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Chainrai M, Kershaw VF, Gray TG, Radley SC. Patient-initiated follow-up in gynaecology: Patient and clinician views. Eur J Obstet Gynecol Reprod Biol 2024; 298:18-22. [PMID: 38705009 DOI: 10.1016/j.ejogrb.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 04/23/2024] [Accepted: 04/25/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVES Follow-up appointments in the UK National Health Service account for up to two thirds of outpatient activity, but there is a significant resource impact in providing time fixed follow-up appointments. Increasingly patient initiated follow-up is being used, to make follow-up appointments work better for patients both in terms of timing and necessity, and to reduce unnecessary outpatient activity. The objective of this study was to use a modified questionnaire to evaluate patient and clinician views regarding Patient-Initiated Follow-Up (PIFU) in gynaecology services and identify subgroups suited to this pathway of care. STUDY DESIGN Participants including both patients and clinicians were recruited from a gynaecology outpatient department. Patients who have poorer access healthcare (with disabilities and black and ethnic minority background) were purposively targeted so their experiences could be included. Value and burden scores were evaluated using patient and clinician surveys based on a modified QQ-10 questionnaire which assessed perceived value and burden of patient initiated follow-up in gynaecology. Free text comments regarding PIFU were also collected. RESULTS 305 patients and 30 clinicians were surveyed. Overall response to patient initiated follow-up was positive. Patients and clinicians attributed high value (77.4 % and 81.4 %) and low burden scores (37.5 % and 44.7 %) to PIFU. Patient autonomy was cited as a reason for this by 84.6 % of patients and 93.3 % of clinicians. Patients attending benign gynaecological sub-specialties including endometriosis (84.2), general gynaecology (82.5) and vulval clinics (81.4) attributed the highest value scores. Gynaecology oncology patients attributed the lowest value (64.0) and highest burden score (51.3) of all subgroups. Younger adults (<60) were more likely to express a preference for PIFU (52.9 %) than older adults (≥60) (28.6 %). CONCLUSIONS In this study, both patients and clinicians are in favour of selected use of PIFU in gynaecology services. Both questionnaires found younger patients with benign gynaecological conditions were perceived as best suited PIFU. We recommend offering PIFU to select patients who are confident in self-monitoring, factoring patient choice so patients are not disadvantaged by this system. Further evaluation of PIFU in practice is needed before widespread implementation.
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Affiliation(s)
- Mira Chainrai
- University of Sheffield, Medical School, Beech Hill Road, Broomhall, Sheffield S10 2RX, United Kingdom
| | - Victoria F Kershaw
- Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield S10 2JF, United Kingdom.
| | - Thomas G Gray
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich NR4 7UY, United Kingdom; University of East Anglia, Norwich, United Kingdom
| | - Stephen C Radley
- University of Sheffield, Medical School, Beech Hill Road, Broomhall, Sheffield S10 2RX, United Kingdom; Jessop Wing, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Road, Sheffield S10 2JF, United Kingdom
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Chaudhry I, Ghassani A, Wray J, Chaudhry B, Coats L. Outpatient care of adults with congenital heart disease in the UK: a qualitative appraisal of the clinician perspective. Open Heart 2024; 11:e002420. [PMID: 38286570 PMCID: PMC10826567 DOI: 10.1136/openhrt-2023-002420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 11/11/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE This study aimed to explore clinicians' perspectives of ambulatory care in adult congenital heart disease (ACHD). METHODS Semistructured interviews were carried out remotely (Zoom) with a range of physicians providing ambulatory care to patients with ACHD across the UK. The chronic care model, thrive and candidacy frameworks were used to design prompt guides and subsequently develop themes. A framework approach was used to code and analyse transcripts, which were managed in NVivo. RESULTS 21 clinicians (43% females, 38% specialists) from 10/12 ACHD networks in the UK participated. Shared themes included the purpose of the clinic appointment, problems in the 'hub-and-spoke' care system, role of the general practitioner and ACHD specialist nurse, communication with patients, burden of ambulatory care and patient self-management. Reflecting on these themes, participants identified resources, what care and how and by it is delivered alongside the role of the patient as key areas for future research. CONCLUSIONS The present structure of ACHD ambulatory care is neither patient-centred nor equitable. The concerned clinicians raise the question whether increasing resource alone without changing structure will lead to better outcomes for patients.
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Affiliation(s)
- Isobel Chaudhry
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Anisa Ghassani
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Institute of Cardiovascular Science, UCL, London, UK
| | - Bill Chaudhry
- Biosciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Louise Coats
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Adult Congenital Heart Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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Rulanda MC, Mogensen O, Jensen PT, Hansen DG, Wu C, Jeppesen MM. Patient-initiated follow-up in women with early-stage endometrial cancer: A long-term follow-up of the OPAL trial. BJOG 2023; 130:1593-1601. [PMID: 37277320 DOI: 10.1111/1471-0528.17567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 05/16/2023] [Accepted: 05/22/2023] [Indexed: 06/07/2023]
Abstract
OBJECTIVE A long-term follow-up of the OPAL trial to compare the effect of patient-initiated (PIFU) versus hospital-based (HBFU) follow-up on fear of cancer recurrence (FCR), quality of life (QoL) and healthcare use after 34 months of follow-up. DESIGN Pragmatic, multicentre randomised trial. SETTING Four Danish departments of gynaecology between May 2013 and May 2016. POPULATION 212 women diagnosed with stage I low-intermediate risk endometrial carcinoma. METHODS The control group attended HBFU with regular outpatient visits (i.e., 8) for 3 years after primary treatment. The intervention group underwent PIFU with no prescheduled visits but with instructions about alarm symptoms and options of self-referral. MAIN OUTCOME MEASURES The endpoints were FCR as measured by the Fear of Cancer Recurrence Inventory (FCRI) and QoL as measured by the European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire C-30 (EORTC QLQ C-30), and healthcare use as measured by questionnaires and chart reviews after 34 months of follow-up. RESULTS FCR decreased from baseline to 34 months in both groups and no difference was found between allocations (difference -6.31 [95% confidence interval -14.24 to 1.63]). QoL remained stable with no difference in any domains between the two arms at 34 months using a linear mixed model analysis. The use of healthcare was significantly lower in the PIFU group (P < 0.01). CONCLUSION Patient-initiated follow-up is a valid alternative to hospital-based follow-up for people who have been treated for endometrial cancer and have low risk of recurrence.
