A cohort study of new referrals from general practitioners to outpatient clinics to determine why some patients become "continuing attenders"
The aim of this thesis was to investigate why some referrals to outpatient clinics made by General Practitioners lead to continuing hospital attendance. A cohort of 392 patients referred to six outpatient clinics by General Practitioners during 1987 were studied from the time of their first attendance until visits ceased up to two years later. Six consultant clinics were studied in three specialties: rheumatology, vascular surgery and dermatology. For each specialty a clinic in both a teaching hospital and a district were included. The cohort members were similar to that found in most adult outpatient clinics: predominantly middle-aged or elderly with a greater proportion of women. A wide distribution of disease severity scores was observed in each clinic. The patients had to wait up to 35 weeks from the date of referral until seen for the first visit. A `continuing attender' was defined as someone in the highest quintile of visits made. Patients who were referred for therapy were more likely to continue attending. The principal reason for 'continuing attendance' as perceived by patients, General Practitioners and hospital doctors was the necessity for consultant supervision. In addition, analysis of observable clinical and non-clinical data was performed. This showed that diagnosis, disease severity and the grade of doctor seeing the patient in the clinic influenced the numbers of visits made and the numbers of weeks of attendance. Different diagnoses had different predictive values: rheumatoid arthritis and peripheral vascular disease patients were most likely to return for four or more visits. Increasing disease severity scores made discharge progressively less likely and seeing a consultant made discharge four times more likely at the first visit and nine times at the second visit. Taken together these three variables could predict up to 80% of discharge decisions in this cohort of patients. (Sensitivity 81%, specificity 75%.) The disease severity scales we employed failed to detect major changes in this variable for the cohort as a whole or within individual specialties. Patients however considered their visit had produced improvement in their condition in 46% of cases. 62% expressed satisfaction with their visits to the clinic. In so far as the idea of consultant review of all cases at every visit cannot be met, it might still be possible for consultants to effectively manage the resources within their own clinic setting. Casenote review with junior staff at the end of a clinic could usefully be performed on patients making a third or subsequent visit. This would be especially valuable where the diagnosis and a measure of disease severity suggest that the patient should be discharged. The results conclude that such an educational activity, combined with formal guidelines to junior staff on the 'Clinic Discharge Policy' are worthy of further study as potential means of reducing unnecessary attendances. This work has shown that it is possible to make useful observations on data such as age and diagnosis which are routinely gathered in the outpatient clinic. It is also suggested that it might prove useful to record prospectively other data such as patient satisfaction, the proportion of patients seen by different grades of doctors and disease severity. The use of such readily collected data would be of value not only to the clinicians engaged in the work of the clinics, but also to the General Practitioners who make referrals to them and to those who plan the services.