Elsevier

The Lancet

Volume 359, Issue 9322, 8 June 2002, Pages 1961-1968
The Lancet

Articles
Joint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial

https://doi.org/10.1016/S0140-6736(02)08828-1Get rights and content

Summary

Background

The current model of general practitioner referral of patients to hospital specialists in the UK is sometimes associated with unnecessary duplication of investigations and treatments. We aimed to compare joint teleconsultations between general practitioners, specialists, and patients (virtual outreach) with standard outpatient referral.

Methods

Virtual outreach services were established in London and Shrewsbury. The general practitioners referred 3170 patients, of whom 2094 consented to participate in the study and were eligible for inclusion. 1051 patients were randomly assigned virtual outreach, and 1043 standard outpatient appointments. We followed up the patients for 6 months after their index consultation. The primary outcome measure was the offer of a follow-up outpatient appointment. Analysis was by intention to treat.

Findings

More patients in the virtual outreach group than the standard group were offered a follow-up appointment (502 [52%] vs 400 [41%], odds ratio 1·52 [95% CI 1·27–1·82], p<0·0001). Significant differences in effects were observed between the two sites (p=0·009) and across different specialties (p<0·0001). Virtual outreach increased the offers of follow-up appointments more in Shrewsbury than in London, and more in ear, nose, and throat surgery and orthopaedics than in the other specialties. Fewer tests and investigations were ordered in the virtual outreach group by an average of 0·79 per patient (0·37–1·21, p=0·0002). Patients' satisfaction (analysed per protocol) was greater after a virtual outreach consultation than after a standard outpatient consultation (mean difference 0·33 scale points [95% CI 0·23–0·43], p<0·0001), with no heterogeneity between specialties or sites.

Interpretation

The trial showed that allocation of patients to virtual outreach consultations is variably associated with increased offers of follow-up appointments according to site and specialty, but leads to significant increases in patients' satisfaction and substantial reductions in tests and investigations. Efficient operation of such services will require appropriate selection of patients, significant service reorganisation, and provision of logistical support.

Introduction

Between 6% and 10% of visits to primary-care practitioners in the UK result in a referral for specialist opinion,1 and most of the patients seen for the first time as outpatients are referred in this way. The process of referral requires effective communication between all parties involved, and deficiencies can lead to a range of problems.2, 3, 4 The current process of referral in the UK often leads to duplication of investigation and unnecessary follow-up, leading to dissatisfaction by all parties concerned.5, 6, 7 Several models have evolved to overcome these difficulties, including the domiciliary visit and, more recently, the outreach clinic.8 The latter was expected to lead to better communication, with educational and clinical benefits, but studies suggest that these targets were rarely achieved because of the lack of involvement of general practitioners.9 In a study in the Netherlands, three general practitioners accompanied patients to an orthopaedic clinic and sat in on the consultations.10 Reported benefits of the general practitioners' extended involvement in referral included reductions in hospital follow-up appointments, tests, and investigations, and improvements in health status for patients 1 year after referral. The general practitioners made significantly fewer referrals after the study. Such an arrangement presents obvious practical and resource problems, making implementation unlikely. In a study on outreach clinics in England, there were more referrals for outpatient appointments among the outreach group, but patients reported higher levels of satisfaction.11

Video-conferencing technologies allow virtual meetings between patients and practitioners, and several studies have investigated such teleconsultations in a range of clinical areas including dermatology, orthopaedics, cardiology, and psychiatry.12 Studies have reported high levels of satisfaction among patients, although the validity of these findings has been questioned.13 We confirmed acceptability to patients in a feasibility study,14 and a subsequent pilot study confirmed the feasibility of recruiting patients and the acceptability of teleconsultations across a range of specialities, and suggested that patients' satisfaction might be higher than with standard outpatient appointments.15 Thus, teleconsultations seemed to have the potential to improve the quality and effectiveness of referral from primary to secondary care. We have now done a large, randomised trial to determine reliably the effect of this technology on the frequency of follow-up, patients' satisfaction and welfare, the use of health-service facilities for investigation and treatment, and the economic implications for primary care, hospitals, patients, and the UK as a whole.

Section snippets

Patients

Virtual outreach services were established at the Royal Free Hampstead NHS Trust, which serves general practitioners in inner-city and urban settings in London, and at the Royal Shrewsbury Trust in Shropshire, which serves general practitioners and patients in small market towns and rural settings. The project teams recruited and trained 134 general practitioners from 29 practices—15 in London and 14 in Shrewsbury—and 20 consultant specialists. Of the specialists, nine were in medical

Results

Of 3170 apparently eligible patients considered for the trial, 2094 were randomised (figure 1). Those who were not randomised, mainly because consent was not obtained, included a greater proportion of younger London patients; however, those not randomised were similar in other ways to the trial participants. 36 patients were subsequently found to be ineligible (most of them because of referral to a consultant who withdrew from the study before seeing any patients) and were excluded from the

Discussion

We postulated that, as in the case of actual joint consultations reported by Vierhout and colleagues,10 the ability of general practitioners and consultants to review their patients together would result in better communication, leading to more effective management and fewer patients being asked to return to outpatients for subsequent review. However, in general, patients seen in virtual outreach were more frequently offered follow-up than those who underwent a standard outpatient consultation.

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