Can A Virtual Clinic Review Replace A Surgical Clinic Visit After Discharge?

Study Overview
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Brief Summary
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To assess if a virtual out patient clinic via a telephone review was an acceptable and safe alternative to a clinic attendance for a broad range of general surgical patients discharged following a hospital admission.

Detailed Description
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The surgical out patients is often the first point of contact between a surgeon and patient after being referred by their general practitioner (GP). Here new patients are assessed, investigations are requested and treatment plans devised. On completion of treatment it has been common practice to review all patients post operatively (1). However the routine review of patients following low risk procedures contribute to increasing healthcare costs without necessarily a significant benefit for the patient. It may indeed be a burden on patients and families, who may miss work or college, have to travel long distances and wait for prolonged periods to be seen. There is also a financial burden associated with travel to appointments and on-site parking fees. Unnecessary appointments also contribute to increased waiting times for new referrals to be seen. This has the potential to lead to delayed diagnosis of serious conditions (2) and further increase the workload of overburdened emergency departments. Previous studies have demonstrated a safe and acceptable alternative to traditional outpatient appointments with telephone follow up in certain paediatric and adult surgical patients (1,3,4). Improved efficiency and high levels of patient satisfaction have also been demonstrated in an Irish setting with the establishment of a virtual outpatient department (VOPD) following endoscopy (5). In an oncology setting telephone follow up has also been identified as an effective means of delivering care (6,7). In particular nurse led follow up of lung, breast and colorectal cancer patients has been associated with a high level of patient satisfaction (8). The aim of this study was to determine whether a virtual out patient clinic via a telephone review was an acceptable and safe alternative to a clinic attendance for a broad range of general surgical patients discharged following a hospital admission. If eligible for inclusion the patient was approached prior to discharge and the study rationale, randomisation and methods of follow up were explained. If they agreed to participate written consent was obtained and an information leaflet about the study was provided. Randomisation was performed by selecting an unmarked white envelope which contained either a coloured card indicating a telephone call follow up within 6-8 weeks or a white card indicating follow up with an outpatient appointment at 6-8 weeks. After randomisation the patient was provided with a letter detailing their specific follow up arrangements and a contact number was provided if they had any further questions after discharge. Patients' were sent a further letter by administration staff after discharge, with the specific date of either the clinic appointment or phone follow up.

Official Title
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Can A Virtual Clinic Review Replace A Surgical Clinic Visit After Discharge?

Conditions
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Outpatients General Surgery Virtual Clinic

Intervention / Treatment
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* Other: Virtual outpatient clinic appointment
* Other: Standard outpatient clinic appointment


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Over 16 years old Could provide written consent Comprised one of four categories based on reason for admission Category 1 - minor surgery Category 2- elective or emergency surgery such as appendicectomy, hernia repair, thyroidectomy Category 3- admitted for investigation or management of conditions such as non specific abdominal pain, head injury, cellulitis Category 4- attended for surveillance endoscopy for conditions such as colonic polys or Barrett's oesophagus Exclusion Criteria: Declined to participate Had a previous, new or suspected diagnosis of malignancy On-going issues requiring follow up such as wound healing problems Required further investigation such as endoscopy after admission with e.g. diverticulitis.

Ages Eligible for Study
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Minimum Age: 16 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Standard outpatient clinic appointment<br>Patients will be sent an appointment letter to return to a scheduled outpatient clinic for review approximately 6 weeks after their discharge from hospital | Other: Standard outpatient clinic appointment<br>* Patients will be sent an appointment letter to return to a scheduled outpatient clinic for review approximately 6 weeks after their discharge from hospital<br>|
| Experimental: Virtual out patient clinic appointment<br>Patients will be sent an appointment letter stating a specific day approximately 6 weeks after their discharge from hospital in which they will be contacted by telephone for a review by a junior doctor from the discharging team. | Other: Virtual outpatient clinic appointment<br>* Patients will be sent an appointment letter stating a specific day approximately 6 weeks after their discharge from hospital in which they will be contacted by telephone for a review by a junior doctor from the discharging team.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| The primary outcome was the rate of complications or on going issues requiring further assessment in either group. | Any unexpected outcome reported by the patient if contacted by telephone or reported and assessed by a doctor on their review at a standard clinic appointment. This would be expected to be an issue resulting in a deviation from a normal and expected post discharge recovery. | At each patients review appointment approximately 6 weeks after discharge. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Secondary outcomes included a did not respond (DNR) or did not attend (DNA) rate | If an attempt to contact the patient by telephone to conduct their review appointment is unsuccessful this will be recorded as a did not respond. A DNA will be recorded if a patient fails to attend for their scheduled review appointment | At each patients review appointment approximately 6 weeks after discharge. | 
| The number of patients listed for further procedures, investigation or referral to other specialities based on their review. | If the patient is not discharged from follow up by the hospital service to the care of their general practitioner, these are the anticipated outcomes of the follow up review for each patient not discharged | At each patients review appointment approximately 6 weeks after discharge. | 
| Patient satisfaction and opinions regarding their follow up arrangements | Questionnaire that allows participants to provide free text responses about their experience. | 6-8 weeks after their review appointment | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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outpatients, general surgery, virtual clinic, patient satisfaction