Breast disease and the general surgeon. II. Effect of audit on the referral of patients with breast problems.

OBJECTIVES--To determine the number of patients with breast problems referred to general surgical clinics in a district general hospital and to assess the effect of changes implemented following the previous study on waiting time, investigations performed, and management of the patients. DESIGN--Two prospective outpatient audits with patient details recorded on questionnaires by the medical staff. SETTING--The general surgical outpatient clinics of a single general surgical firm at Newbury District Hospital, Berkshire. PATIENTS--Those patients attending the above clinics during two 3-month periods, 1 October to 31 December 1989 (Study 1), and 16 April to 19 July 1990 (Study 2). RESULTS--Of new referrals, 25% were for a breast problem. The waiting time fell from a median of 22 days in Study 1 to 10 days in Study 2. There was no significant difference between the studies for the proportion of each type of investigation performed. Between 80% and 85% of new patients did not need admission for an operation; however, of those operations performed, 65% were for carcinoma. The number of patients diagnosed as having carcinoma was the same in the two studies. CONCLUSIONS--That 25% of new, and up to 40% of follow-up patients seen in a general surgical clinic have breast problems. Many patients do not regard their symptoms as worrying and will not attend early clinic appointments even if these are offered. Writing to patients and general practitioners with the results of investigations ensures quicker receipt of the diagnosis and treatment plan, and reduces follow-up attendance. Only 15-20% of new patients need admission for an operation, and carcinoma is found in only 13-17%. Open access to the clinics does not result in general practitioners referring patients unnecessarily with breast problems.     

'Paper Clinics'- a model for improving delivery of outpatient colorectal services.

OBJECTIVES: The overburdening of colorectal out-patient clinics necessarily leads to delays in time from referral to consultation and subsequent clinic attendance. This study aimed to ascertain the feasibility of 'paper clinic' follow-up rather than all patients receiving a routine follow-up appointment following investigation. A more efficient outpatient follow-up process should reduce unnecessary follow-up, thereby facilitating the speedy investigation and diagnosis of patients through changes in clinic profiles. METHODS: From August 2001 all patients seen in the outpatient clinic of one (part time) Consultant colorectal surgeon, who required investigation, were prospectively recorded on a 'paper clinic' form. These patients were given the necessary test request forms but were not given a further outpatient appointment. The results of the investigations were reviewed, together with the patients' medical records at a formal fortnightly 'paper clinic' session carried out by the Consultant and Nurse Consultant, and a treatment plan derived. Patients then followed one of 5 follow-up pathways and were notified in writing with a copy to their GP. RESULTS: During a 24-month period a total of 897 patients were reviewed using the 'paper clinic' follow-up system. Of these, 285 (31.8%) patients were discharged without further follow-up. In a given 3-month period when the clinic was well established, 152 patients were reviewed, of whom 27% were discharged from follow-up, 17% received SOS appointments, 13% required further investigation (and consequently were returned to 'paper clinic' follow-up), and 7% received Nurse led follow-up. In this 3-month period 64% of patients reviewed by 'paper clinic' follow-up did not return to Surgical Outpatient's and 12% received a Surgical Outpatient appointment for review. CONCLUSION: 'Paper clinic' follow-up is an effective and feasible follow-up alternative, resulting in a major decrease in outpatient follow-up burden. This has allowed the redesign of the outpatient clinic profile allowing for an increase in new urgent slots, and more rapid clinic follow up review of those patients who need it. Re-design and rationalization of existing services can result in considerable service improvement. Expanding clinics should not be considered the only option when faced with capacity and demand issues.     

One-stop diagnosis for symptomatic breast disease.

