Chronic disease has a wide impact around the world. The World Health Organization (WHO) reported that 63% of all deaths are from chronic disease (WHO 2011).
Missed hospital appointments is a commonly reported problem in healthcare services around the world; for example, they cost the National Health Service (NHS) in the UK millions of pounds every year (HES 2010). This unnecessary cost and change in public expectations has brought into question the efficiencies of secondary care appointment scheduling systems, particularly in chronic conditions. Alternative appointment systems have been explored to an extent. For example, the Expert Patient Programme (in the UK) was specifically aimed at people with long-term conditions (DoH 2001). While alternative forms of appointment scheduling may not be appropriate for all healthcare areas, those areas managing people who have long-term or chronic conditions may see some benefits.
In 2002, the WHO published a report highlighting the need for a model of care that more readily meets the needs of people with chronic conditions (WHO 2002). The authors suggested that innovations that build on evidence-based decision-making, have a population and quality focus, and are flexible to the needs and demands of the patient population should do well in improving the management of chronic conditions.
Description of the condition
Chronic conditions, defined as "diseases of long duration and generally slow progression" (WHO 2013) include diseases such as rheumatoid arthritis, asthma, cancer and diabetes, as well as others. People are faced with an opportunity to manage their condition but not cure it. Traditionally, people with these types of conditions are managed by the clinician through regularly scheduled appointments (e.g. one to four times per year) at outpatient clinics (Kirwan 1991; Probert 1993). These appointments often occur at a time when a person is feeling relatively well with little action taken as a result. Conversely, when symptoms recur or suddenly worsen it may be difficult to obtain immediate urgent appointments if needed. Subsequently, people are often unable to get help during periods of exacerbated disease due to the number of regular follow-up appointments also needed in the system. In some cases, conditions are managed in primary care; a number of studies reported on the success of similar systems in this setting (Liu 2010; Robinson 2010; Rose 2011).
Description of the intervention
A patient-initiated appointment system enables patients to make urgent appointments when they are going through a time when they feel they cannot manage their condition or where something has unexpectedly changed. The system does not completely replace the need for a scheduled follow-up appointment but the new system could decrease the number of follow-up appointments (e.g. every one to two years).
How the intervention might work
The patient-initiated appointment system could free up clinician time, therefore making the service more flexible for urgent appointments, while still being able to deliver a standard of care acceptable to patients. Using this type of service may also mean that the numbers of missed appointments are reduced (and therefore financial and resource costs too) as most patients will be attending because they need to or choose to, or both, and not just because the appointment is a requirement. There is a potential risk in situations where the patient fails to request an appointment at the time of relapse or escalation of their condition, and symptoms become worse, possibly critical. This risk is more likely when the appointment systems do not include a 'safety net' appointment system (an appointment which is scheduled by the clinician for a certain point in time to ensure the patient is using the system correctly) or when clinicians are unable to select appropriate patients for the patient-initiated appointment system pathway. In addition, there are elements of preventive health care or patient education that occur during a routine appointment that are not addressed during a patient-initiated appointment. This risk can be minimised by incorporating an appropriate checklist into a 'safety net' appointment. There have been several studies that have explored the effectiveness of patient-initiated appointment systems in primary care (Liu 2010; Robinson 2010; Rose 2011). The results of some of these studies suggest that patient initiation of care results in improvements in satisfaction with a reduced cost for care delivery.
Why it is important to do this review
There are a number of Cochrane reviews that have considered alternative methods to improve attendance to appointments (Car 2012; Reda 2012); however, none of these reviews has looked at the impact of patient-initiated appointment systems in secondary care. With the increasing focus on healthcare efficiencies and the increasing emphasis on enabling people to manage their own conditions (Nuffield 2011; WHO 2002), determining the benefits and harms of patient-initiated appointment systems in secondary care is crucial to understanding their worth for both healthcare systems and patients.