J R Soc Med 2003;96:333-337
doi:10.1258/jrsm.96.7.333
© 2003 Royal Society of Medicine
Can we see more outpatients without more doctors?
Michelle L Hughes BA PHYSIO
Stephen J Leslie BSc MRCP 1
Gordon K McInnes MB DCH 2
Kathleen McCormac MLitt RCNT
Norman R Peden MA FRCPE
Redesign Office, Forth Valley Acute Hospitals NHS Trust, Falkirk and District
Royal Infirmary, Falkirk FK1 5QE
1
Medical Unit, Forth Valley Acute Hospitals NHS Trust, Falkirk and District
Royal Infirmary, Falkirk FK1 5QE
2
Forth Valley Primary Care Trust, Falkirk, Scotland, UK
Correspondence to: Dr N R Peden E-mail:
norman.peden{at}fvah.scot.nhs.uk
 |
SUMMARY
|
|---|
A reduction in the number of return patients attending general
cardiology
clinics, if achievable without harm, would improve
access for newly referred
patients. Outpatient clinic letters
(525) sent to general practitioners over a
three-month period
were reviewed. Simultaneously, physicians' opinions were
collected
by questionnaire. A subset of 30 clinic patients who attended
three
local general practitioners were studied to identify
how many were assessed in
primary care, and how often, in a
six-month period. The hospital records of
these patients were
reviewed to determine whether information about these
visits
to the general practitioner was documented in the hospital notes.
From the outpatient clinics the discharge rates were only 26% and the
reason for further clinic review was often not clear. The fact that many
patients had no intervention or treatment change performed at the clinic (42%)
indicates that patients are reviewed to assess symptom change rather than to
receive further interventions. The use of fixed times for review appointment
(six months or 1 year) suggests that the intervals are determined by habit
rather than clinical indication. A high proportion of patients (28/30) were
reviewed at least once in primary care by general practitioners between
hospital clinic visits and 20/30 were seen three or more times. There was poor
documentation of these consultations in the hospital case notes, and so
hospital physicians may be unaware that symptoms are under regular review in
primary care.
This study suggests that a substantial proportion of current cardiology
return outpatients do not require regular outpatient review. However,
alternative management demands good communication and exchange of information
between secondary and primary care, development of formal written discharge
planning in outpatient letters and other forms of follow-up.
|
BACKGROUND
|
|---|
Waiting times to see a cardiologist in the UK are often long;
thus patients
with cardiovascular conditions are often managed
by non-cardiologists. It is
possible, however, that changes
to current practice would help reduce waiting
times for cardiology,
and outpatient services are an obvious area for
attention.
Most patients seen in outpatient clinics are
'returns'—i.e.
patients who have been seen previously. Which
cardiac patients
benefit from outpatient follow-up is unclear. This study was
designed to determine whether it may be possible to reduce
the numbers of
return patients attending cardiology clinics,
thereby increasing access to
specialist care for newly referred
patients.
|
METHODS
|
|---|
Data were collected retrospectively on return patients seen
at cardiology
outpatient clinics in two district general hospitals
within one acute NHS
trust in Scotland. Clinic letters sent
to general practitioners over a
three-month period were retrieved
in electronic form from the relevant medical
secretaries, anonymized,
and
reviewed
1 by two
independent observers. Both observers
reviewed all letters. Observer 1 is a
specialist registrar
in cardiology, while observer 2 is a project manager in
redesign
with a background in physiotherapy. There was good agreement
between
observers. Simultaneously physicians' views were collected
by questionnaire. A
subset of 30 clinic patients who attended
three local general practitioners
were studied to see how many
were seen in primary care and how often they were
seen over
a six-month period. The hospital records of these patients were
reviewed to determine whether they contained information about
these visits to
the general practitioner.