A consultant-led one-stop diagnostic service has been available at a busy symptomatic breast clinic each week at St Bartholomew's Hospital for 18 months. Women can be investigated appropriately using mammography, ultrasonography and cytology with immediate reporting. The aim is to achieve a diagnosis and management plan for each patient at the initial outpatient visit. A prospective audit of four consecutive clinics was undertaken to assess the impact of this service on clinical practice. Fifty patients out of 134 new and 386 follow-up clinic attenders had one-stop investigations. As a result of immediate reporting, 48 (96%) patients had a management decision made at the first outpatient visit, 9 (18%) were offered surgery, and 18 (36%) were discharged with a benign diagnosis and no dominant mass. Four symptomatic cancers were detected and evaluated on a one-stop basis, constituting 8% of the workload of this clinic. The mean wait from designated appointment until surgical consultation was 37.7 min (range -68-171 min) and that for investigation until subsequent clinical review was 56.9 min (range -4-191 min). Thirty-six (72%) one-stop patients had a total wait of less than 2 h and 95% were seen in under 3 h. It is felt that the one-stop clinic allows optimum patient management, minimises anxiety associated with symptomatic breast disease, and maximises utilisation of hospital outpatient resources.     

Resource implications of outpatient referrals to a general urological service.

The effects of new outpatient referrals on the dynamics of global provision in a surgical service has not previously been defined. Because of managerial pressure to reduce the time interval between general practitioner referral and first specialist assessment, many services are now faced with additional outpatient loads without any clear idea of the effect that this additional burden will have on overall practice. In an attempt to define the logistic implications of a new outpatient load, 293 patients, referred from primary care to a general urological service, were followed for a further two interactions with the secondary care team. 'One-stop' visits with in-clinic investigation and an active discharge policy were employed to assist with efficient patient management. Of the original patients, 28% required investigations not available in the clinic, with cost and logistic implications for support services. In all, 32% of the patients needed further follow-up appointments, despite the active discharge policy. This necessitated 95 people being seen in additional clinic time. Of the patients referred, 37% needed inpatient treatment; 46% being day case procedures, the remainder constituting a variable case mix. This work necessitated 7.1 operating sessions and an additional 75 inpatient bed days for every 100 new patients referred. A model for determining the resource requirements for a surgical outpatient load is proposed.     

A one-stop vascular clinic: a practical proposition with non-invasive assessment.

One-stop clinics are becoming increasingly popular with both patients and their general practitioners. Traditionally, vascular patients have needed to attend hospital two or three times for clinical examination and investigations. We have introduced a one-stop clinic for patients with lower limb arterial disease (LLAD) and aortic aneurysms. In 92 clinics over 2 years, 1194 new patients and 1409 follow-up patients were seen, with LLAD being the largest single category comprising 40% of the patients seen, followed by varicose veins (25%), carotid disease (12%), and aortic aneurysms (8%). Overall, 57% of patients had non-invasive imaging performed, either in the clinic or on a separate visit. Performing all LLAD and aortic scans in the clinic requires 1.9 h of imaging time per clinic. Extending in-clinic scanning to patients with varicose veins and carotid disease would increase this to 3.9 h of scanning per clinic and require a duplex scanner and an additional technologist in the clinic.     

A nurse-led preadmission clinic for elective ENT surgery: the first 8 months.

A nurse-led preadmission clinic was set up in the Department of Otolaryngology of The Royal Berkshire Hospital, Reading, for patients undergoing elective ENT surgery. The progress of the clinic has been monitored during its first 8 months of service. A two-part study was undertaken: (a) A prospective study of the process from the time an admission appointment was sent until completion of surgery and, (b) a retrospective review of the case notes to study the quality of clerking and note keeping and the pattern of requests for investigations made by the nurses. In all, 514 patients were invited to attend the preadmission clinic before operation. Of these patients, 454 attended the clinic for preadmission clerking, 440 (96.9%) of whom underwent their operation without complication. All clerking notes were well kept, but a number of unnecessary investigations were requested. It is concluded that a nurse-led preadmission clinic is effective in the management of elective ENT operating lists. It assists in improving the quality of an SHO's training by reducing time spent on service commitments, thereby increasing the potential training time. More guidance to nurses on the use of preoperative investigations is needed.     

