessment; NPRS, Numeric Pain Rating Scale; PHQ-2, Patient Health Questionnaire-2; PHQ-9, Patient Health Questionnaire-9; PROMIS, Patient Reported Outcomes Measurement Information System; QOL VAS, Quality Of Life Visual Analog Scale; SF-8, Short Form 8 health survey; SF-12, Short Form 12 health survey. Study type abbreviations: CCCR, cohort comparison chart review; CCS, cohort comparison survey; NRCT, non-randomised controlled trial; PP, pre-post study; PPCR, pre-post chart review; PPS, pre-post survey; RCT, randomised controlled trial.

Figure 2 Summary and overlap of outcome measures in reviewed studies.

Abbreviations: ACS, Activities Card Sort; ADA, American Diabetes Association; ARAT, Action Research Arm Test; BBS, Berg Balance Scale; BMI, Body Mass Index; COPM, Canadian Occupational Performance Measure; EQ-5D, EQ-5D self-rated quality of life scale; HbH1c, glycated haemoglobin/blood glucose levels; HIV, human immunodeficiency virus; lbs, weight in pounds; LDL = low-density lipoproteins; MoCA, Montreal Cognitive Assessment; mmHg, millimetre of mercury; NPRS, Numeric Pain Rating Scale; PHQ-9, Patient Health Questionnaire-9; PROMIS, Patient Reported Outcomes Measurement Information System; QOL VAS, Quality Of Life Visual Analog Scale; SF-8, Short Form 8 health survey; SF-12, Short Form 12 health survey.

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