What is the aim of this review?
We aimed to establish if patient-initiated appointments (appointments requested by the patient) for people with chronic and recurrent conditions is a better way of managing care in hospital outpatient settings than standard appointments scheduled by the consultant. Researchers found 17 studies to analyse.
Key messages
Overall, this review provides mainly low-quality evidence that patient-initiated appointment systems may have little or no impact on patient anxiety, depression, quality of life, adverse events and satisfaction. This system may also have little or no impact on the contact that patients have with services but impact on the costs of the service are unclear. There is some variability in the way patients experience care.
What is studied in the review?
Follow-up appointments scheduled by a hospital consultant is currently used for people with chronic conditions such as (but not limited to) rheumatoid arthritis, inflammatory bowel disease and cancer. This system often results in missed appointments, patients unable to access care when they need it, and a backlog of patients waiting to be diagnosed or treated for the first time. Allowing patients to access healthcare advice and appointments when they need it (patient-initiated appointments) could help alleviate these problems and free-up appointments. The patient-initiated system of care may also lead to greater satisfaction for patients with a more convenient service, and may reduce costs for patients and service providers. This review compares patient-initiated appointment systems that allow the patient to telephone a specialist nurse on a helpline, where they can discuss their query first, and have an appointment with the consultant booked as necessary, to consultant-led appointment systems. We want to know if these systems are safe for patients to use, if patients and clinicians find them appropriate and satisfactory to use, how they may impact patients physical and mental health, and how they may impact on health service resources and costs.
What are the main results of the review?
The review identified 17 studies. The studies covered six health conditions cancer (seven studies), rheumatoid arthritis (four), digestive conditions (three), asthma (one), psoriasis (one) and coronary obstructive pulmonary disease (one). Most studies were based in the UK (nine) but Sweden (three), Denmark (three), Finland (one) and the Netherlands (one) were also represented. The mean age of the 3854 patients ranged from 41 to 76 years and most were female. The results suggest patient-initiated appointment systems may make little or no difference to patient anxiety, depression and quality of life compared to the consultant-led appointment system (low-quality evidence due to high risk of bias and variation in results). Other aspects of disease status and experience also appear to show little or no difference between patient-initiated and consultant-led appointment systems. Results for service utilisation (contact with health services and staff) suggest there may be little or no difference in service contacts between the patient-initiated and consultant-led services (low-quality evidence due to different levels of contact reported across studies making it difficult to assess). We do not know if service utilisation (costs of services or staff) are reduced in the patient-initiated compared to the consultant-led appointment groups as the quality of this evidence is very low (due to the risk of bias and the variability of currencies and levels of costs reported across studies). The results suggest that there may be little or no impact on adverse events such as relapses in some conditions (cancer or inflammatory bowel disease) in the patient-initiated appointment group in comparison with the consultant-led appointment group (low-quality evidence due to the inconsistency and precision across studies in reporting and measuring relapse). The results suggest there may be little or no impact on patient satisfaction (low-quality evidence as each study used different questions to collect their data at different time points and across different illnesses). Not all studies reported their funding sources, but of those that were reported, most were funded by not-for-profit organisations. One study (on asthma) was funded by a pharmaceutical company.
How up-to-date is this review?
The review authors searched for studies that had been published up to March 2019.
Patient-initiated appointment systems may have little or no effect on patient anxiety, depression and quality of life compared to consultant-led appointment systems. Other aspects of disease status and experience also appear to show little or no difference between patient-initiated and consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on service utilisation in terms of service contact and there is uncertainty about costs compared to consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on adverse events such as relapse or patient satisfaction compared to consultant-led appointment systems.
Missed hospital outpatient appointments is a commonly reported problem in healthcare services around the world; for example, they cost the National Health Service (NHS) in the UK millions of pounds every year and can cause operation and scheduling difficulties worldwide. In 2002, the World Health Organization (WHO) published a report highlighting the need for a model of care that more readily meets the needs of people with chronic conditions. Patient-initiated appointment systems may be able to meet this need at the same time as improving the efficiency of hospital appointments.
To assess the effects of patient-initiated appointment systems compared with consultant-led appointment systems for people with chronic or recurrent conditions managed in secondary care.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and six other databases. We contacted authors of identified studies and conducted backwards and forwards citation searching. We searched for current/ongoing research in two trial registers. Searches were run on 13 March 2019.
We included randomised trials, published and unpublished in any language that compared the use of patient-initiated appointment systems to consultant-led appointment systems for adults with chronic or recurrent conditions managed in secondary care if they reported one or more of the following outcomes: physical measures of health status or disease activity (including harms), quality of life, service utilisation or cost, adverse effects, patient or clinician satisfaction, or failures of the 'system'.
Two review authors independently screened all references at title/abstract stage and full-text stage using prespecified inclusion criteria. We resolved disagreements though discussion. Two review authors independently completed data extraction for all included studies. We discussed and resolved discrepancies with a third review author. Where needed, we contacted authors of included papers to provide more information. Two review authors independently assessed the risk of bias using the Cochrane Effective Practice and Organisation of Care 'Risk of bias' tool, resolving any discrepancies with a third review author. Two review authors independently assessed the certainty of the evidence using GRADE.
The 17 included randomised trials (3854 participants; mean age 41 to 76 years; follow-up 12 to 72 months) covered six broad health conditions: cancer, rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, psoriasis and inflammatory bowel disease. The certainty of the evidence using GRADE ratings was mainly low to very low. The results suggest that patient-initiated clinics may make little or no difference to anxiety (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.68 to 1.12; 5 studies, 1019 participants; low-certainty evidence) or depression (OR 0.79 95% CI 0.51 to 1.23; 6 studies, 1835 participants; low-certainty evidence) compared to the consultant-led appointment system. The results also suggest that patient-initiated clinics may make little or no difference to quality of life (standardised mean difference (SMD) 0.12, 95% CI 0.00 to 0.25; 7 studies, 1486 participants; low-certainty evidence) compared to the consultant-led appointment system. Results for service utilisation (contacts) suggest there may be little or no difference in service utilisation in terms of contacts between the patient-initiated and consultant-led appointment groups; however, the effect is not certain as the rate ratio ranged from 0.68 to 3.83 across the studies (median rate ratio 1.11, interquartile (IQR) 0.93 to 1.37; 15 studies, 3348 participants; low-certainty evidence). It is uncertain if service utilisation (costs) are reduced in the patient-initiated compared to the consultant-led appointment groups (8 studies, 2235 participants; very low-certainty evidence). The results suggest that adverse events such as relapses in some conditions (inflammatory bowel disease and cancer) may have little or no reduction in the patient-initiated appointment group in comparison with the consultant-led appointment group (MD –0.20, 95% CI –0.54 to 0.14; 3 studies, 888 participants; low-certainty evidence). The results are unclear about any differences the intervention may make to patient satisfaction (SMD 0.05, 95% CI –0.41 to 0.52; 2 studies, 375 participants) because the certainty of the evidence is low, as each study used different questions to collect their data at different time points and across different health conditions. Some areas of risk of bias across all the included studies was consistently high (i.e. for blinding of participants and personnel and blinding of outcome assessment, other areas were largely of low risk of bias or were affected by poor reporting making the assessment unclear).