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Affiliation(s)
| | - Ole Mogensen
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pernille Tine Jensen
- Department of Gynaecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Dorte Gilså Hansen
- Research Unit for General Practice, Institute of Public Health, University of Southern Denmark, Odense, Denmark
| | - Chunsen Wu
- The Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Odense University Hospital, Odense, Denmark
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Dretzke J, Chaudri T, Balaji R, Mehanna H, Nankivell P, Moore DJ. A systematic review of the effectiveness of patient-initiated follow-up after cancer. Cancer Med 2023; 12:19057-19071. [PMID: 37602830 PMCID: PMC10557867 DOI: 10.1002/cam4.6462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 07/25/2023] [Accepted: 08/06/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND The traditional cancer follow-up (FU) model for cancer survivors is by scheduled clinic appointments; however, this is not tailored to patient needs and is becoming unsustainable. Patient-initiated follow-up (PIFU) may be a more effective and flexible alternative. This systematic review aims to analyse all existing evidence from randomised controlled trials (RCTs) on the effectiveness of PIFU compared with other FU models that include routinely scheduled appointments in adults who have been treated with curative intent for any type of cancer. METHODS Standard systematic review methodology aimed at limiting bias was used for study identification, selection and data extraction. MEDLINE, Embase, CINAHL, the Cochrane Database of Systematic Reviews and Epistemonikos were searched for systematic reviews to March 2022, and Cochrane CENTRAL was searched for RCTs from 2018 (April 2023). Ongoing trial registers were searched (WHO ICTRP, ClinicalTrials.gov, April 2023). Eligible studies were randomised controlled trials comparing PIFU with an alternative FU model in adult cancer survivors. Risk of bias assessment was via the Cochrane risk of bias tool-2. Meta-analysis was precluded by clinical heterogeneity and results were reported narratively. RESULTS Ten RCTs were included (six breast, two colorectal, one endometrial cancer and one melanoma, total n = 1754); all studies had risk of bias concerns, particularly relating to how missing data were handled, and populations were unlikely to be representative. Limited findings in breast cancer suggested that type of FU does not affect recurrence detection or patient-related outcomes, while PIFU may reduce the number of clinic visits. Adding patient-led surveillance to routine FU may increase melanoma detection. Evidence for other types of cancer is too limited to draw firm conclusions. CONCLUSIONS PIFU may be a viable FU model in breast cancer, but further research is needed for other types of cancer and on long-term outcomes. A protocol was registered with PROSPERO (CRD42020181424).
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Affiliation(s)
- Janine Dretzke
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
| | - Talhah Chaudri
- Birmingham Medical SchoolUniversity of BirminghamBirminghamUK
| | - Rishab Balaji
- Birmingham Medical SchoolUniversity of BirminghamBirminghamUK
| | - Hisham Mehanna
- Institute for Head and Neck Studies and EducationUniversity of BirminghamBirminghamUK
| | - Paul Nankivell
- Institute for Head and Neck Studies and EducationUniversity of BirminghamBirminghamUK
| | - David J. Moore
- Institute of Applied Health ResearchUniversity of BirminghamBirminghamUK
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Jensen AL, Schougaard LMV, Laurberg T, Hansen TK, Lomborg K. Flexible patient-reported outcome-based telehealth follow-up for type 1 diabetes: A qualitative study. Scand J Caring Sci 2023; 37:662-676. [PMID: 36775917 DOI: 10.1111/scs.13154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 12/29/2022] [Accepted: 01/14/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND Successful diabetes management requires collaboration between patients and healthcare professionals and should be aligned with an individual's condition and resources. We developed a flexible, individualised, patient-reported outcome (PRO)-based telehealth intervention called "DiabetesFlex Care" in which patients completed an annual self-reported questionnaire from home, one required face-to-face appointment, and two optional outpatient consultations. In this study, we investigated patients' experiences using DiabetesFlex Care. METHODS We conducted a qualitative, interpretive descriptive (ID) study based on semi-structured interviews with a purposeful sample of 36 patients with type 1 diabetes (T1D) who had used DiabetesFlex Care. Recorded audio data were transcribed and analysed inductively using the constant comparative method. RESULTS DiabetesFlex Care changed participants' perspectives on living with diabetes. Patients became more involved in their own care and found that DiabetesFlex Care helped to make their conversations with healthcare professionals more relevant. Furthermore, participants appreciated the ability to both choose the format of their appointments (face-to-face vs. phone call) and cancel unnecessary appointments. CONCLUSION DiabetesFlex Care was a flexible and inclusive health service that enabled patients to take more responsibility for their own diabetes management. The questionnaire-based approach in DiabetesFlex Care can help healthcare professionals systematically account for patients' perspectives and support user involvement and self-management. By extension, this approach can also help minimise healthcare-related disruptions in patients' lives. Further studies are needed to determine whether flexible PRO-based telehealth is an acceptable solution for all patients.
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Affiliation(s)
- Annesofie L Jensen
- Steno Diabetes Centre Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Department of Clinical Medicine, Incuba/Skejby, Aarhus University, Aarhus, Denmark
- ResCenPI - Research Centre for Patient Involvement, Aarhus University & the Central Denmark Region, Aarhus, Denmark
| | - Liv Marit Valen Schougaard
- AmbuFlex - Centre for Patient-reported Outcomes, Central Denmark Region, Gødstrup Hospital, Herning, Denmark
| | - Tinne Laurberg
- Steno Diabetes Centre Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Troels Krarup Hansen
- Steno Diabetes Centre Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Department of Clinical Medicine, Incuba/Skejby, Aarhus University, Aarhus, Denmark
| | - Kirsten Lomborg
- Steno Diabetes Centre Copenhagen, Capital Region, Herlev, DK, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, DK, Denmark
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Barmon D, Tak A, Baruah U, Begum D, Gupta S, Khanikar D, Nath J, Yadav G. Pattern of Care of Recurrent Cervical Cancer in Low-resource Settings: Challenges and Patient-initiated Follow-up as a Novel Opportunity. J Midlife Health 2023; 14:205-211. [PMID: 38312765 PMCID: PMC10836429 DOI: 10.4103/jmh.jmh_103_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/29/2023] [Accepted: 07/29/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction The availability of optimum diagnostic strategies remains a major problem in resource-constraint countries. This technique of patient-initiated follow-up (PIFU) has been recently adopted in the UK for gynecological cancers and has proven cost benefits. However, no study from the Indian subcontinent has ever been reported. Aims and Objectives The primary objective was to study the pattern of care of recurrent cervical cancer in low-resource settings. The secondary objective was to compare the reliability of symptomatology/clinical evaluation and imaging methods on follow-up to detect recurrence and thus explore the feasibility of symptom-based PIFU. Materials and Methods This was a single-institutional retrospective analysis of recurrent cervical cancer cases for a period of 3 years from January 2019 to January 2022. Patients who followed up for minimum of 6 months were included in the study. Results In 57 of the total 69 patients, symptoms alone were the index diagnostic method. Interestingly, neither of the methods of recurrence detection had impact on overall survival (OS). Cox regression analysis revealed adverse impact of erratic/lost to follow-up (hazard ratio [HR] = 3.8) and pelvic side wall disease (HR = 1.33) on survival. Patients with positive para-aortic nodes had significantly shorter disease-free interval of 11 months, so adding systemic therapy to adjuvant treatment in this cohort needs to be further investigated. Conclusion Our analysis showed that patients with recurrence who were diagnosed with clinical manifestations alone vis-à-vis the ones who were diagnosed primarily on routine follow-up visit by some imaging or diagnostic test had comparable oncologic outcomes. PIFU can be a "practice changing modality" in patient management system, especially in low-resource settings. It will prove to be a simple cost-effective method to detect recurrence and prevent fallouts. Our study points to the feasibility of PIFU in Indian scenario.
