Routine Follow-up Appointments Research Articles

Making sense of blood pressure values in follow-up appointments for hypertension

Background Although there are effective ways of treating hypertension, only a minority of all hypertensive people reach target blood pressure levels. This may be a function of how patients and physicians put measured values into context when they decide if the blood pressure is well controlled or too high. Methodology Qualitative analysis of audio-taped follow-up appointments for hypertension between 51 outpatients and their 11 physicians. All patients came for routine follow-up appointments for hypertension. The setting was primary and a specialist outpatient care in the south of Sweden. Principal findings Borderline blood pressure values led to more deliberation. Common ways of contextualising the blood pressure were by comparing it to previous values and by explaining it in terms of stress or lack of rest. The net effect of this was that the representativity and severity of the measured blood pressure value were downplayed by both patients and physicians. In some instances, physicians (but not patients) worked in the opposite direction. Patients were less actively engaged in interpreting the blood pressure values, stated their views about therapy less often, and were careful not to express views that were overly critical of the drug treatment. Conclusions Patients and physicians make sense of the blood pressure through a contextualisation process which tends to normalise the face values towards the reference values. The resulting (processed) value is the one acted upon. Discursive handling of the blood pressure therefore makes up an important part of the decision-making.

Retention and Use of Breast Cancer Recurrence Risk Information from Genomic Tests: The Role of Health Literacy

New genomic technology now allows physicians to provide women with individualized and highly accurate breast cancer recurrence risk estimates that are a key factor in adjuvant (after surgery) therapy decisions. Because these genomic tests are so new, little is known about how well patients understand the tests and their results. We interviewed 163 stage I or II breast cancer patients at a routine follow-up appointment. We assessed their health literacy (using the Rapid Estimate of Adult Learning in Medicine) as well as their knowledge of and attitudes towards a genomic test that identifies risk of recurrence in hormone receptor-positive, node-negative breast cancer (the OncoType Dx Recurrence Score). Women with lower health literacy recalled less of the information provided about the recurrence risk test than women with higher health literacy. Health literacy was not related to the amount of additional information women desired. Women with higher health literacy preferred to have a more active role in decisions about the test. Health literacy may affect women's capacity to learn about the new genomic tests as well as their desire for informed participation in their medical care.

Contraceptive practices in women with repeat termination of pregnancies

SummaryThe incidence of repeat termination of pregnancies (TOP) has been increasing in the past decade in-spite-of widespread availability of free and effective contraceptive methods. A retrospective analysis of case notes of women referred for TOP in the Family Planning clinic at Luton, between January and October 2005 was carried out. A total of 159 women were referred for TOP. Of these, 42 (26.4%) were repeat procedures. In this subgroup, 78.5% had used one or more contraceptive methods after the first termination. However, only 61.9% of them continued to use contraception at the time of presentation for a repeat TOP, the most common method being the male condom. Half of the total women seen for a repeat TOP were under 6-weeks' gestation and 14.2% had been treated for sexually transmitted infections in the past. The incidence of repeat TOPs is increasing in the UK. Many studies have shown that the periabortion contraceptive practices are generally poor. In our study, women undergoing repeat termination of pregnancies were either not using contraception or using a method with a high failure rate. We also found the highest number of repeat TOPs occurring in the 20 – 25 age group. Effective contraceptive counselling is vital to combat this worrying trend. Routine 2-week follow-up appointments after TOP and regular auditing of the periabortion contraceptive practices are needed.

Trust, standards and healthcare quality: a case of babies and bathwater?