Data are expressed as absolute value and percentage unless otherwise
stated. Differences between responses were assessed by non-parametric tests;
chi-squared and binomial multisample tests. Data from observer 1 are
reported.
|
RESULTS
|
|---|
525 clinic letters were retrieved. Eleven doctors were involved
in
reviewing patients in these general cardiology clinics—three
consultants
and eight non-consultant physicians. 323 patients
(59%) were male. The average
age was 61 years.
Quality of clinic letter documentation
Most letters recorded symptoms (97%) and a clinical plan (97%) but few
documented a staged management plan (22%)—i.e. a plan in which general
practitioners are provided with multiple options should therapy or conditions
change. Follow-up arrangements were recorded in 92% of letters.
Outcomes of clinic visit
Overall 34% of patients had further tests requested (not including blood
tests), 33% had treatment changes, 2% were referred to a third party and 41%
had no intervention. 26% of patients were discharged from the outpatient
clinics to primary care. Discharge rates differed according to the initial
diagnosis—ischaemic heart disease (IHD) 36%, arrhythmia 26%, heart
failure 12%, valve disease 4%. 71% of review appointments were made for six
months or 1 year. The timing of review appointment did not vary greatly with
different diagnoses except that review intervals for patients with valve
disease tended to be longer (Figure
1). In 41% of patients the reason for initial review was the same
as that for the follow-up. In this subgroup of patients 46% had no treatment
change, tertiary referral or test ordered during their clinic visit.
View larger version (21K):
[in this window]
[in a new window]
|
Figure 1. Percentage of patients in a diagnostic category given a follow-up
appointment at different intervals
|
|
Alternative options for follow-up
Both observers judged from the clinic letters that, for as many as 60% of
patients not discharged, either the need for consultant review was unclear or
the patient could have been dealt with outside the traditional outpatient
review. Of these 219, 91 (42%) were thought suitable for follow-up in primary
care, the others requiring secondary care follow-up, with or without
consultant supervision. Most patients who were identified as potentially
manageable in primary care had a diagnosis of IHD or heart failure
(Table 1).
View this table:
[in this window]
[in a new window]
|
Table 1. Number of patients considered not to require a traditional outpatient
clinic follow-up (219 of 525 reviewed) and potential alternative follow-up
strategies: reason for continuing review and diagnosis
|
|
Physician questionnaire
All physicians responded to the questionnaire examining physicians'
perceptions of their activity in outpatient clinic. Doctors were good at
estimating the proportion of patients they discharged (25% estimated versus
26% actual) and with treatment change (30% versus 34%) but overestimated the
proportion in whom tests were ordered (40% versus 34%) and who had tertiary
referrals (11% versus 2%). All respondents believed that there were potential
alternatives to traditional clinic review, and their suggestions included a
nurse-led heart failure service, a technician-led valve clinic, a nurse-led
chest pain service and telephone consultations with patients.
Follow-up in primary care
Of 30 patients from three general practices included in this study, 28 were
reviewed in primary care at least once in a six-month period. Indeed 20 of
these patients were seen three or more times
(Figure 2). Review of the
hospital case notes revealed that in only 2 cases was there written
communication from the primary care team on clinical status or treatment
change.
Potential impact of reducing return appointments
Availability of new patient appointments might be substantially increased
by small reductions in numbers of return patient appointments
(Table 2). For example, in a
clinic with a new-to-return patient ratio of 1 to 5, a 10% reduction in return
patients will permit a 25% increase in new patient appointments. In one of the
study hospitals, a 20% reduction in return outpatient appointments would
increase the yearly throughput of new outpatients from about 700 to 910.
View this table:
[in this window]
[in a new window]
|
Table 2. Potential increases in new outpatient capacity created in response to
reviewing fewer patients depending on current new patient to review patient
ratio for the clinic: based on 1 new patient appointments substituting 2
return patient appointments
|
|
|
DISCUSSION
|
|---|
In this study of return patients attending cardiology clinics
42% had no
treatment change but only 26% were discharged. The
reason for continued review
was often not clear. Seemingly
in many cases the aim of review was to assess
symptom change
rather than to offer further interventions. The most common
intervals for review were six months and 1 year, and the use
of these fixed
times may be 'habit' or 'custom and usual
practice'
2
(though perhaps influenced by the perceived availability of
clinic
appointments).