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Affiliation(s)
- Debabrata Barmon
- Department of Gynecologic Oncology, Dr. Bhubaneswar Cancer Institute, Guwahati, A Grant in Aid Unit of DAE India and Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Apoorva Tak
- Department of Gynecologic Oncology, Dr. Bhubaneswar Cancer Institute, Guwahati, A Grant in Aid Unit of DAE India and Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Upasana Baruah
- Department of Gynecologic Oncology, Dr. Bhubaneswar Cancer Institute, Guwahati, A Grant in Aid Unit of DAE India and Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Dimpy Begum
- Department of Gynecologic Oncology, Dr. Bhubaneswar Cancer Institute, Guwahati, A Grant in Aid Unit of DAE India and Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sakshi Gupta
- Department of Oncopathology, Dr. Bhubaneswar Cancer Institute, Guwahati, A Grant in Aid Unit of DAE India and Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Duncan Khanikar
- Department of Medical Oncology, Dr. Bhubaneswar Cancer Institute, Guwahati, A Grant in Aid Unit of DAE India and Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jyotiman Nath
- Department of Radiation Oncology, Dr. Bhubaneswar Cancer Institute, Guwahati, A Grant in Aid Unit of DAE India and Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Garima Yadav
- Department of Obstetrics and Gynaecology, AIIMS, Jodhpur, Rajasthan, India
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Brewer CF, Young-Sing Q, Sierakowski A. Cost Comparison of Kirschner Wire Versus Intramedullary Screw Fixation of Metacarpal and Phalangeal Fractures. Hand (N Y) 2023; 18:456-462. [PMID: 34308715 PMCID: PMC10152536 DOI: 10.1177/15589447211030690] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Intramedullary screw fixation is a relatively new technique for fixation of metacarpal and phalangeal fractures. The objective of this study was to compare health care-associated costs and outcomes for intramedullary screw versus Kirschner wire (K-wire) fixation of hand fractures. METHODS A retrospective review of patients undergoing intramedullary screw fixation of hand fractures at a single center during 2016-2019 inclusive was conducted. Health care-associated costs were compared with age-matched and fracture pattern-matched controls who underwent K-wire fixation. RESULTS Fifty patients met the study inclusion criteria, incorporating 62 fractures (29 K-wire, 33 intramedullary screw fixation). The median age was 34.6 years (18.0-90.1 years). There was no significant difference in primary operative costs (£1130.4 ± £162.7 for K-wire vs £1087.0 ± £104.2 for intramedullary screw), outpatient follow-up costs (£958.7 ± £149.4 for K-wire vs £782.4 ± £143.8 for intramedullary screw), or total health care-associated costs (£2089.1 ± £209.0 for K-wire vs £1869.4 ± £195.3 for intramedullary screw). However, follow-up costs were significantly lower for the uncomplicated intramedullary screw cohort (£847.1 ± £109.1 for K-wire vs £657.5 ± £130.8 for intramedullary screw, P = .05). Subgroup analysis also revealed that overall costs were significantly higher for buried K-wire techniques. Complication rates, time to return to active work, and Disabilities of the Arm, Shoulder, and Hand scores were similar. CONCLUSIONS This study identified significantly lower outpatient follow-up costs for uncomplicated intramedullary screw fixation of hand fractures compared with K-wires, along with a trend toward lower overall health care-associated costs. In addition, buried K-wire techniques were also found to carry a significantly higher financial burden. Higher powered prospective studies are required to determine indirect costs.
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Luk HM, Ngu SF, Lau LSK, Tse KY, Chu MMY, Kwok ST, Ngan HYS, Chan KKL. Patient-Initiated Follow-Up in Ovarian Cancer. Curr Oncol 2023; 30:3627-3636. [PMID: 37185389 PMCID: PMC10136438 DOI: 10.3390/curroncol30040276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/13/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
This study aimed to assess the feasibility of patient-initiated follow-up (PIFU) in combination with regular tumour marker monitoring as an alternative to conventional hospital follow-up for ovarian cancer survivors. Women who had recently completed treatment for ovarian cancer and had a raised pre-treatment tumour marker were recruited. Participants were allocated to PIFU (intervention group) or conventional hospital follow-up (control group) according to their own preference. Both groups had regular tumour marker monitoring. The change in fear of cancer recurrence (FCR) score as measured by the FCR inventory, and the supportive care need (SCN) scores as measured by the SCN survey at baseline and at 6 months between PIFU and hospital follow-up were compared. Out of 64 participants, 37 (58%) opted for hospital follow-up and 27 (42%) opted for PIFU. During the 6-month study period, there was no significant difference in the change of FCR between the two groups (p = 0.35). There was a significant decrease in the sexuality unmet needs score in the intervention group from baseline to 6-month FU (mean difference −8.7, 95% confidence interval −16.1 to −1.4, p = 0.02). PIFU with tumour marker monitoring is a feasible follow-up approach in ovarian cancer survivorship care. FCR and SCN were comparable between PIFU and conventional hospital follow-up.
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Newton C, Beaver K, Clegg A. Patient initiated follow-up in cancer patients: A systematic review. Front Oncol 2022; 12:954854. [PMID: 36313728 PMCID: PMC9606321 DOI: 10.3389/fonc.2022.954854] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/21/2022] [Indexed: 12/02/2022] Open
Abstract
Background Patient-initiated follow-up (PIFU) is increasingly being implemented for oncology patients, particularly during the COVID-19 pandemic, given the necessary reduction in face-to-face hospital outpatient appointments. We do not know if PIFU has a positive (or negative) impact on overall, or progression free, survival. Objectives To investigate the impact of PIFU on overall survival, progression free survival, patient satisfaction, psychological morbidity, specifically quality of life (QoL) and economic costs compared to hospital follow up (HFU), for any type of cancer. Methods We carried out a systematic review using five electronic databases: MEDLINE, CINAHL, EMBASE, PsycInfo and Cochrane Central Register of Controlled Trials. Studies were eligible if they were controlled clinical trials comparing PIFU with another form of active follow-up. Effectiveness was assessed using the primary outcome of overall survival and secondary outcomes of progression free survival, patient satisfaction, psychological morbidity, QoL and cost effectiveness. Results Eight studies met the inclusion criteria and were included. Only one study included survival as a primary outcome and indicated no significant differences between hospital-based follow-up and PIFU, although not adequately powered to detect a difference in survival. For secondary outcomes, few differences were found between PIFU and other forms of active follow-up. One study reported significant differences in fear of cancer recurrence between PIFU and HFU although did not reach the limit of clinical significance; in the short term, fear decreased significantly more in hospital based follow-up. Conclusion We do not have evidence to support the impact of PIFU on survival or progression free survival. Fully powered randomized controlled trials are required to determine the full impact of PIFU in the longer term.
