Outpatient follow up

Who benefits: doctors or patients?

One of the first questions that trainee surgeons learn to ask a new boss before the first outpatient clinic gets under way is, “Do you routinely follow up all your patients?” The reason the question needs asking is that some consultants do and others don't. The paper in this issue by Alison Waghorn and colleagues (p 1344) confirms this impression.1 According to their survey of 100 randomly selected general surgeons, the decision to offer an outpatient appointment depended largely on the consultant's view of outpatient visits in general. The bimodal distribution of responses showed that some surgeons offered appointments to almost all their patients, irrespective of diagnosis or procedure, while others followed up almost none.

In keeping with this observation, a recent review of individual urological services in the South West Thames area of London showed that from 1991 to 1994, urological provider units were remarkably consistent in the ratio of new patients to follow up patients seen in their clinics.2 However, there was substantial variation between providers. A ratio of one new to one follow up patient in one unit contrasted with a ratio of 1:4.9 at another, despite the two hospitals being only six kilometres apart and serving similar communities.

How is it that surgeons are able to adopt this all or nothing approach with regard to outpatient review? One way of justifying such behaviour is to suggest that routine surgical outpatient review is an unnecessary luxury, otherwise half the patients--those being denied follow up--would be getting worse care. Evidence is accumulating to support the idea that routine follow up confers little benefit to patients. Certainly, the benefit of outpatient review after one of the commonest urological procedures, transurethral resection of the prostate, has recently been questioned.3 Perkins et al found that 92% of patients were discharged at their first postoperative visit and only 2% remained under review at one year. Moreover, 90% of general practitioners and 78% of patients expressed confidence in a system without routine hospital review.

Similar questions now exist with regard to longer term follow up in other specialties. Colorectal surgeons have become increasingly pessimistic about the usefulness of routine outpatient follow up compared with opportunistic detection of early recurrence of colorectal cancer by general practitioners.4 5 In the only randomised study across surgical specialties that compared follow up by general practitioners and hospital outpatient departments, reoperation rates, mortality, and cost to providers were similar for the two groups.6 The cost to patients in terms of time and money was greater for the group attending hospital outpatients. Despite acknowledging that more work would result, general practitioners were in favour of immediate hospital discharge.

Two themes emerge. Firstly, these reports and others7 highlight the fact that patients, if well informed, are good at detecting and reporting complications or clinical deterioration--and, importantly, they tend to report them to their general practitioner. The second relates to access. It is ironic that provider units that decide to provide a comprehensive outpatient follow up service are likely to have no spare capacity to respond quickly to a phone call or letter from the patient or general practitioner requesting an early unscheduled appointment.

These two areas will require attention if community follow up is to be widely adopted. At present, patients find that written information on their postoperative recovery and possible complications is inadequate for their needs.8 In addition, there is increasing recognition of the importance of access to outpatients departments and of patients' perception of access, since better access improves health care outcomes.9 With a little imagination surgeons could do much to improve access to urgently requested appointments. Both the general practitioner and patient need to know that, should an outpatient appointment be necessary, it is no more than a phone call away.