ArticlesJoint teleconsultations (virtual outreach) versus standard outpatient appointments for patients referred by their general practitioner for a specialist opinion: a randomised trial
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.
References (33)
- et al.
Effectiveness of joint consultation sessions of general practitioners and orthopaedic surgeons for locomotor-system disorders
Lancet
(1995) - et al.
Defining and measuring patient satisfaction with medical care
Eval Program Plann
(1983) - et al.
Intensive versus standard case management for severe psychotic illness: a randomised trial
Lancet
(1999) Measuring referral rates
- et al.
Referral to medical outpatients: different agendas of patients
How well do general practitioners and hospital specialists work together? A qualitative study of co-operation and conflict within the medical profession
Br J Gen Pract
(1998)European Study of Referrals from Primary to Secondary Care
(1992)Are follow-up consultations at medical outpatient departments futile?
BMJ
(1982)- et al.
Long-term follow-up in outpatient clinics, 1—the view from general practice
Fam Pract
(1997) - et al.
Reasons for referral to hospital: extent of agreement between the perceptions of patients, general practitioners and consultants
Fam Pract
(1986)
Specialist outreach clinics in general practice
BMJ
Specialist outreach clinics in general practice: what do they offer?
Br J Gen Pract
A national evaluation of specialists' clinics in primary care settings
Br J Gen Pract
Survey of research in telemedicine, 2—telemedicine services
J Telemed Telecare
Systematic review of studies of patient satisfaction with telemedicine
BMJ
Can telemedicine be used to improve communication between primary and secondary care?
BMJ
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