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Acute Decompensated Aortic Stenosis: State of the Art Review. Curr Probl Cardiol 2022; 48:101422. [PMID: 36167225 DOI: 10.1016/j.cpcardiol.2022.101422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/21/2022]
Abstract
Aortic stenosis (AS) is a progressive disease that carries a poor prognosis. Patients are managed conservatively until satisfying an indication for transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) based on AS severity and the presence of symptoms or adverse impact on the myocardium. Up to 1 in 3 TAVIs are performed for patients with acute symptoms of dyspnoea at rest, angina, and/or syncope - termed acute decompensated aortic stenosis (ADAS) and require urgent aortic valve replacement. These patients have longer hospital length of stay, undergo physical deconditioning, have a higher rate of acute kidney injury and mortality compared to stable patients with less severe symptoms. There is an urgent need to prevent ADAS and to deliver pathways to manage and improve ADAS-related outcomes. We provide here a contemporary review on epidemiological and pathophysiological aspects of ADAS, with a focus on the impact of ADAS from clinical and economic perspectives. We will offer also a global overview of the available evidence for treatment of ADAS and with priorities suggested for addressing current gaps in the literature and unmet clinical needs to improve outcomes for AS patients.
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Laurberg T, Schougaard LMV, Hjollund NHI, Lomborg KE, Hansen TK, Jensen AL. Randomized controlled study to evaluate the impact of flexible patient-controlled visits in people with type 1 diabetes: The DiabetesFlex Trial. Diabet Med 2022; 39:e14791. [PMID: 35028992 DOI: 10.1111/dme.14791] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 12/30/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022]
Abstract
AIM The objective of this study was to assess the impact of health care-initiated visits versus patient-controlled flexible visits on clinical and patient-reported outcomes in people with type 1 diabetes. METHODS The DiabetesFlex trial was a randomized controlled, pragmatic non-inferiority 15-month follow-up study comparing standard care (face-to-face visits every 4 months) with DiabetesFlex (patient-controlled flexible visits using patient-reported, outcome-based telehealth follow-up). Of 343 enrolled participants, 160 in each group completed the study. The primary outcome was mean change in HbA1c from baseline to 15-month follow-up. Secondary outcomes were blood pressure, lipid levels, frequency of visits, the World Health Organization score-five well-being-index (WHO-5), the Problem Areas In Diabetes (PAID) scale and experience of participation in own care (participation score). RESULTS The adjusted mean difference in HbA1c between standard care and DiabetesFlex was similar and below the predefined non-inferiority margin of 0.4% (-0.03% [95%CI: 0.15, 0.11]/-0.27 mmol/mol [-1.71, 1.16]). No intergroup mean changes in lipid or blood pressure were observed. Conversely, DiabetesFlex participants presented an increased mean WHO-5 index of 4.5 (1.3, 7.3), participation score of 1.1 (0.5, 2.0), and decreased PAID score of -4.8 (-7.1, -2.6) compared with standard care. During follow-up, DiabetesFlex participants actively changed 23% of face-to-face visits to telephone consultations, cancelled more visits (17% vs. 9%), and stayed away without cancellation less often (2% vs. 8%). CONCLUSION Compared with standard care, flexible patient-controlled visits combined with patient-reported outcomes in participants with metabolic controlled type 1 diabetes and good psychological well-being further improved diabetes-related well-being and decreased face-to-face visits while maintaining safe diabetes management.
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Affiliation(s)
- Tinne Laurberg
- Steno Diabetes Centre Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | - Liv Marit Valen Schougaard
- AmbuFlex, Center for Patient-Reported Outcomes, Regional Hospital West Jutland, Herning, Denmark
- ResCenPI - Research Centre for Patient Involvement, Aarhus University and the Central Denmark Region, Denmark
| | - Niels Henrik Ingvar Hjollund
- AmbuFlex, Center for Patient-Reported Outcomes, Regional Hospital West Jutland, Herning, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kirsten Elisabeth Lomborg
- ResCenPI - Research Centre for Patient Involvement, Aarhus University and the Central Denmark Region, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Steno Diabetes Centre Copenhagen, Herlev, Denmark
| | - Troels Krarup Hansen
- Steno Diabetes Centre Aarhus, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annesofie Lunde Jensen
- Steno Diabetes Centre Aarhus, Aarhus University Hospital, Aarhus, Denmark
- ResCenPI - Research Centre for Patient Involvement, Aarhus University and the Central Denmark Region, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Patient initiated follow up in Obstetrics and Gynaecology: A systematic review. Eur J Obstet Gynecol Reprod Biol 2022; 272:123-129. [PMID: 35303674 DOI: 10.1016/j.ejogrb.2022.02.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/19/2022] [Accepted: 02/26/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND The demand for outpatient hospital appointments has risen steadily over recent years, almost doubling since 2008; now standing at 120 million appointments per year. Initiatives to reduce unnecessary appointments are a key area of interest, as they can be an effective way of both improving patient care and satisfaction, as well as reducing NHS costs. Patient Initiated Follow-Up (PIFU) provides an alternative to traditional hospital instigated follow-up, by which patients have autonomy in their future care, allowing them to make appointments based on their own perception of need. PIFU has proved successful when implemented in Rheumatology, Inflammatory Bowel Disease and Oncology, with trends towards reduced burden on outpatient appointments, improved patient satisfaction and lower costs. To-date, the use of PIFU in women's health has been limited to gynaecological oncology, where observations include high patient satisfaction and fewer appointments than traditional follow-up. This study aims to undertake a systematic review of the literature relating to PIFU in Obstetrics and Gynaecology in order to identify evidence-based indications for PIFU in the specialty, as well as form a foundation for a subsequent service evaluation. METHODS The project was registered with Prospero, University of York. Using the OVID platform, a literature search was conducted using the terms "patient initiated follow up", "gynaecology", "women's health", and "follow up care". Papers were then screened in accordance with the PRISMA protocol, and relevant articles identified based on our inclusion criteria. The quality of the studies was assessed using the Newcastle-Ottawa Scale, and data from the studies were extracted and compared. RESULTS Eight papers were identified as relevant, two were randomised controlled trials, three were retrospective cohort studies, and the remaining three were prospective cohort studies. The majority of these studies (5/8) were of good quality, scoring 6 or more points on the Newcastle-Ottawa Scale. Four of the eight studies examined cost-effectives; all reported cost-savings relating to PIFU. Seven of the eight studies also reported an association between PIFU and greater patient satisfaction, fewer overall appointments and reduced non-attendance. One study reported no effect on patient satisfaction. Five studies related to gynaecological oncology, two were obstetric and one urogynaecology. The studies which investigated PIFU use in selected gynaecological oncology patients reported that PIFU did not have a negative impact on detection of cancer recurrence, but evidence regarding the psychological impact of PIFU on cancer survivors was conflicting. CONCLUSION PIFU was received largely positively and was well accepted by women across these studies. It was also shown to be cost-effective, without a negative impact on health outcomes. PIFU also has the potential to offer additional benefits including reducing diagnostic delay and increasing patient engagement with their own health status. This review found a paucity of data for PIFU in Obstetrics and Gynaecology, with the exception of gynaecological oncology, and further evaluation is required before more widespread implementation.