The last few years have not been too comfortable for the members of many professional groups. Concerns about behaviour, propriety, effectiveness, public safety and, in the case of the public sector, cost have resulted in significant scrutiny of the position and role of professionals. One manifestation of this scrutiny has been a growing tendency to establish and impose external standards of practice embodied in codes of conduct or legislation. This issue has had its most recent airing in the fifth report of the Shipman Inquiry.1 Historically, the majority of professionals have relied on internally derived and self-managed standards of care; witness the concept of a basic set of `ancient virtues' at the heart of a medical ethos.2 The growing trend of externally imposed standards raises the question as to whether the possible resulting disempowerment will lead to professionals relying less on their intrinsic mechanisms of quality improvement—which, it could be argued, are the mainstay to underpinning safe and effective practice. Are we throwing the baby out with the bathwater? From the point of view of the patient their long-term interests are likely to be best served by a timely response from the doctor. An internalized professional ethos to act in the patient's best interests would support this. An over reliance on external mechanisms of quality improvement might see professionally derived internal mechanisms atrophy and cease to influence behaviour. In the example of Box 1, a doctor may fail to respond to a patient's vague history of chest pain simply because there are no external drivers to do so. A timely completion of a routine follow-up appointment might be all that the external standards require. The patient may well be satisfied and unaware of the implications of his vague symptoms being passed off. A weakened professional ethos may no longer be able to guide professional practice in those areas where external standards are absent (and perhaps could never even be applied), and hence the quality of patient care would suffer.

Study of Sexual Functioning Determinants in Breast Cancer Survivors

Our goal was to identify the treatment, personal, interpersonal, and hormonal (testosterone) factors in breast cancer survivors (BCSs) that determine sexual dysfunction. The treatment variables studied were type of surgery, chemotherapy, radiation, and tamoxifen. The personal, interpersonal, and physiologic factors were depression, body image, age, relationship distress, and testosterone levels. A sample of 55 female breast cancer survivors seen for routine follow-up appointments from July 2002 to September 2002 were recruited to complete the Female Sexual Functioning Index (FSFI), Hamilton Depression Inventory (HDI), Body Image Survey (BIS), Marital Satisfaction Inventory-Revised (MSI-R), a demographic questionnaire, and have a serum testosterone level drawn. The average time since diagnosis was 4.4 years (SD 3.4 years). No associations were found between the type of cancer treatment, hormonal levels, and sexual functioning. BCS sexual functioning was significantly poorer than published normal controls in all areas but desire. The BCSs' level of relationship distress was the most significant variable affecting arousal, orgasm, lubrication, satisfaction, and sexual pain. Depression and having traditional role preferences were the most important determinants of lower sexual desire. BCSs on antidepressants had higher levels of arousal and orgasm dysfunction. Women who were older had significantly more concerns about vaginal lubrication and pain. Relationship concerns, depression, and age are important influences in the development of BCS sexual dysfunction. The relationship of testosterone and sexual dysfunction needs further study with larger samples and more accurate assay techniques.

'Paper Clinics'- a model for improving delivery of outpatient colorectal services.

The overburdening of colorectal out-patient clinics necessarily leads to delays in time from referral to consultation and subsequent clinic attendance. This study aimed to ascertain the feasibility of 'paper clinic' follow-up rather than all patients receiving a routine follow-up appointment following investigation. A more efficient outpatient follow-up process should reduce unnecessary follow-up, thereby facilitating the speedy investigation and diagnosis of patients through changes in clinic profiles. From August 2001 all patients seen in the outpatient clinic of one (part time) Consultant colorectal surgeon, who required investigation, were prospectively recorded on a 'paper clinic' form. These patients were given the necessary test request forms but were not given a further outpatient appointment. The results of the investigations were reviewed, together with the patients' medical records at a formal fortnightly 'paper clinic' session carried out by the Consultant and Nurse Consultant, and a treatment plan derived. Patients then followed one of 5 follow-up pathways and were notified in writing with a copy to their GP. During a 24-month period a total of 897 patients were reviewed using the 'paper clinic' follow-up system. Of these, 285 (31.8%) patients were discharged without further follow-up. In a given 3-month period when the clinic was well established, 152 patients were reviewed, of whom 27% were discharged from follow-up, 17% received SOS appointments, 13% required further investigation (and consequently were returned to 'paper clinic' follow-up), and 7% received Nurse led follow-up. In this 3-month period 64% of patients reviewed by 'paper clinic' follow-up did not return to Surgical Outpatient's and 12% received a Surgical Outpatient appointment for review. 'Paper clinic' follow-up is an effective and feasible follow-up alternative, resulting in a major decrease in outpatient follow-up burden. This has allowed the redesign of the outpatient clinic profile allowing for an increase in new urgent slots, and more rapid clinic follow up review of those patients who need it. Re-design and rationalization of existing services can result in considerable service improvement. Expanding clinics should not be considered the only option when faced with capacity and demand issues.

