Podcast: Patient-initiated appointments for people with chronic conditions managed in hospital outpatient settings

One technique that has been suggested to improve patients’ interaction with secondary care is to give them more control over the setting of their appointments. In April 2020, a new Cochrane Review of relevant research was published by a team of authors from the south west of England. We asked two of them to tell us about the findings in this podcast, beginning with Mark Perry from United Hospitals Plymouth and Plymouth University Peninsula School of Medicine and Dentistry, followed by Rebecca Whear from the University of Exeter’s Medical School.

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Monaz: Hello, I'm Monaz Mehta, editor in the Cochrane Editorial and Methods department. One technique that has been suggested to improve patients’ interaction with secondary care is to give them more control over the setting of their appointments. In April 2020, a new Cochrane Review of relevant research was published by a team of authors from the south west of England. We asked two of them to tell us about the findings in this podcast, beginning with Mark Perry from United Hospitals Plymouth and Plymouth University Peninsula School of Medicine and Dentistry, followed by Rebecca Whear from the University of Exeter’s Medical School.

Mark: People with long term or recurrent conditions, like arthritis, cancer, inflammatory bowel disease, some lung and certain skin conditions, receive care including appointments from hospital specialist teams, from the time of their diagnosis and for the rest of their lifetime. Their hospital appointments are often scheduled by the medical team, but the fluctuating nature of people’s symptoms means that they might attend appointments when they are feeling well. Sometimes other people’s unnecessary routine appointments may mean someone can’t easily see their medical team when required.  Many people have several health conditions, meaning they need to be able to prioritise which condition requires their current attention and then access care promptly. This difficulty with accessing care can be inconvenient for the patient, and inefficient for the health service.
One way around this might be patient-initiated appointment systems, which encourage people to understand and manage their own long-term condition. Patients don’t receive scheduled appointments, but instead contact a clinical nurse specialist for advice when they need it, and when appropriate are offered an appointment within a few days. If no contact is made by the patient after a certain amount of time, a so called safety net appointment is triggered. If such systems are to be widely adopted, it’s important to know whether they work.

Becky: To find out, we looked at existing research into whether patient-initiated appointment systems for people with chronic and recurrent conditions were better for managing hospital outpatient care than the traditional appointments scheduled by the medical team. We were interested in whether these systems might reduce patient contact with health services and the associated costs, but while still being safe.
We found 17 randomised trials involving nearly 4000 people living with conditions such as cancer, rheumatoid arthritis, inflammatory bowel disease, psoriasis, asthma and chronic obstructive pulmonary disease who had tested the patient-initiated appointment system. Most studies were from the UK and the rest were from elsewhere in Europe.
Overall, the studies suggest little or no difference between the patient-initiated appointment system and the traditional system for most of the outcomes we assessed. These include the patient’s experience of disease specific symptoms, disease progression and adverse events. Their experiences also seemed to be similar for anxiety, depression and quality of life.
It is likely that there is no difference in the number of contacts with health services between the two systems, but there may be a difference in who is being contacted and how this occurs. This might impact on the costs related to the patient-initiated system, but there is currently insufficient evidence to be sure about this. Likewise, there was scarce information on the number of missed appointments, but what data there are suggests that the number of missed appointments may be lower with the patient-initiated system.

Mark: In summary our Cochrane Review suggests that a patient-initiated appointment system may be a safe alternative to a clinician-initiated appointment system, may provide flexibility to patients and care providers, and give more autonomy to patients and their families. There is some uncertainty in these data, but a patient-initiated approach has been endorsed by the Royal College of Physicians London from 2018, and the NHS Longterm Plan in 2019. Care is needed when helping patients chose whether a patient-initiated appointment system will work for them, and guidance is available for example from NHS England and Improvement. The choice needs to consider the condition being monitored and the individual’s personal characteristics.

Monaz: If you would like to read more about these systems, and who they might be useful for, there’s a lot more detail in the Cochrane Review. It’s available online at Cochrane Library dot com, with a simple search for 'patient-initiated appointment system'.

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