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Balhorn J, Su'a B, Jin J, Peng S, Weston M, Israel L, Connolly A, Hill AG, Taneja A. Changing the routine: a move to patient initiated follow up to improve surgical outpatient clinic. ANZ J Surg 2022; 92:1394-1400. [PMID: 35429226 PMCID: PMC9324913 DOI: 10.1111/ans.17676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/17/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022]
Abstract
Introduction Patient initiated follow up (PIFU) allows patients to initiate a hospital follow up appointment on an ‘as required’ basis in contrast to the traditional physician‐initiated model. We present a clinical pathway for patients referred with rectal bleeding at a large tertiary public hospital in South Auckland, New Zealand and demonstrate the utility of PIFU and its impact on reducing follow up appointments. Method The purpose of the pathway was to allow standardized care by the clinicians and allow for PIFU. Two separate protocols were developed ‐ ‘Painful PR bleeding’ and ‘Painless PR bleeding’. A new clinic (NC) was started following these protocols, and this was compared to historical controls (HC). The primary outcome was the rate of follow up appointments. Results There were 133 patients in the NC and 135 in the HC, with significantly less follow ups in the NC (6% versus 45%, p < 0.0001). A small percentage of patients in the NC group were directly discharged (10%) whilst 70% of patients were discharged with a PIFU card. Thirty phone calls were made using PIFU, with 10 patients returning to clinic and 20 requiring advice and reassurance only. At 5 year follow up, there was a single colorectal malignancy found in both groups. Conclusion Initiating a protocol that includes patient initiated follow up vastly reduces the need for routine return to clinic for the majority of patients, without sacrificing patient care. A protocolised approach to clinic for other areas in general surgery should be considered.
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Affiliation(s)
- Joshua Balhorn
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Bruce Su'a
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - James Jin
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Sze‐Lin Peng
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Maree Weston
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Lincoln Israel
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Andrew Connolly
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Andrew G. Hill
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
| | - Ashish Taneja
- The Department of General Surgery Middlemore Hospital Auckland New Zealand
- Faculty of Medical and Health Sciences The University of Auckland Auckland New Zealand
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Sarwar A, Van Griethuysen J, Waterhouse J, Dehbi HM, Eminowicz G, McCormack M. Stratified follow-up for endometrial cancer: a move to more personalized cancer care. Int J Gynecol Cancer 2021; 31:1564-1571. [PMID: 34795021 DOI: 10.1136/ijgc-2021-002903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/20/2021] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Hospital based follow-up has been the standard of care for endometrial cancer. Patient initiated follow-up is a useful adjunct for lower risk cancers. The purpose of this study was to evaluate outcomes of endometrial cancer patients after stratification into risk groupings, with particular attention to salvageable relapses. METHODS All patients treated surgically for International Federation of Gynecology and Obstetrics (FIGO) stage I-IVA endometrial cancer of all histological subtypes, from January 2009 until March 2019, were analyzed. Patient and tumor characteristics, treatment details, relapse, death, and last follow-up dates were collected. Site of relapse, presence of symptoms, and whether relapses were salvageable were also identified. The European Society of Medical Oncology-European Society of Gynecological Oncology 2020 risk stratification was assigned, and relapse free and overall survival were estimated. RESULTS 900 patients met the eligibility criteria. Median age was 66 years (range 28-96) and follow-up duration was 35 months (interquartile range 19-57). In total, 16% (n=144) of patients relapsed, 1.3% (n=12) from the low risk group, 3.9% (n=35) from the intermediate risk group, 2.2% (n=20) from the high-intermediate risk group, and 8.7% (n=77) from the high risk group. Salvageable relapses were less frequent at 2% (n=18), of which 33% (n=6) were from the low risk group, 22% (n=4) from the intermediate risk group, 11% (n=2) from the high-intermediate risk group, and 33% (n=6) from the high risk group. There were only three asymptomatic relapses in the low risk patients, accounting for 0.33% of the entire cohort. CONCLUSIONS Relapses were infrequent and most presented with symptoms; prognosis after relapse remains favorable. Overall salvageable relapses were infrequent and cannot justify intensive hospital based follow-up. Use of patient initiated follow-up is therefore appropriate, as per the British Gynaecological Cancer Society's guidelines, for all risk groupings.
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Affiliation(s)
- Asma Sarwar
- University College London Hospitals NHS Foundation Trust, London, UK .,University College London, London, UK
| | | | | | | | - Gemma Eminowicz
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
| | - Mary McCormack
- University College London Hospitals NHS Foundation Trust, London, UK.,University College London, London, UK
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Müskens WD, Rongen-van Dartel SAA, Vogel C, Huis A, Adang EMM, van Riel PLCM. Telemedicine in the management of rheumatoid arthritis: maintaining disease control with less health-care utilization. Rheumatol Adv Pract 2021; 5:rkaa079. [PMID: 33688619 PMCID: PMC7928564 DOI: 10.1093/rap/rkaa079] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/02/2020] [Indexed: 12/15/2022] Open
Abstract
Objectives We aimed to evaluate the use of an eHealth platform and a self-management outpatient clinic in patients with RA in a real-world setting. The effects on health-care utilization and disease activity were studied. Methods Using hospital data of patients with RA between 2014 and 2019, the use of an eHealth platform and participation in a self-management outpatient clinic were studied. An interrupted time series analysis compared the period before and after the introduction of the eHealth platform. The change in trend (relative to the pre-interruption trend) for the number of outpatient clinic visits and the DAS for 28 joints (DAS28) were determined for several scenarios. Results After implementation of the platform in April 2017, the percentage of patients using it was stable at ∼37%. On average, the users of the platform were younger, more highly educated and had better health outcomes than the total RA population. After implementation of the platform, the mean number of quarterly outpatient clinic visits per patient decreased by 0.027 per quarter (95% CI: -0.045, -0.08, P = 0.007). This was accompanied by a significant decrease in DAS28 of 0.056 per quarter (95% CI: -0.086, -0025, P = 0.001). On average, this resulted in 0.955 fewer visits per patient per year and a reduction of 0.503 in the DAS28. Conclusion The implementation of remote patient monitoring has a positive effect on health-care utilization, while maintaining low disease activity. This should encourage the use of this type of telemedicine in the management of RA, especially while many routine outpatient clinic visits are cancelled owing to COVID-19.