Consultation audio-tapes: an information aid, and a quality assurance and research tool.

Facilities for audio-taping medical consultations are widely available, and an increasing proportion of cancer patients request and/or appreciate the offer of an audio-tape after an oncology consultation. We have examined the usefulness to patients and their families of audio-tapes of initial and follow-up consultations. We have used consultation audio-tapes as a research tool investigating doctor-patient communication. Audio-tapes may ultimately find a place as an audit tool to monitor oncologist performance. We have audio-taped several hundred medical and radiation oncology consultations over the past 10 years. We have developed methods of analysing oncologist-patient communication and studied a variety of interventions designed to enhance communication in the cancer consultation. We have offered consultation audio-tapes to cancer patients after their initial oncology consultation and after routine outpatient follow-up appointments, and documented their use. Cancer patients and their family's value consultation audio-tapes as an information aid, and to assist recall. Consultation audio-tapes document information provision and allow analysis of oncologist-patient interaction in discussion of prognosis, treatment options and seeking/giving informed consent. Consultation audio-tapes have a role in providing feedback concerning oncologist performance. Oncologists should consider installing audio-tape-recording facilities and offer new and follow-up patients a taped consultation. Audio-tapes are a valuable tool in the investigation of oncologist-patient interactions.

Wrestling with Prostate Cancer

Wrestling with Prostate Cancer

Telemedicine: a solution to the followup of rural trauma patients?

Background: Outpatient followup of rural trauma patients is problematic for physicians and patients. Our hypothesis was that telemedicine-based followup of trauma patients discharged to remote areas is feasible and is associated with high patient and physician satisfaction. Study Design: We chose 11 counties in Kentucky surrounding a remote telemedicine site as our region of interest. Any adult trauma patient who was discharged from our Level I trauma center to this geographic region was eligible to have routine followup appointment(s) at the TeleTrauma Clinic. Patients were examined and interviewed with the assistance of a nurse, an electronic stethoscope, and a close-up imaging instrument. Radiographs performed at the telemedicine site were viewed. Patients and physicians completed a survey after the appointment. Results: To date, we have conducted 22 telemedicine-based followup assessments of trauma patients. The average age and Injury Severity Score were 42 years and 18, respectively. Plain radiographs were reviewed in 13 cases. Our patient surveys indicated a high degree of satisfaction with the teleappointment. In 15 of 22 patients, no further clinical followup was arranged. The differences in travel distances and times for an appointment at the TeleTrauma Clinic versus an appointment at our Level I trauma center were significant. The average and median duration of the appointments was 14 minutes. All telemedicine encounters were done by two physicians, who recorded a high level of satisfaction. Conclusions: Our early experience with the outpatient followup of remote trauma victims by telemedicine is encouraging. Patient surveys indicate a high degree of satisfaction. As a result of our favorable experience, telemedicine-based followup may be expanded to other regions of Kentucky.

Value of contralateral surveillance mammography for primary breast cancer follow-up.

Mammographic screening of the contralateral breast is often advocated during follow-up of women previously treated for primary operable breast cancer. The purpose of this study was to determine the value of this investigation. Between 1987 and 1995 a total of 5102 contralateral screening mammograms were performed biennially on 2511 women aged </= 70 years following treatment for primary operable breast cancer. Sixty-five metachronous contralateral breast cancers were identified: 21 (32%) at routine clinical examination, 24 (37%) at mammography, and 20 (31%) by patients between routine follow-up appointments. The prognostic features of metachronous cancers were better or similar to those of the first cancer in 59 of 65 (91%) cases. Because of the favorable prognostic characteristics of the contralateral cancer, mammographic screening may have contributed to the long-term survival of 16 of 26 women in whom the histologic characteristics of the first cancer predicted a good prognosis. The cancer detection rate with mammography for these women was 6.5 per 1000 contralateral mammogram investigations at a cost of pound3852 per cancer detected. The results of this study suggest that surveillance mammography of the contralateral breast is of value in women whose first cancer predicted a favorable prognosis.

