Systematic review of patient-initiated appointment systems (PIAS) in secondary care for people with chronic disease

Background

More than 17.5million people in the UK have a chronic condition. Most of these people have regular outpatient appointments at the hospital to manage and review their care. In 2017/18 there were 94 million face-to-face (F2F) hospital outpatient attendances in England alone. Missed hospital appointments are reported to cost the UK National Health Service millions of pounds every year (in 2017/8 there were 8 million missed outpatient appointments).

Alternative methods of appointment scheduling with improved flexibility have been developed such as the Choose and Book service implemented in 2004 and the Expert Patient Programme courses implemented in 2006. The Expert Patient Programme aimed to help people with long-term conditions develop the skills and confidence to self-manage their condition and make more effective use of healthcare services. Other strategies commonly used to improve appointment attendance include over-booking, fines for missed appointments and appointment reminder systems; these strategies are less responsive to patient need.

In 2002 the World Health Organisation published a report which highlighted the need for a model of care that more readily meets the needs of people with chronic conditions. The authors of the report suggested that innovations that build on evidence-based decision-making, have a population and quality focus and are flexible to the needs and demands of the patient population should do well in improving the management of chronic conditions for the healthcare system and the people that use it.

More recently, the concept of patient-initiated appointment systems was recommended by the Royal College of Physicians (RCP) report 2018 “Outpatients: the Future”, identifying the urgency of reviewing how secondary care outpatient services are delivered and continued in the NHS Long Term plan 2019. The importance of using limited resources whilst protecting standards of patient care and health has been identified as a priority.

In contrast to a traditional appointment system, a patient-initiated appointment system (PIAS) aims to be responsive to patient need; routine appointments are not regularly scheduled by the physician and if, for example a patient is experiencing an exacerbation of their condition they can phone a specialist nurse advice line and arrange a consultant appointment as soon as possible where necessary.

We collaborated with South West Academic Health Science Network to evaluate Patient Initiated Appointment Systems for people with long term conditions. You can learn about Patient Initiated Clinics (PIC) here.

The Evidence Synthesis Team have conducted a Cochrane Systematic Review of patient-initiated appointment systems and their impact on patient outcomes.

Why did we do this review?

The objective was to systematically review the evidence for a PIAS in secondary care for patients with chronic or recurrent conditions. In particular we were interested in whether these clinics can effectively manage conditions without causing clinical harm to patients and whether resource use can be reduced in comparison to usual care.

How did we do this review?

A systematic review brings together all existing research on a particular question. To find studies that might help us to answer the question we searched the relevant academic literature.

17 studies were included in the review. Nine studies were from the UK, three were from Sweden, three from Denmark, one from Finland and one from the Netherlands. Studies included people with cancer, rheumatoid arthritis, inflammatory bowel disease, psoriasis, asthma and chronic obstructive pulmonary disease

What did we find?

• Minimal differences in psychological and quality of life measures between patient-initiated appointments (PIAS) and usual care suggest PIAS systems may be safe to use.
• Patient satisfaction with PIAS is mixed but generally positive.
• There were few differences in outcomes between PIAS and usual care, some research suggests there could be cost savings and better use of resources.
• Ongoing evaluations of long term outcomes, costs and variation in benefits according to particular population characteristics is necessary.

Quality of the research and cautionary notes

Although the studies were randomised controlled trials – one of the most reliable types of evidence, the quality of the research was often poor, with important details missing from reports. With the potential impact of the resulting bias unknown this limits the interpretation of the results and also their use in other contexts.

There are two areas where safety may be a concern: PIAS may not be suitable for everyone as it relies on patients knowing when to ask and being confident in, asking for help and there may be elements of preventative care or patient education that are not covered in a more urgent appointment.

Project Outputs and Impact

The results of the systematic review broadly suggest that there may be no harm to patients in using this alternative system of outpatient care. However, we identified a need for care to be taken in implementing the system successfully, to consider those patients who may truly benefit from the patient-initiated system and those for whom the system would not work, in particular taking into account the condition(s) being monitored and the characteristics of the patient.

We hope the findings of this review serve to inform and instigate conversation on the use of patient-initiated appointment systems as an alternative for more sustainable outpatient care for those with chronic and recurring conditions.