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Affiliation(s)
- Wieland D Müskens
- Radboud Institute for Health Sciences, Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Nijmegen
| | - Sanne A A Rongen-van Dartel
- Radboud Institute for Health Sciences, Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Nijmegen.,Department of Rheumatology, Bernhoven, Uden
| | | | - Anita Huis
- Radboud Institute for Health Sciences, Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Nijmegen
| | - Eddy M M Adang
- Radboud Institute for Health Sciences, Radboud University Medical Center, Scientific Department of Health Evidence, Nijmegen, The Netherlands
| | - Piet L C M van Riel
- Radboud Institute for Health Sciences, Radboud University Medical Center, Scientific Institute for Quality of Healthcare, Nijmegen.,Department of Rheumatology, Bernhoven, Uden
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16
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Ritschl V, Stamm TA, Aletaha D, Bijlsma JWJ, Böhm P, Dragoi R, Dures E, Estévez-López F, Gossec L, Iagnocco A, Negrón JB, Nudel M, Marques A, Moholt E, Skrubbeltrang C, Van den Bemt B, Viktil K, Voshaar M, Carmona L, de Thurah A. Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider. RMD Open 2020; 6:e001432. [PMID: 33161377 PMCID: PMC7856118 DOI: 10.1136/rmdopen-2020-001432] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/08/2020] [Accepted: 10/17/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs). METHODS An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews. RESULTS After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise. CONCLUSIONS The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.
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Affiliation(s)
- Valentin Ritschl
- Section for Outcomes Research, Medical University of Vienna, Wien, Austria
| | - Tanja A Stamm
- Section for Outcomes Research, Medical University of Vienna, Wien, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Medical University of Vienna, Wien, Austria
| | | | - Peter Böhm
- Deutsche Rheuma-Liga Bundesverband e.V., Bonn, Germany
| | - Razvan Dragoi
- University of Medicine and Pharmacy Victor Babes Timisoara, Timisoara, Romania
| | - Emma Dures
- University of the West of England Bristol, Bristol, UK
- Academic Rheumatology, Bristol Royal Infirmary, Bristol, UK
| | | | - Laure Gossec
- Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France
- APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
| | | | - José B Negrón
- Instituto de Investigación Social y Sanitaria, Puerto Rico
| | | | - Andréa Marques
- Centro Hospitalar e Universitário de Coimbra, Health Sciences Research Unit: Nursing, UICISA-E, Coimbra, Portugal
| | - Ellen Moholt
- Diakonhjemmet Hospital, Division of Rheumatology and Research, Oslo, Norway
| | | | - Bart Van den Bemt
- Pharmacy, Sint Maartenskliniek, Nijmegen, Netherlands
- Radboud University Medical Centre, Nijmegen, Netherlands
| | - Kirsten Viktil
- University of Oslo, Oslo, Norway
- Diakonhjemmet Hospital Pharmacy, Oslo, Norway
| | | | - Loreto Carmona
- Instituto de Salud Musculoesquelética (Inmusc), Madrid, Spain
| | - Annette de Thurah
- Rheumatology, Aarhus University Hospital, Århus N, Denmark
- Clinical Medicine, Aarhus University, Aarhus, Denmark
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17
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Bech B, Lykkegaard JJ, Lundbak T, Schrøder HM, Birkeland LM, Schlyter ML, Hansen LH, Dalsgaard L, Esbensen BA. Patient-Initiated Follow-Up (PIFU) as reorganized support for increased patient involvement - focus group discussions among patients' with inflammatory arthritis. BMC Rheumatol 2020; 4:44. [PMID: 32613158 PMCID: PMC7325086 DOI: 10.1186/s41927-020-00143-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 06/01/2020] [Indexed: 01/08/2023] Open
Abstract
Background Inflammatory Arthritis is characterized by lifelong medical treatment and an unpredictable trajectory because of the fluctuating nature of the diseases. Proactive disease management is recommended, which includes close monitoring of disease activity that traditionally has been ensured by outpatient visits to rheumatologists at various fixed intervals. Internationally, there is a growing interest in how healthcare systems can be more flexible, individual-oriented and increasingly involve patients with lifelong diseases in their own treatment and care. We aimed to explore how patients with Inflammatory Arthritis with low disease activity or remission (DAS-CRP < 2.9) experience patient involvement in a reorganized follow-up care based on flexibility and patient-initiated contact. Methods We conducted a qualitative study based on four mixed group discussions focused on patients with inflammatory arthritis (rheumatoid arthritis [n = 21], axial spondyloarthritis [n = 3] and psoriatic arthritis [n = 1]) participating in a reorganized follow-up care. Changes in follow-up included access to a nurse and patient-initiated follow-up (PIFU). The analysis was based on content analysis. The reporting adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ). Results In total, 25 patients (20 females (80%), mean age 61.8 [range 28–79]) participated. We identified three categories. 1) Patient-Initiated Follow-Up do not affect patients’ perceived support in disease control; this refers to patients’ experience of more time available through better resource utilization, as well as trust that access to professional support would be available whenever needed. The category 2) Information is valued by patients to delineate responsibilities in a new patient role reflects patients’ uncertainty in the transition to PIFU, combined with confusion about the distribution of responsibilities. 3) Patients need both extended perspectives of their arthritis and focused dialogue is about expanding patients’ understanding of their arthritis by interaction over time with both a rheumatologist and a rheumatology nurse in a focused dialogue to involve the patient. Conclusions Patients participating in PIFU welcome the flexibility and involvement. However, patients need relevant information to act adequately within a new patient role. Interaction with both rheumatologists and nurses, combined with sufficient time for dialogue, broaden patients’ perspective, make opportunities for action visible, and contribute to patients’ ability to participate in follow-up care.
