Outpatient Services: literature review summary
Question
Reference
1. What can be done in the primary care or community setting to reduce
pressure on outpatient clinics?
1, 9, 14
2. What can be done to decrease the numbers of new and return
appointments to the outpatient clinics?
7, 12, 16
3. How can outpatient appointments be used more effectively?
3 - 6, 8, 13,
15 & 17 - 24
4. How can efficiency be improved by reducing variation and overall demand
and what are the resultant effects on savings and cost containment?
2, 10, 11, 13
25 - 35
The tables in this report are an overview of the evidence base presented in two separate reports on
the UK and international evidence on interventions to improve delivery of outpatient care, produced
by Healthcare Improvement Scotland in February and December 2012. Table 1 lists the references
for each type of study found, Table 2 shows potentially successful interventions and in which study
they appear, Table 3 shows the interventions which were shown to be ineffective and Table 4 shows
the interventions for which there was inconclusive findings (and which therefore may warrant
further study). Although not essential, it may be beneficial to read this document in conjunction with
the more detailed presentation of the evidence contained in the original reports.
Only 4 studies included in the reports contained costing or economic data and these are highlighted
at the bottom of Table 1. What is striking is the lack of crossover between UK and international
studies with the exception of appointment reminders, alternative patient booking systems and
outreach clinics. The reasons for this are due to the possibility of differing terminology which is
masking the cross over in the type of interventions described as well as variations in the types of
health care systems. One US study, for example, was carried out in order to determine if profits
could be increased in a private clinic 17. One international systematic review also included studies
from the UK 4 which is why it appears in both reference columns.
Table 1: Evidence breakdown by study type
Publication Type
UK
evidence
Health Technology Assessment
2
Systematic review
3
Comprehensive scoping report
1
Structured review
International
evidence
14
24
Primary studies
4-13
15-23, 25-35
Studies which also included economic information
3
15, 17, 18
Outpatient Services: literature review summary
Table 2: Potentially effective interventions
UK
evidence
Intervention
Discharge of patients to no follow up or patient-initiated follow-up or GP
follow-up instead of routine outpatient follow-up.
1
Direct access for GPs to hospital-based tests or investigations or
treatments, without approval of outpatient specialist.
1
Structured referral sheets prompting GPs to conduct necessary prereferral tests or treatments
1
GP and/or nurse education
1, 4
Triaging by pre-assessment and pre-specifying management plans
2, 11
Paper clinics (treatment plans based on medical records after outpatient
appointment rather than further follow-up)
International
evidence
10, 13.
Close monitoring of unnecessary visits based on pre-attendance test or
investigation results
16
Waiting list validation
4
Text message surveillance of patients
13
Text message and paper based appointment reminders
3
22, 23
12, 7
33
Patient booking systems where patients can choose their appointment
time and date, or variations
Group medical appointments
17, 18, 19
Quick diagnostic clinics to reduce inpatient numbers by treating in
outpatient services
15
Six Sigma modelling
26, 27, 28
Capacity modelling
30
Lean Management
31, 32
Supply and demand matching
35
Patient Letters in improving patient satisfaction or non-attendance rates.
Nurse or service worker role extension
4, 5, 6, 8
4
Table 3: Ineffective Interventions
Intervention
UK
evidence
Relocation of specialists to primary care settings
1
Joint working between primary and secondary clinicians
1
Outreach clinics
14
Nurse led telephone service
4
Referral proformas
4
International
evidence
14
Outpatient Services: literature review summary
Table 4: Inconclusive Interventions
Intervention
UK
evidence
GPs with special interest acting as substitute outpatient specialists.