Antihypertensive treatment and patient autonomy – the follow-up appointment as a resource for care

Since hypertension is a chronic condition which generally requires long-term commitment to pharmacological therapy as well as alterations of patient lifestyle, the patient–physician communication in the clinical setting is an important determinant of the quality of care and health outcome. The aim of the present study was to explore the structure and content of the communication between the patient and the physician, and the process of decision-making at a routine follow-up appointment for hypertension. The study was based on 51 audio-recordings of authentic consultations. Most patients had a passive role in the consultations, and initiated few topics of conversation. The few topics that the patients initiated were usually not about hypertension. Patients’ questions about medication mainly referred to unwanted effects of the drugs. Little time was invested in discussing risks related to hypertension. A collaborative shared decision-making was seldom observed in the consultations.

Anemia and Serum Protein Deficiencies in Patients With Traumatic Spinal Cord Injury

This study was conducted to further investigate the natural history of the anemia, hypoproteinemia and hypoalbu- minemia commonly observed in patients with traumatic spinal cord injury (SCI). Blood samples were taken from 46 traumatic SCI patients at the time of initial admission to an acute rehabilitation hospital and again approximately one year later during a routine follow-up appointment. At initial admission, 65 percent of patients were anemic (hemoglobin <13.0 g/dl), 86.7 percent were hypoalbuminemic (albumin <3.2 g/dl) and 48.9 percent were hypoproteinemic (total protein <6.5 g/dl). Deficiencies were most commonly observed in tetraplegics and in patients with complete injuries. At the time of follow-up, 6.8 percent of patients were anemic, 2.2 percent demonstrated abnormally low serum protein concentrations and a significant (p = 0.01 ) decrease in the incidence of each deficiency was observed. Our findings suggest that anemia and decreased serum protein concentrations, while commonly observed in the acute SCI population, are much less frequently encountered in the more chronically injured. If noted in the chronic SCI patient, these deficiencies should alert clinicians to the likelihood of a concurrent process. (J Spinal Cord Med 1997; 20:335-340)

Quality of life outcomes after primary radiotherapy for squamous cell carcinoma of the base of tongue

To determine quality of life functional outcome after primary radiotherapy for carcinoma of the base of tongue. At the University of Florida, essentially all patients with squamous cell carcinoma of the base of tongue are treated with primary continuous-course, external-beam radiotherapy alone or followed by a neck dissection. Fifty-three patients who remained continuously free of disease at 2 to 23 years were eligible to participate in an assessment of the posttreatment quality of their lives. Three patients could not be located for quality of life assessment, and one patient refused to participate, leaving 49 evaluable patients. Radiotherapy doses were 60 to 75 Gy in once daily fractions, or 74 to 79 Gy in twice daily fractions. The subjective Performance Status Scale for Head and Neck Cancer, which assigns a functional score ranging from 0 to 100, was completed by each of the patients during routine follow-up appointments. The scale measures ability to eat in public, understandability of speech, and normalcy of diet. Patients treated with external-beam radiotherapy alone had excellent results with regard to eating in public though scores showed a decline as T stage increased (average scores were T1: 90.6%; T2: 88.1%; T3: 82.8%; T4: 75.0%). Results for understandability of speech were T1: 93.75%; T2: 100%; T3: 82.8%; and T4: 87.5%. Fixation of the tongue at diagnosis was not a predictor of poor function. Normalcy of diet scores likewise decreased with increasing T stage: T1: 93.8%; T2: 89.5%; T3: 71.3%; T4: 60.0%. The addition of a neck dissection had no impact on the functional outcomes that were evaluated. Functional results did not deteriorate with prolonged follow-up of more than 5 years. Results were compared with those from the literature for patients treated by surgery plus postoperative radiotherapy or external-beam irradiation plus interstitial 192Ir implant. The functional results of high-dose external-beam irradiation alone in the present series were similar to those reported after external plus interstitial irradiation. The functional results after both types of radiation treatment were superior to results for patients who underwent surgery. Functional outcomes after external-beam radiotherapy were similar to those after external-beam plus 192Ir implant, and were superior to the results of surgical resection. Planned postradiotherapy neck dissection did not affect the analyzed functional endpoints. Function appeared to be stable by 5 years without subsequent change.