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Affiliation(s)
- Bianca Bech
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark.,Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark
| | - Jens Jørgen Lykkegaard
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Tine Lundbak
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Heidi Morsø Schrøder
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Line Mette Birkeland
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Mette Lund Schlyter
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | - Lotte Hanne Hansen
- Center for Rheumatology and Spine Diseases, Centre for Head and Orthopaedics, Rigshospitalet, Valdemar Hansens Vej 17, Indgang 5, stuen, 2600 Glostrup, Denmark
| | | | - Bente Appel Esbensen
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Centre of Head and Orthopaedics, Rigshospitalet, Glostrup, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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18
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Beaver K, Martin-Hirsch P, Williamson S, Kyrgiou M. Exploring the acceptability and feasibility of patient-initiated follow-up for women treated for stage I endometrial cancer. Eur J Oncol Nurs 2020; 44:101704. [DOI: 10.1016/j.ejon.2019.101704] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/08/2019] [Accepted: 11/26/2019] [Indexed: 12/14/2022]
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Schougaard LMV, Mejdahl CT, Christensen J, Lomborg K, Maindal HT, de Thurah A, Hjollund NH. Patient-initiated versus fixed-interval patient-reported outcome-based follow-up in outpatients with epilepsy: a pragmatic randomized controlled trial. J Patient Rep Outcomes 2019; 3:61. [PMID: 31520247 PMCID: PMC6744536 DOI: 10.1186/s41687-019-0151-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 08/27/2019] [Indexed: 12/14/2022] Open
Abstract
Background The use of patient-reported outcome (PRO) could potentially contribute to the reorganization of the health care system. AmbuFlex is a PRO system used in remote patient monitoring, in which questionnaires are sent to patients at fixed intervals. The PRO data are used by clinicians to decide whether patients need clinical attention. Better self-management and cost-saving follow-up activities may be achieved by letting patients initiate need of contact. We evaluated the effects of patient-initiated PRO-based outpatient follow-up on health care resource utilization, quality of care, and the patient perspective. Methods We conducted a parallel two-arm pragmatic randomized controlled trial at the Department of Neurology, Aarhus University Hospital, Denmark. Outpatients with epilepsy (≥ 15 years old), attending fixed-interval PRO-based follow-up with web-based questionnaires, were randomly assigned in a ratio of 0.55:0.45 to either 1) patient-initiated PRO-based follow-up (open access telePRO) or 2) fixed-interval PRO-based follow-up (standard telePRO). The primary outcome was the number of outpatient hospital contacts related to epilepsy retrieved from a regional registry. Hospitals admissions and emergency room visits were also assessed. Secondary self-reported outcomes including general health, well-being, health literacy, self-efficacy, number of seizures, side effects, confidence, safety, and satisfaction were retrieved from questionnaires. Data were analyzed by the intention-to-treat and per-protocol approaches. Results Between January 2016 and July 2016, 593 patients were randomized to either open access telePRO (n = 346) or standard telePRO (n = 247). At 18 months, no statistically significant differences were found between the arms regarding number of telephone consultations or outpatient visits. Patients in the open access arm had a slightly lower, statistically significant number of emergency room visits than patients in the standard arm. Self-reported mental well-being in the open access arm was slightly, statistically significantly lower than in the standard arm. Other secondary outcomes did not differ statistically significantly between arms. Conclusion This study did not find, as hypothesized, less use of health care resources or improved patient self-management or satisfaction in the patient-initiated PRO-based initiative compared to fixed-interval PRO-based follow-up. Patient-initiated PRO-based follow-up may be used as an alternative to fixed-interval PRO-based follow-up in patients who prefer this approach, but there is insufficient evidence for recommending a system-wide shift to patient-initiated PRO-based follow-up. Trial registration Registered 4 February 2016 with ClinicalTrials.gov: NCT02673580. Electronic supplementary material The online version of this article (10.1186/s41687-019-0151-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liv Marit Valen Schougaard
- AmbuFlex/WestChronic, Occupational Medicine, University Research Clinic, Aarhus University, Gl. Landevej 61, DK-7400, Herning, Denmark.
| | - Caroline Trillingsgaard Mejdahl
- AmbuFlex/WestChronic, Occupational Medicine, University Research Clinic, Aarhus University, Gl. Landevej 61, DK-7400, Herning, Denmark
| | - Jakob Christensen
- Department of Neurology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 165, DK-8200, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark
| | - Kirsten Lomborg
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark
| | | | - Annette de Thurah
- Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 82, DK-8200, Aarhus N, Denmark.,Department of Rheumatology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 59, DK-8200, Aarhus N, Denmark
| | - Niels Henrik Hjollund
- AmbuFlex/WestChronic, Occupational Medicine, University Research Clinic, Aarhus University, Gl. Landevej 61, DK-7400, Herning, Denmark.,Department of Clinical Epidemiology, Aarhus University Hospital, Olof Palmes Allé 43-45, DK-8200, Aarhus N, Denmark
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Kumarakulasingam P, McDermott H, Patel N, Boutler L, Tincello DG, Peel D, Moss EL. Acceptability and utilisation of patient-initiated follow-up for endometrial cancer amongst women from diverse ethnic and social backgrounds: A mixed methods study. Eur J Cancer Care (Engl) 2019; 28:e12997. [DOI: 10.1111/ecc.12997] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 10/24/2018] [Accepted: 12/16/2018] [Indexed: 02/01/2023]
Affiliation(s)
| | - Hilary McDermott
- School of Sport, Exercise and Health Sciences; Loughborough University; Loughborough UK
| | - Nafisa Patel
- Department of Gynaecological Oncology; University Hospitals of Leicester; Leicester UK
| | - Louise Boutler
- Department of Gynaecological Oncology; University Hospitals of Leicester; Leicester UK
| | | | - David Peel
- Department of Gynaecological Oncology; University Hospitals of Leicester; Leicester UK
| | - Esther L. Moss
- Leicester Cancer Research Centre; University of Leicester; Leicester UK
- Department of Gynaecological Oncology; University Hospitals of Leicester; Leicester UK
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Jeppesen MM, Jensen PT, Hansen DG, Christensen RD, Mogensen O. Patient-initiated follow up affects fear of recurrence and healthcare use: a randomised trial in early-stage endometrial cancer. BJOG 2018; 125:1705-1714. [PMID: 29978593 DOI: 10.1111/1471-0528.15396] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To test the hypothesis that patient-initiated follow up reduces the fear of cancer recurrence (FCR) and healthcare use when compared with traditional hospital-based follow up. DESIGN Pragmatic, multicentre randomised trial. SETTING Four Danish departments of gynaecology between May 2013 and May 2016. POPULATION One hundred and fifty-six women diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I low-intermediate risk endometrial carcinoma. METHODS Women allocated to the control group attended hospital-based follow up consisting of regular outpatient visits for 3 years after primary treatment. Women in the intervention group were instructed in patient-initiated follow up, which included careful instruction in alarm symptoms and options for self-referral rather than a schedule of examinations. MAIN OUTCOME MEASURES The primary end point was FCR as measured by the Fear of Cancer Recurrence Inventory (FCRI) after 10 months of follow up. Secondary end points included cancer-related use of primary and secondary health care during the first 10 months after treatment. RESULTS In the primary analysis, FCR decreased significantly more in the control group from baseline to 10 months of follow up (difference -5.9, 95% CI -10.9 to -0.9). The majority of this improvement happened after only 3 months of follow up. Women receiving the intervention had fewer examinations at the department compared with the control group (0 versus 2 median visits, P < 0.01) and 58% of these examinations were scheduled because of vaginal bleeding. CONCLUSIONS Hospital-based follow up alleviates FCR significantly more than patient-initiated follow up, though the estimated difference was small. Patient-initiated follow up is a feasible, potentially cost-reducing follow-up approach in a population of endometrial cancer survivors with low risk of recurrence. The decision to use patient-initiated follow up should balance these benefits and harms. TWEETABLE ABSTRACT Patient-initiated follow up reduces healthcare use but maintains fear of recurrence in endometrial cancer. PLAIN LANGUAGE SUMMARY Why and how was the study carried out? Follow up of women with endometrial cancer is resource consuming and previous research suggests that it is not effective. Even though the women benefit from reassurance at follow up, routine examinations may also remind the women of the disease and induce fear of cancer recurrence. Furthermore, routine follow up may delay recurrence diagnosis, because the women do not report their symptoms until the next scheduled visit. In the research explained in this article, patient-initiated follow up was evaluated as an alternative to traditional follow up. The women were randomly assigned to one of two follow-up programmes: regular gynaecological examinations at the department of gynaecology or self-referral with careful instruction in alarm symptoms, that is, patient-initiated follow up. The level of fear of cancer recurrence in the two groups was obtained by questionnaires. Information on healthcare use was obtained by questionnaires and a chart review. What were the main findings? Regular examinations at the department of gynaecology reduced the fear of cancer recurrence significantly more than patient-initiated follow up, though the difference was small. Women who were instructed in alarm symptoms, under self-referral, were able to monitor their symptoms, and this approach significantly reduced the number of examinations at the department of gynaecology. What are the limitations of the work? Participants in the self-referral group knew that they were examined less than other women, and this may have induced fear of cancer recurrence. Similarly, the regular completion of questionnaires regarding fear of cancer recurrence may have reminded the women of the disease and diminished the difference between the two groups. What are the implications for patients Patient-initiated follow up reduced healthcare use but maintained fear of cancer recurrence in women who had survived early-stage endometrial cancer. Future analyses on quality of life and cost-effectiveness are needed to balance the benefits and harms of patient-initiated follow up.