Plastic surgery outpatient audit: principles and practice of "consultant only" clinics

The effect of instituting "consultant only" clinics on plastic surgery outpatient activity was to produce a 19% reduction in both clinic sessions and new patient bookings, but a 50% reduction in booked follow-up patients; non-attender rates reduced from 20% to 11% (Northern General Hospital, April 1986-March 1989). Mean clinic attendances reduced from 35 to 26 (Northern General Hospital) and from 33 to 27 (Barnsley District Hospital)--26% and 18%, respectively. Analysis of new referrals to such clinics in the 6 months January-June 1989 showed 41% of patients came from general practitioners, although 80% of "aesthetic" conditions came from this source. 31% of referrals were for malignancy, 51/72 (70%) being basal cell carcinomas. Malignancies waited on average 4 weeks, benign conditions 15 weeks, and "aesthetic" conditions 28 weeks from referral to consultation. Such clinic management has dramatically reduced follow-up episodes, but regulation of new patient attendances is associated with appreciable waiting times for non-malignant conditions. To reduce such waiting times and pursue a "consultant only" clinic policy nationally requires many more consultants.     

Views of UK melanoma patients on routine follow-up care.

Although the need for melanoma follow-up is universally accepted, there is still much debate on the duration and frequency of appointments. The UK guidelines were revised in June 2002 to streamline melanoma follow-up. Following the change in protocol, some of our patients expressed concern at the shorter duration of follow-up. We therefore polled all our active melanoma patients to obtain their views on the outpatient clinics. In particular we asked whether they would be happy to have routine follow-up in a primary care setting. In conjunction with the department of psychology, a short questionnaire was devised assessing patient satisfaction and concerns about follow-up. This was sent to all active melanoma patients in our trust. Out of 304 eligible patients currently attending outpatients, 231 (76%) completed replies were received. Ninety-eight percent of respondents found the clinics to be useful. Twenty two and a half percent felt it was difficult to attend the clinic and this was mainly due to logistical problems, i.e. hospital car parking. The majority were reassured by the clinic visits and felt it was a chance to ask questions and check for new disease. Of the 12% of respondents who had a recurrence, 52% indicated that they had detected it themselves. Sixty percent of patients would be happy to consider routine follow-up with their GP, provided they were suitably experienced and trained. A survey of 50 local GP's found that 70% would be unhappy to monitor their patients. Patients want and benefit from follow-up. However, they are an increasing burden on outpatient clinics, given the increasing incidence of melanoma. GP follow-up may be appropriate for a small subgroup of patients. This combined with shared care and practice based clinical nurse specialists may be the way forward in melanoma follow-up.     

The management of women with breast symptoms referred to secondary care clinics in Sheffield: implications for improving local services

Information was collected about 302 women referred for breast symptoms and seen in surgical outpatient or outreach clinics during one month at two hospitals in Sheffield. Three-quarters of the women (n = 244) were referred to specialist breast clinics, 22% (n = 70) were referred to general surgical clinics and 3% (n = 6) were referred to outreach clinics. The ages of the women ranged from 16 to 85 years with a mean and median age of 45 years. Some 200 women (66%) presented with a lump or lumpiness, 42 women (14%) presented with pain, 29 women (10%) had a skin and/or nipple problem, and the remaining 31 women (10%) were concerned about their family history or reported other symptoms. A total of 23 women (8%) were diagnosed as having cancer, 180 (60%) were diagnosed as having benign breast disease, and 99 (33%) were diagnosed as normal. Of the 23 women with cancer, 22 were over 40 years of age; 21 women presented with a lump, one presented with pain, and one presented with metastatic disease. The time required to reach a final clinical diagnosis varied from the same day as the clinic visit to 35 weeks, with a median time of 3 weeks. Surgeons assessed the appropriateness of GPs' referrals for 257 cases and judged that 122 (47%) could have been managed by a GP. The implications of the findings for the organisation of specialist outpatient clinics are discussed, and a categorisation of women as either urgent or routine cases is suggested.     

Maximizing use of a surgical clinic for referrals of patients having back problems.