Responses to the questionnaire indicated that physicians overestimated the
number of clinic interventions, so the perceived workload may differ from the
reality. In addition, a high proportion of patients are reviewed in primary
care by general practitioners between hospital clinic visits, some of them
three or more times in the space of six months. Similar findings have been
recorded for patients attending outpatient clinics in other
specialties.3 There
was poor documentation of these appointments in the hospital notes, so
hospital physicians may be unaware that a patient's symptoms are under regular
review in primary care. If physicians recognized the duplication of work, they
might be less reluctant to discharge patients from clinic follow-up. This
would not necessarily increase general practitioner workload. Much depends on
the consultant's letter, from which consultants and general practitioners
require different
things.4–6
The general lack of staged management plans in our clinic letters and length
of time between review appointments suggests that, with our current routines,
the general practitioner may be deprived of information from the cardiology
clinic regarding continuing management. The time required to implement
structured discharge criteria and make the necessary arrangements to
facilitate discharge from outpatient clinics is said to be a concern for
hospital
clinicians.2
However, positive outcomes have been shown for heart failure patients with an
integrated care plan in which follow-up alternated between general
practitioner and a heart failure
clinic.7
Might patients themselves do more to monitor their symptoms on discharge
from secondary care services? In cardiology, a self-management plan for
patients with newly diagnosed angina had beneficial impact on their
psychological, symptomatic and functional
status.8 If patients
receive a copy of their discharge management plan they have more reason to
become actively involved. This ties in with the Department of Health
initiative to copy letters to patients, due to be implemented in
2004,9 and with
previous recommendations on sharing information with patients to facilitate
discharge.2,10
Effective management by either the patient or the primary care practitioner
also depends on rapid access to secondary care services when they are
needed.3 Williams et
al. showed that, rather than routine follow-up, patients with inflammatory
bowel disorders simply wanted access as
required.11 Shared
decision-making between primary care, secondary care and the patient has the
potential to alter service usage and allows sharing of risk but depends
greatly on
information.12–14
In general, alternatives to outpatient review, other than discharge to primary
care and patient self-management, are likely to require some supervision by
consultant staff. The hope, however, is that they will allow more efficient
use of consultant time and effective management of more patients. In the
present study the conditions most commonly identified as manageable by
alternative pathways were IHD and heart failure—two diagnoses that are
making increasing demands on health services. Examples of alternative
follow-up strategies shown to have a positive impact include nurse-led
secondary prevention
clinics15,16
for CHD, nurse specialist or multidisciplinary team based intervention for
heart failure at home or in
clinics17,18
and telemedicine.19
The likelihood, therefore, is that some cardiology patients can be safely and
appropriately followed up by a non-consultant review.
In a clinical area where there is negligible scope to manipulate supply to
match demand, a combination of supply and demand management is required. Our
study suggests that a substantial proportion of current cardiology return
outpatients could be managed effectively by alternative methods, allowing a
large increase in new patient appointments for assessment by cardiologists.
This process, if it is to work, demands good communication and exchange of
information between secondary and primary care, formal written discharge
planning and further development of alternative care pathways.
|
Acknowledgments
|
|---|
We thank Dr A Bridges, Dr A Hargreaves, Dr P McSorley, their
medical
secretaries and Ms A Love for cooperation and assistance.
|
REFERENCES
|
|---|
- Hughes ML, McCormac K, Peden NR. The medical secretary's PC: an
underutilised information resource. J Clin
Effectiveness (in press)
- Burkey Y, Black M, Reeve H, Roland M. Long term follow up in
outpatient clinics. 2: the view from the specialist clinic. Fam
Practice 1997;14: 29
-33[Abstract/Free Full Text]
- Reeve H, Baxter K, Newton P, Burkey Y, Black M, Roland M. Long term
follow up in outpatient clinics. 1: the view from general practice.
