JRSM >
Volume 96, Number 7 >
Pp. 333-337
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 |
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 TOP SUMMARY BACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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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 |
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TOPSUMMARYBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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| METHODS |
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TOPSUMMARYBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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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 |
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TOPSUMMARYBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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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.
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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).
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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.
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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.
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| DISCUSSION |
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TOPSUMMARYBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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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 |
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| REFERENCES |
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TOPSUMMARYBACKGROUNDMETHODSRESULTSDISCUSSIONREFERENCES |
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