OBJECTIVE: To determine ways to improve the delivery of service in a surgical clinic, based on the outcome of surgical consultations for back pain. DESIGN: A prospective outcome study. SETTING: A university teaching hospital providing secondary and tertiary care. PATIENTS: One hundred and forty-two consecutive patients who presented to surgical clinics for assessment of a back problem between Apr. 14 and May 30, 1996. INTERVENTIONS: Surgeons determined the diagnosis and visit outcome; data were tabulated objectively by a third-party researcher. OUTCOME MEASURES: Waiting time for consultation, presence of referral letter, third-party interests, diagnosis and visit outcome. RESULTS: Twenty-five percent of patients had chronic pain not amenable to surgery, 19% of patients were surgical candidates and were offered an operation, 13% were symptomatically improved to the point of not wanting an operation, 11% wanted a second opinion only, 10% had mechanical back pain appropriate for referral to physiotherapy, 9% had not undergone an adequate trial of nonoperative treatment when seen in the clinic and were given follow-up appointments, 5% were "no shows," 3.5% were seen for a medicolegal assessment, 3.5% wanted confirmation from a specialist that they did not need surgery and 1% had symptoms due to a vascular rather than a spinal cause and were referred to a vascular surgeon. CONCLUSION: Delivery of service could be improved by more rigorous screening to reassign appointment times of patients who have not had an adequate trial of nonoperative treatment, are improved or do not intend to keep their appointment.     

Do patients require outpatient follow‐up after rapid referral double contrast barium enema?

Introduction  In our hospital, patients above the age of 40 years referred with a change in bowel habit without rectal bleeding undergo a double contrast barium enema (DCBE) ideally within 2 weeks. Results of benign studies are sent to a consultant colorectal surgeon and a routine clinic visit arranged. The aim of this study was to identify whether, following DCBE, patients (i) presented at a later date with colorectal cancer and (ii) needed assessment in clinic.
Method  This is a review looking at all patients who underwent DCBE prior to routine clinic visit between January 2004 and December 2005. Hospital databases were cross-referenced to identify any patients presenting with a new diagnosis of colorectal malignancy between DCBE and April 2007. Clinic letters were reviewed to identify the number of outpatient visits prior to discharge and reasons for continued follow-up.
Results  During the study period, 521 patients (age range 31–93 years, 316 female) had DCBE prior to assessment in clinic. Diagnoses: cancer 48 (9.2%), polyps 13 (2.5%), colitis 3 (0.6%), no significant pathology 457 (87.7%). Of this latter cohort, 387 (84.7%) were discharged after one clinic visit; 54 (11.9%) attended twice and 11 (2.4%) were seen more than twice. Reasons for multiple attendances were management of haemorrhoids/anal fissure or investigations of unrelated symptoms. No new cancers were identified in this cohort between January 2004 and April 2007.
Conclusion  Double contrast barium enema is a safe screening tool following a '2-week rule' referral with CIBH. Following a report of no significant pathology, there is no need to arrange routine follow-up.     

The workload of a surgical unit in a district general hospital.

A 3-month prospective study of the workload of a surgical unit in a district general hospital was performed to identify the relationship between outpatient work, admissions to hospital, and scheduled operating lists. We have shown that under 60% of all new cases seen in the outpatient clinic had admissions arranged after initial consultation. Over two-thirds of inpatient admissions were for emergencies or urgent cases, and thus not able to be controlled by the surgical team. One-third of emergency admissions had an operation within 24 h of admission. One third of the total number of cases on scheduled lists were emergency or urgent cases (taking up approximately 50% of the operating time). Of all admissions, 32% were as day cases. Of all routine operations, 35% were performed at a community hospital taking only 18% of all our admissions.     

Follow-up in women with breast cancer: the patients' perspective

We surveyed the opinions of patients on routine follow-up for early breast cancer to assess their satisfaction with current breast cancer follow-up arrangements, establish the issues that are important to patients in this setting and to assess their opinions on different models of care in breast cancer follow-up. A self-completion questionnaire was issued to 134 women attending an outpatient breast cancer follow-up clinic at a central teaching hospital in Glasgow. Most women (84%) considered follow-up 'important' and 90% were satisfied with current follow-up practice. Almost all patients (91%) were content with both the current frequency and duration of their appointments. Risk of recurrence and effects of treatment were considered the most important topics for discussion. Two-thirds of patients felt it was important to see the same member of staff at each follow-up appointment. The majority (64%) would have been satisfied with a nurse-led system of follow-up, whereas only 38% would be happy with General Practitioner-led care. Although patients are generally satisfied with current follow-up arrangements, most would accept the involvement of specialist nurses in conjunction with a consultant.     

Does Limiting Long-Term Follow-Up for Breast Cancer Allow All Referrals to be Seen in 2 Weeks?