1, 4
Transfer of care for common chronic conditions from secondary to
primary care
1, 4
In-house second opinion prior to referral
1
One-stop clinic
9
Electronic Medical/Health Records
20, 21
Electronic Consultation (as augmentation to face to face consultations)
24
Flow modelling
25, 29
Risk assessment coupled with streaming into short or longer
appointment times
GP telephone access to consultants and specialist nurses
International
evidence
34
4
References
UK Evidence
1. National Primary Care Research and Development Centre: University of Manchester.
Outpatient services and primary care : a scoping review of research into strategies for
improving outpatient effectiveness and efficiency [online]. 2005 Available from:
http://www.medicine.manchester.ac.uk/primarycare/npcrdcarchive/Publications/Studyinghealthcare_Roland_finalreport.pdf.
2. NHS Quality Improvement Scotland. Service delivery organisation for acute low back pain.
2008. Available from:
http://www.healthcareimprovementscotland.org/previous_resources/hta_report/hta_syste
matic_review_1.aspx
3. Hasvold PE, Wootton R. Use of telephone and SMS reminders to improve attendance at
hospital appointments: a systematic review. Journal of Telemedicine & Telecare.
2011;17(7):358-64.
4. Appleby A, Lawrence C. From blacklist to beacon, a case study in reducing dermatology outpatient waiting times. Clinical & Experimental Dermatology. 2001;26(6):548-55.
5. Hardy KJ, O'Brien SV, Furlong NJ. Quality improvement report: information given to patients
before appointments and its effect on non-attendance rate. British Medical Journal.
2001;323(7324):1298-300.
6. Saunders NC, Georgalas C, Blaney SP, Dixon H, Topham JH. Does receiving a copy of
correspondence improve patients' satisfaction with their out-patient consultation? Journal of
Laryngology & Otology. 2003;117(2):126-9.
7. Lloyd J, Dillon D, Hariharan K. Outpatient clinics. Down the line. Health Service Journal.
2003;113(5837):22-3.
8. Fox AT, Palmer RD, Crossley JG, Sekaran D, Trewavas ES, Davies HA. Improving the quality of
outpatient clinic letters using the Sheffield Assessment Instrument for Letters (SAIL). Medical
Education. 2004;38(8):852-8.
Outpatient Services: literature review summary
9. Sulaiman S, Wei CK, Gaudoin M. One-stop postmenopausal bleeding clinics reduce patient
waiting times and theatre costs. Scottish Medical Journal. 2004;(4):152-4.
10. Rao GN, Basnyat P, Taffinder N, Hudson C, Insall R. Reducing surgical outpatient waiting is not
the solution to meeting the 2005 colorectal cancer target. Colorectal Disease. 2006;8(2):1359.
11. Phillips SA, Ross PD, Chalmers K, MacDougall G. Can we improve dysphagia referrals? Journal
of Laryngology & Otology. 2007;121(6):584-7.
12. Parmar V, Large A, Madden C, Das V. The online outpatient booking system 'Choose and
Book' improves attendance rates at an audiology clinic: a comparative audit. Informatics in
Primary Care. 2009;17(3):183-6.
13. Corrigan MA, McHugh SM, Murphy RK, Dhillon P, Shah A, Hennessy I, et al. Improving surgical
outpatient efficiency through mobile phone text messaging. Surgical Innovation.
2011;18(4):354-7.
International evidence
14. Gruen RL, Weeremanthri TS, Knight SS, Bailie RS. Specialist outreach clinics in primary care
and rural hospital settings. 2012 [cited 20112 Jan 13];Available from: URL:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003798.pub2/pdf
15. Bosch X, Foix A, Jordan A, Coca A, Lopez-Soto A. Outpatient Quick Diagnosis Units for the
evaluation of suspected severe diseases: an observational, descriptive study. Clinics
2011;66(5):737-41.
16. Donnellan F, Hussain T, Aftab AR, McGurk C. Reducing unnecessary outpatient attendances.
International Journal of Health Care Quality Assurance 2010;(5):527-31.
17. Sidorsky T, Huang Z, Dinulos JG. A business case for shared medical appointments in
dermatology: improving access and the bottom line. Archives of Dermatology 2010
Apr;146(4):374-81.
18. Davies S, Quintner J, Parsons R, Parkitny L, Knight P, Forrester E, et al. Preclinic group
education sessions reduce waiting times and costs at public pain medicine units. Pain
Medicine 2011 Jan;12(1):59-71.