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Affiliation(s)
- M M Jeppesen
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - P T Jensen
- Department of Gynaecology and Obstetrics, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - D G Hansen
- The National Research Centre of Cancer Rehabilitation, Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - R D Christensen
- Research Unit of General Practice, University of Southern Denmark, Odense, Denmark
| | - O Mogensen
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,The Pelvic Cancer Patient Area, Karolinska University Hospital and the Karolinske Institute, Stockholm, Sweden
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Egan A, Lennon O, Power CK, Fullen BM. "I've Actually Changed How I Live"-Patients' Long-Term Perceptions of a Cognitive Behavioral Pain Management Program. PAIN MEDICINE 2018; 18:220-227. [PMID: 28204751 DOI: 10.1093/pm/pnw148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective To determine patients’ perceptions regarding cognitive behavioral pain management programs, and to determine what, if any, strategies learned on the program patients continue to use long-term to manage their pain. Design A qualitative, focus-group based study. Setting An outpatient multidisciplinary pain management program in a university teaching hospital. Patients Patients with chronic pain who had previously completed a 4-week cognitive behavioral pain management program (2001–2014). Methods Sixteen patients attended one of four focus groups. A battery of semi-structured questions explored their perceptions of the cognitive behavioral program, and which strategies they found useful and continued to use long-term to manage their pain. Results Six key themes emerged: 1) universal long-term positive feedback on the utility of the program; 2) the program facilitated long-term changes in daily life; 3) participants now considered themselves as the “new me”; 4) request for more updates on emerging new treatments/pain knowledge; 5) recognizing that the key to maximizing gain from the program was to be open, to listen, and accept; and 6) participants sharing pain management knowledge with others in pain. Conclusion There was universal positive feedback for the pain management program. Despite the years since they participated in one, patients continue to use key strategies to effectively manage their pain (pacing, relaxation), embedding them in their daily lives to maximize their quality of life.
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Affiliation(s)
- Aine Egan
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield Campus, Dublin
| | - Olive Lennon
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield Campus, Dublin
| | - Camillus K Power
- Department of Anesthesia and Pain Medicine, Tallaght Hospital, Dublin, Ireland
| | - Brona M Fullen
- School of Public Health, Physiotherapy and Sports Science, University College Dublin, Belfield Campus, Dublin.,Centre for Translational Pain Research, University College Dublin, Belfield Campus, Dublin
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23
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Abbott P. Patient-centred health care for people with chronic skin conditions. Br J Dermatol 2017; 177:329-330. [PMID: 28833008 DOI: 10.1111/bjd.15709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- P Abbott
- School of Medicine, Western Sydney University, Campbelltown, NSW, Australia
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24
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Schougaard LMV, Mejdahl CT, Petersen KH, Jessen A, de Thurah A, Sidenius P, Lomborg K, Hjollund NH. Effect of patient-initiated versus fixed-interval telePRO-based outpatient follow-up: study protocol for a pragmatic randomised controlled study. BMC Health Serv Res 2017; 17:83. [PMID: 28122609 PMCID: PMC5267418 DOI: 10.1186/s12913-017-2015-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The traditional system of routine outpatient follow-up of chronic disease in secondary care may involve a waste of resources if patients are well. The use of patient-reported outcomes (PRO) could support more flexible, cost-saving follow-up activities. AmbuFlex is a PRO system used in outpatient follow-up in the Central Denmark Region. PRO questionnaires are sent to patients at fixed intervals. The clinicians use the PRO data to decide whether a patient needs a visit or not (standard telePRO). PRO may make patients become more involved in their own care pathway, which may improve their self-management. Better self-management may also be achieved by letting patients initiate contact. The aim of this study is to obtain data on the effects of patient-initiated follow-up (open access telePRO) on resource utilisation, quality of care, and the patient perspective. METHODS The study is a pragmatic, randomised, controlled trial in outpatients with epilepsy. Participants are randomly assigned to one of two follow-up activities: a) standard telePRO or b) open access telePRO. Inclusion criteria are age ≥ 15 years and previous referral to standard telePRO follow-up at Aarhus University Hospital, Denmark. Furthermore, patients must have answered the last questionnaire via the Internet. The number of contacts will be used as the primary outcome measure. Secondary outcome measures include well-being (WHO-5 Well-Being Index), general health, number of seizures, treatment side effects, mortality, health literacy (Health Literacy Questionnaire), self-efficacy (General Self-Efficacy scale), patient activation, confidence, safety, and satisfaction. In addition, the patient perspective will be explored by qualitative methods. Data will be collected at baseline and 18 month after randomisation. Inclusion of patients in the study started in January 2016. Statistical analysis will be performed on an intention-to-treat and per-protocol basis. For qualitative data, the interpretive description strategy will be used. DISCUSSION The benefits and possible drawbacks of the PRO-based open access approach will be evaluated. The present study will provide important knowledge to guide future telePRO interventions in relation to effect on resource utilisation, quality of care, and the patient perspective. TRIAL REGISTRATION ClinicalTrials.gov: NCT02673580 (Registration date January 28, 2016).
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Affiliation(s)
| | - Caroline Trillingsgaard Mejdahl
- The Research Programme in Patient involvement, Aarhus University Hospital, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | | | - Anne Jessen
- AmbuFlex, Regional Hospital West Jutland, Herning, Denmark
| | - Annette de Thurah
- The Research Programme in Patient involvement, Aarhus University Hospital, Aarhus, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Per Sidenius
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Kirsten Lomborg
- The Research Programme in Patient involvement, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Niels Henrik Hjollund
- AmbuFlex, Regional Hospital West Jutland, Herning, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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