INTRODUCTION

The UK National Institute for Health and Clinical Excellence (NICE) recommends that breast cancer follow-up should be limited to 2–3 years stating this will ‘release resources’ making it ‘possible for all women with breast symptoms to be seen within 2 weeks’. In 2000, breast cancer follow-up services in North Bristol were redesigned to reflect evidence-based best practice. The aim of this paper is to assess the impact of this policy on numbers of follow-ups, clinic capacity and waiting times.

PATIENTS AND METHODS

Data regarding the numbers of new and follow-up patients seen in breast clinic between January 2000 and December 2005 were collected from the hospital Patient Administration System. New patients were categorised as either ‘routine’ or ‘urgent’ according to ‘2-week wait’ rule guidelines. Median waiting times were calculated for each group and nominal appointment times assigned in an attempt to assess the effect of any changes on clinic capacity.

RESULTS

The number of follow-ups decreased by 33% as a result of the new policy. Numbers of referrals over the same period, however, increased by 14%. Routine referrals declined, but there was a 27% increase in ‘2-week wait’ patients. Waiting times for routine appointments initially decreased in response to reduced follow-up, but then rose as the number of ‘2-week wait’ referrals increased.

CONCLUSIONS

Reducing long-term follow-up is a simple and effective method of increasing clinic capacity but its effects are inadequate and transient in the face of increasing service demand. Additional innovative and creative strategies will be required if all breast patients are to be seen within 2 weeks.     

Telephone Follow-Up by a Midlevel Provider After Laparoscopic Inguinal Hernia Repair Instead of Face-to-Face Clinic Visit

Methods:This is a retrospective review of consecutive patients who prospectively agreed to undergo telephone follow-up after laparoscopic inguinal hernia repair instead of standard face-to-face clinic visits. Patients received a telephone call from a dedicated physician assistant 2 to 3 weeks after surgery and answered a predetermined questionnaire. A face-to-face clinic visit was scheduled based on the results of the call or on patient request.Results:Of 62 patients who underwent surgery, all agreed to telephone follow-up instead of face-to-face clinic visits. Their mean round-trip distance to the hospital was 122 miles. Fifty-five patients (88.7%) successfully completed planned telephone follow-up. Three patients (4.8%) were lost to follow-up, and 4 (6.5%) were erroneously scheduled for a clinic appointment. Of the 55 patients who were reached by telephone, 50 (90.9%) were satisfied and declined an in-person clinic visit. Five patients (9.1%) returned for a clinic appointment based on concerns raised during the telephone call. Of these, 1 was found to have an early hernia recurrence and 1 had a seroma.Conclusion:Telephone follow-up by a midlevel provider after laparoscopic inguinal hernia repair is feasible and effective and is well received by patients.     

Design of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: a review of computer simulation and patient survey studies.

Anesthesiologists can use the science of clinic scheduling to design appointment systems for preanesthesia evaluation clinics. The principal reasons reported for inappropriately [or arguably unethically] long patient waiting times are provider tardiness, lack of patient punctuality, patient no-shows, and improperly designed appointment systems. However, the fundamental reason why anesthesia clinics have such long patient waiting times is because of their relatively long mean (and consequently standard deviation) of consultation times. If commonly applied valuations of provider idle time to patient waiting time are used in anesthesia clinics, appointment intervals will be sufficiently brief that the mean patient waiting time will be at least the mean consultation time or half an hour. Patients will be dissatisfied with this level of service. Therefore, efforts to decrease the mean patient waiting time in anesthesia clinics should focus foremost on minimizing the mean consultation time and its variability, which can most likely be achieved by assuring that providers have rapid access to relevant clinical information, including external medical records, surgical dictations, etc. Anesthesiologists managing anesthesia clinics may find it valuable to apply other interventions to decrease patient waiting times. Scheduling of preanesthesia evaluation and surgical clinics should be coordinated to assure patient punctuality. Providers should be on time for the start of their sessions. If an add-on patient cannot be seen during a scheduled clinic session, because all appointment times have been assigned to other patients, the add-on patient should be seen by a different provider or at the end of the regularly scheduled clinic session. Mean consultation times should be measured accurately for each provider. Substantial provider idle time should be expected. Appropriate values for breaks, appointment intervals, and percentage no-shows should be determined by computer simulation, using parameters appropriate for each provider and anesthesia clinic. Finally, traditional efforts at making waiting for a consultation tolerable should be made.     

