Background/Purpose

Logistical difficulties associated with managing a large, publically funded secondary service, means that service delivery is costly in terms of physician time. Patients frequently do not have medication lists with them when they attend clinic. Recent results are not available to the physician at the time of clinic visit. Disease activity scores to assist in informing clinical decisions with a treat-to-target approach, are not calculated. Patient reported outcome measures (PROM) are rarely formally assessed and recorded, because these too are often time consuming.

Physician Extenders (PE) have been used to improve efficiency in out-patient clinics.(1) In this action-research endeavour(2), we introduced changes both to the structure and process of how return patients are assessed, making use of a PE to prepare for patient visits.

The specific aims were:

1. To decrease the time physicians spend with inflammatory arthropathy (IA) return patients.
2. To perform a standardised and validated measurement of disease activity for all patients.
3. To increase the proportion of patients acquiring staging hands and feet plain film radiographs every two years in compliance with the consensus of rheumatologists at the hospital.

Methods:

The PE recorded the results of the last inflammatory markers and plain film radiographs of hands and feet in a pro-forma. Where these results were not recent (2 weeks for blood results and 2 years for radiographs), the PE liaised with a physician, on a scheduled basis, to arrange for the latter to complete the required ordering forms.

The PE assembled and mailed the pro-forma and ordering forms to returning IA patients 2 weeks in advance of their clinic visit. The pro-forma included a patient global assessment; other PROMs, e.g. HAQ-DI, SF-36; as well as an accurate current medication list. Patients were asked to complete the pro-forma, and to have the bloods and radiographs taken a few days before their appointment.

Patients presented to clinic with a self-completed pro-forma as well up to date results.

Results:

125 patients (85 female) with IA were sent pro-formas before their clinic visit.

Mean time a physician spent at clinic per patient was decreased from 23 minutes to 15 minutes.

120 (96.0%), patients had DAS28-CRP scores calculated, 5 (4%) did not have scores calculated because of a piece of missing data.

68/125 (54.4%) had no radiographs in the three 3 years before their clinic visit. Of the 68 who had no radiographs taken during this time, 49 (72.1%) had radiographs directly as a result of this action-research.

Conclusion:

The use of a PE in preparation for clinic visits decreases the time physicians need to spend reviewing patients, and increases the quality of the visit as measured by the collection of DAS scores, and PROMs, and relevant radiological investigations. A cost analysis needs to be done to demonstrate that this approach is cost effective.

1.            Norris B, Harris T, Stringer S. Effective use of physician extenders in an outpatient otolaryngology setting. Laryngoscope. 2011;121(11):2317-21.

2.            Coghlan D, Brannick T. Doing action research in your own organization: Sage; 2014.

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