Fam Practice 1997; 14: 24
-8[Abstract/Free Full Text]
- Young DW, Parkes J, Davis WA, Harman D, William RS. Outpatient
letters: requirements and contents. Effective Health
Care 1985;2: 225
-9[Medline]
- McConnell D, Butow PN, Tattersall MHN. Improving the letters we
write: an exploration of doctor–doctor communication in cancer care.
Br J Cancer 1990; 80: 427
-37
- Tattersall MHN, Griffin A, Dunn SM, Monaghan H, Scatchard K, Butow
PN. Writing to referring doctors after new patient consultation. What is
wanted and what is contained in letters from one medical oncologist?
Aust N Z J Med 1995; 25: 479
-82[Medline]
- Doughty RN, Wright SP, Pearl A, Walsh JH, Muncaster S, Whalley GA,
et al. Randomized controlled trial of integrated heart failure
management: the Auckland Heart Failure Management Study. Eur Heart
J 2002;23: 139
-46[Abstract/Free Full Text]
- Lewin RJP, Furze G, Robinson J, Griffith K, Wiseman S, Pye M,
et al. A randomised controlled trial of a self-management plan for
patients with newly diagnosed angina. Br J Gen Pract 2002; 52: 194
-201[Medline]
- http:/www.doh.gov.uk/patientletters/issues.htm
- Burkey Y, Black M, Reeve H. Patients views on their discharge from
follow up in outpatient clinics: qualitative study.
BMJ 1997; 315: 1138
-41[Abstract/Free Full Text]
- Williams JG, Cheung WY, Russell IT, Cohen DR, Longo M, Lervy B.
Open access follow up for inflammatory bowel disease: pragmatic randomised
trial and cost effectiveness study. BMJ 2000; 320: 544
-8[Abstract/Free Full Text]
- Pencheon D. Matching demand and supply fairly and efficiently.
BMJ 1998; 316: 1665
-7[Free Full Text]
- Coulter A. Managing demand at the interface between primary and
secondary care. BMJ 1998; 316: 1974
-6[Free Full Text]
- Edwards N, Hensher M. Managing demand for secondary care services:
the changing context. BMJ 1998; 317: 135
-8[Free Full Text]
- Campbell NC, Thain J, Dean HG, Ritchie LD, Rawles JM, Squair JL.
Secondary prevention clinics for coronary heart disease: randomised trial of
effect on health. BMJ 1998; 316: 1434
-7[Abstract/Free Full Text]
- Murchie P, Campbell NC, Ritchie D, Simpson JA, Thain J. Secondary
prevention clinics for coronary heart disease: four year follow up of a
randomised controlled trial in primary care. BMJ 2003; 326: 84[Abstract/Free Full Text]
- Cline CM, Israelsson BY, Wilenheimer RB, Broms K, Erhardt LR. Cost
effective management programme for heart failure reduces hospitalisation.
Heart 1998; 80: 430
-1[Free Full Text]
- Blue L, Lang E, McMurray JJV, et al. Randomised controlled
trial of specialist nurse intervention in heart failure.
BMJ 2001; 323: 715
-18[Abstract/Free Full Text]
- Jerant AF, Azari R, Nesbitt TS. Reducing the cost of frequent
hospital admissions for congestive heart failure: a randomized trial of a home
telecare intervention. Med Care 2001; 39: 1234
-45[CrossRef][Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
|
|
 
A. Bowling, C. Harries, D. Forrest, and N. Harvey
Variations in cardiac interventions: doctors' practices and views
Fam. Pract.,
August 1, 2006;
23(4):
427 - 436.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
SUMMARY
BACKGROUND