Referral prioritization at the specialist breast clinic

Aim: The workload of specialist breast clinics is ever increasing and long waiting time is expected. Clinical guidelines were employed to sort out the priority of consultation. The effectiveness of this system is reviewed. Methods: All referrals seen at the specialist breast clinic from January 2002 to March 2002 were retrospectively studied. The guidelines for allocation to urgent appointment included – (1) urgent referral as determined by referring physician; (2) referral not labelled as urgent but certain ‘high risk’ criteria were present: age more than 50, lump bigger than 3 cm, bloody nipple discharge and physical signs suggestive of malignancy like irregular or fixed breast lump. Routine appointment was given if these criteria were not met. Patients with imaging and cytology results available before specialist consultation were given appointment with reference to the investigation result and excluded from the present analysis. Outcome of the patients in each category was assessed. Results: 165 referrals were analysed and 14 cancers were diagnosed. The mean waiting time for urgent and routine appointments were 2 weeks and 20 weeks, respectively. There were 52 urgent referrals and eight (15.4%) cancers were diagnosed compared to six cancers (5.3%) diagnosed in the 113 non‐urgent referrals. Forty‐two patients among these 113 patients were given urgent appointment due to the presence of high‐risk criteria and as a result, all the six patients with cancers were allocated to urgent appointments. None of the patients given routine appointment had breast cancer diagnosed. Conclusion: It was reassuring that no cancer was diagnosed in patients who had been allocated to routine appointment. In addition to the clinical assessment by the referring physicians, certain ‘high‐risk’ criteria serve as useful guides in assigning the urgency of specialist consultation.     

Role of pre-admission clinics in a general surgical unit: a 6-month audit.

We report a 6-month audit of the running of a pre-admission assessment clinic for routine general surgical admissions. An attendance rate of 91.4% of fit patients ready for surgery on the day of admission was achieved. Of all patients attending the pre-admission clinics, 79.5% underwent surgery as planned. Pre-admission clinics are recommended as a method of improving the efficiency of elective surgical admissions.     

Lost to follow up: contributing factors and challenges in South African patients on antiretroviral therapy.

BACKGROUND: Patients who do not return for follow-up at clinics providing comprehensive HIV/AIDS care require special attention. This is particularly true where resources are limited and clinic loads are high. Themba Lethu Clinic at Helen Joseph Hospital in Johannesburg is a facility supported by PEPFAR funding through Right to Care (Grant CA-574-A-00-02-00018); more than 800 HIV/AIDS patients are seen there each week. Data on a sample of patients who failed to return for follow-up were analysed to identify the causes and to plan strategies to overcome the problem. METHODS: A group of 182 patients who missed follow-up appointments at the clinic were identified. Their files were examined to identify possible contributing factors. The patients were then contacted telephonically and asked their reasons for non-attendance. RESULTS: Results show that the leading cause of failure to follow up was financial (34% of patients). Patients cited transport costs and having to pay to open a file at each visit as the biggest monetary obstacles to obtaining treatment. Fifty-five per cent of patients lost to follow-up showed an improvement in CD4 count on treatment. Death accounted for 27% of the patients lost to follow-up and the mean ( +/- standard deviation (SD)) duration of treatment in this group was only 8 ( +/- 6) weeks. Of the patients in this group who had been seen at 4 months, 60% had failed to respond to treatment. The mean duration of ARV treatment before being lost to follow-up was 21 ( +/- 28) weeks. The mean CD4+ count was 92 ( +/- 74.5) cells/ microl and the mean number of visits was 3.33 ( +/- 2.17). Seventy-four per cent of the patients were on regimen 1A, and only 1 cited side-effects of medication as a reason for not returning. CONCLUSIONS: This study highlighted financial difficulty as the major obstacle to obtaining treatment. There is evidence in support of providing ARV treatment free of charge to HIVpositive patients who qualify, as occurs in other provinces in South Africa. It is also suggested that providing ARV therapy at more local clinics in the community would make treatment more accessible. Provision of several months' supply of medicines per visit would help to reduce transport costs and minimise patient expenditure. These interventions may reduce the incidence of patients lost to follow-up in this community.