19. De VB, rling-Fisher C, Thomas AC, Belanger-Shugart EB. Implementation and outcomes of
group medical appointments in an outpatient specialty care clinic. Journal of the American
Academy of Nurse Practitioners 2008 Mar;20(3):163-9.
20. Furukawa M. Electronic Medical Records and Efficiency and Productivity During Office Visits.
AM J MANAGE CARE 2011;17(4):296-303.
21. McAlearney AS, Robbins J, Hirsch A, Jorina M, Harrop JP. Perceived efficiency impacts
following electronic health record implementation: An exploratory study of an urban
community health center network. Int J Med Inf 2010;79(12):807-16.
22. Kitcheman J, Adams CE, Pervais A. Timely encouraging letters increase attendance at first
consultations at outpatient psychiatric clinics. 2008 [cited 2012 Jan 13];Available from: URL:
http://ebmh.bmj.com/content/11/4/122.full.pdf+html?ath_user=efscsleith001&ath_ttok=%3
CTxBKYaNErN8EIL3n1g%3E
23. Downer SR, Meara JG, Da Costa AC. Use of SMS text messaging to improve outpatient
attendance. MJA 2005;183(7):366-8.
Outpatient Services: literature review summary
24. Caffery LJ, Smith AC. A literature review of email-based telemedicine. Studies in Health
Technology & Informatics 2010;161:20-34, 2010.:20-34.
25. Zonderland ME, Boer F, Boucherie RJ, de RA, van Kleef JW. Redesign of a university hospital
preanesthesia evaluation clinic using a queuing theory approach. Anesthesia & Analgesia
2009 Nov;109(5):1612-21.
26. Patrick J, Puterman ML. Improving resource utilization for diagnostic services through flexible
inpatient scheduling: A method for improving resource utilization. J Oper Res Soc
2007;58(2):235-45.
27. Bush SH, Lao MR, Simmons KL, Goode JH, Cunningham SA, Calhoun BC. Patient access and
clinical efficiency improvement in a resident hospital-based women's medicine center clinic.
AM J MANAGE CARE 2007 Dec;13(12):686-90.
28. Daggy J, Lawley M, Willis D, Thayer D, Suelzer C, DeLaurentis PC, et al. Using no-show
modeling to improve clinic performance. Health Informatics Journal 2010;16(4):246-59.
29. Parks JK, Engblom P, Hamrock E, Satjapot S, Levin S. Designed to Fail: How Computer
Simulation Can Detect Fundamental Flaws in Clinic Flow. Journal of Healthcare Management
2011;56(2):135-44.
30. Elkhuizen SG, Das SF, Bakker PJM, Hontelez JAM. Using computer simulation to reduce access
time for outpatient departments. Quality & Safety in Health Care 2007;16(5):382-6.
31. Casey JT, Brinton TS, Gonzalez CM. Utilization of lean management principles in the
ambulatory clinic setting. Nature Clinical Practice Urology 2009 Mar;6(3):146-53.
32. Smith C, Wood S, Beauvais B. Thinking lean: implementing DMAIC methods to improve
efficiency within a cystic fibrosis clinic. Journal for healthcare quality : official publication of
the National Association for Healthcare Quality 2011;(2):37-46.
33. Price RS, Balcer LJ, Galetta SL. Education research: a new system for reducing patient
nonattendance in residents' clinic. Neurology 2010 Mar 9;74(10):e34-e36.
34. Heijman TLJ, van der Bij AK, de Vries HJC, van Leent EJM, Thiesbrummel HFJ, Fennema HSA.
Effectiveness of a risk-based visitor-prioritizing system at a sexually transmitted infection
outpatient clinic. Sex Transm Dis 2007;34(7):508-12.
35. Rouppe van der Voort MM, van Merode FG, Berden BH. Making sense of delays in outpatient
specialty care: a system perspective. Health Policy 2010 Sep;97(1):44-52.