Experience with varicose vein surgery in a day surgical centre

The Vascular Surgery Department at the Royal North Shore Hospital commenced a day-only surgery programme to expedite the treatment of patients with varicose veins and to reduce the waiting list for these procedures. The aim was also to assess the efficacy of the Day Surgery Centre (DSC) in reducing the waiting list for varicose vein surgery and to evaluate the acceptability of day only surgery, and the results of that surgery, for both surgeon and patient. We conducted a retrospective review of 73 patients who had had varicose vein surgery in the DSC since its use by the vascular unit in January 1992. The operations were performed by a consultant vascular surgeon or fellow in vascular surgery. The patients were reviewed at 1 and 6 weeks postoperatively. Seventy-three patients had their operations in the DSC, 16 of these patients had intercurrent medical illnesses. The surgical procedures took a median of 73 min and the median postoperative time until readiness for discharge was 159 min. All patients were able to be discharged on the day of surgery. At follow-up 20 patients had some postoperative difficulty. Seventy percent of the patients with cosmesis as a presenting symptom failed to attend the routine follow-up appointments. The increase in the DSC utilization rate from 23% in the first 12 months to 60% in the last 12 months of the study reduced the waiting list time from 300 days in 1992 to 68 days in 1994. This median decrease of 7.8 months is significant (95% confidence limits 3.7–12.5 months). The subgroup of patients who failed to attend the routine follow-up appointments emphasizes the psychosocial, as well as the physical, aspects of the surgical problems of varicose vein sufferers in the community. This experience demonstrates that varicose vein surgery in the DSC is a safe and efficacious approach to the modern management of varicose veins, and since its introduction has resulted in a significant reduction in the waiting list for this surgery.

Effective service for outpatient clinics.

Routine follow-up appointments following hospital admission or initial clinic referral should be avoided and, if initiated, a precise reason for the appointment should be identified.

The trend of breast‐feeding in a primary child care program

The tendency toward the practice of breastfeeding during 1969-81 was evaluated in the Brazilian population served by the Primary Child Health Care Program developed by the Communitary Social Medical Center of Vila Lobato (CSMCVL). The purpose was to evaluate the influence of several measures taken to encourage the breastfeeding practice in the assisted population whether these be internal administrative measures of the CSMCVL or part of the official federal or state policies. The study of children matriculated in 1977 permits the evaluation of 2 additional supporting measures added to the original program: 1) the provision of a nutritional supplement called Gestal to the mothers consisting of a mixture of soya beans and dehydrated cow milk; and 2) the provision of integral dehydrated cow milk as powder during 18 months as a reward for the children who were fed exclusively with breast milk and who had not missed any routine followup appointment in the 1st 6 months of life. In 1980 there was a massive campaign through the social communication systems about the advantages of breastfeeding. The population assisted by CSMCVL is a low income population with low maternal educational level. Overall there was great increase in lactation frequencies over the 1st months. The greatest increase occurred after 1977 when Gestal was supplied to the nursing mothers as a reward. The official campaigns also helped to raise the frequency of breastfeeding in the 1st 6 months of life. Hypogalactia weak milk or little milk were the most frequent reasons cited for early weaning. Orientation and followup of the nursing mothers are important to avoid situations that may lead to premature weaning. The main objective of the program to increase breastfeeding was reached. Maintenance of the increased level of breastfeeding should be supported by incorporating the practice into the cultural values of the population. Legal and social protection of nursing mothers is also needed without the authoritarian and paternalistic measures used as incentives.