Method and resultsDetails of 400 consecutive new patients were entered onto the spreadsheet, and analysed by diagnostic group and follow-up pattern. The results were compared with historical data (Bamji, Dieppe, Haslock and Shipley) and against contemporary audit data from a neighbouring hospital (Yanni, personal communication).

Numbers. ia: inflammatory arthritis (141) ; sp: spinal condition (neck/back pain) (65); bo: bone disorder (9); cr: crystal arthritis (5); sh: shoulder disorder (28); oa: osteoarthritis (any site) (51); st: soft tissue injury excl shoulder (81); ot: non-rheum diagnosis(7); qd: diagnosis uncertain (9); cp: chronic pain syndrome (4); total 400

As expected, follow-up was heavily biased towards RA and IJD. Analysis also showed that these categories tended to earlier follow-up than other conditions. Reasons for not booking follow-ups varied; for some conditions (e.g. back pain) a onward referral to physiotherapy was the primary reason while for others appointments were “suspended” pending investigations or were booked to reassess after investigation, and initial treatment.

The results confirmed that “one-stop” patients would not generally be followed up; overall 53% of patients received no immediate follow-up appointment. 85% of patients with inflammatory conditions including RA did get a further appointment ( a slight underestimate because some patients had “suspended” appointments pending investigation) , but only 20% of non-inflammatory conditions received one. It thus became clear that the difference in overall new-follow-up ratio between Queen Mary’s and Lewisham could be at least partly accounted for on the basis of a difference in casemix, as shown below.

Diagnostic category casemix comparison between Lewisham Hospital (100 consecutive referrals) and QMH Sidcup (400 referrals). The relative proportions of IA (likely to generate follow-up) and back pain (one-stop) are reversed (Lewisham data courtesy of Dr Ghada Yanni)

Anna Litwic*, Andrew Bamji$, $ Queen Mary's Hospital, Sidcup, Kent DA14 6LT and *Queen Alexandra Hospital, Portsmouth PO6 3LY

ReferencesBamji A, Dieppe P, Haslock I, Shipley M. What do Rheumatologists do? A Pilot Audit Study. Br J Rheumatol 1990, 24, 295-8

Correspondence: andrew.bamji@qms.nhs.uk

ConclusionA historical comparison of casemix indicates that (1) it is possible to change patterns of practice (2) a substantial proportion of patients seen does not require any follow-up (3) use of crude new:follow-up ratios to compare hospital performance will mislead if it fails to account for casemix differences but (4) any shift of caseload away from a “traditional” mix of IJD and non-inflammatory musculoskeletal conditions will change follow-up patterns and may concentrate care on more complex and thus more expensive conditions.

Data collectionThe rheumatology department at Queen Mary’s Sidcup has developed a simple Excel spreadsheet for recording patients on long-term follow-up, with data on patient age, PCT origin, diagnosis, treatment, length of follow-up and time to next appointment. Onto this have been added separate analysis sheets for audit projects; in addition to a breakdown of casemix – RA, other inflammatory joint disease (IJD) and non-inflammatory conditions (NIC) that are in long-term follow-up – we collect data on new referrals, discharges (by cause) and patients on biologic agents. The spreadsheet also allows automatic calculation of the Disease Activity Score (DAS). Thus at any time we can take a snapshot of clinic activity, track changes in follow-up pattern and check new patient casemix. The database template is available through the department’s website at

www.sidcuprheum.org.uk/bsractionplan.html

We expected that arranged follow-up from first consultation would be skewed in favour of RA and IJD but were not clear why our new:follow-up ratio (1:4.2) was twice that of a neighbouring unit (Lewisham University Hospital, 1:2.1) which we assumed would have a similar casemix. We also wished to confirm that patients with NIC, soft tissue lesions, shoulder pain and spinal conditions were indeed treated in a “one-stop” fashion rather than simply relying on an assumption that this was the case - though this was likely from the numbers in follow-up which were

RA 529

IJD (including seronegative arthritis, SLE, vasculitis,JIA) 473

NIC 56

The numbers in follow-up are not necessarily directly related to appointment numbers; patients in an unstable state will have more frequent appointments and the offer of emergency open-access will also increase overall numbers.

IntroductionThe costs of secondary care should be justified by analysis of patient outcomes. There is a perception that many patients seen in hospital outpatient clinics are followed up unnecessarily and for protracted periods; thus pressure is applied to rheumatology departments to reduce follow-up numbers with the aim of saving money. The ways in which this has been approached are crude and often based on attempts to align departments’ ratios of new:follow-up appointments. Such policies may conflict with disease management guidelines and it is thus important to understand the casemix of one’s department and the likely effects of this on the need for continuing follow-up. In addition an analysis of new patient casemix can provide useful information on the numbers of “one-stop” appointments.

It is also necessary to audit changes in follow-up patterns if new policies are adopted. The collection of such data allows explanation of practice, change and differences between units and may enable the successful defence of traditional outpatient care. Ongoing analysis of new patient referrals will also detect changes that occur as the result of outside pressures, such as the introduction of referral management systems or the development of alternative provision.

In 1990 we noted differences between centres in the numbers of new patients seen with specific diagnoses as shown on the graph below.

Comparison of SE London (SEL), The Middlesex (L), Bristol Royal Infirmary (Br) & Middlesbrough (Mi) Hospitals (from Bamji, Dieppe, Haslock & Shipley, 1990) . NT

and T refer to teaching hospital status. IA includes RA & IJD

Direct comparison of data from a single unit (QMH) shows that there has been a significant shift in casemix pattern.

We assumed this could be accounted for in particular by the introduction of a physiotherapy-led back pain triage service which significantly reduced the numbers of spinal disorders attending the rheumatology new patient clinic – which also explains the disparity with Lewisham Hospital, which at the time of analysis did not run such a service. In one year nearly 1500 patients were seen in the QMH triage service. We calculated that, if they had been included within the rheumatology figures, the new:follow-up ratio would have reduced from 1:4.2 to 1:1.7 on the basis of expected outcome and follow-up pattern. This underlines the dangers of uncritical comparison of crude outpatient figures as a basis for planning care and the need to include casemix in any comparative exercise.

However it is apparent that the major change in percentage terms has been the reduction in numbers of soft tissue and shoulder problems seen. Discussion with local GPs indicates that this is due to an increased number of these problems being treated in general practice. The relatively minor shift in OA/spine new patients may also reflect the deliberate withdrawal of low back pain patients from the orthopaedic service; those still seen in rheumatology also include patients who have been through the triage service once and for whom automatic triage straight to rheumatology is indicated according to the service protocol.

Figures from 1990 (1) show clearly that IA attracts a much higher new;follow-up ratio than NIC and, indeed, our results show that this remains the case. However we decided to target follow-up in an attempt to reduce the number of IA follow-up patients (as requested by one PCT) using clinical criteria. These were:

•Elongation of F/U interval where appropriate

•Compliance with BSR guideline of minimum 1 review/yr

•Discharge if stable for > 3yr unless on biologic agents (approx 230 IA patients)

The graphs indicates the success of this measure; however the overall reduction in F/U appointment numbers did not reach the level requested by the PCT – largely because the area for maximum impact (NI) was the smallest group.

Follow-up or discharge? A new patient outcome analysis

New patient comparison between units 1990

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Graphs showing the change in follow-up patterns as the result of explicit decision-making on the need for continuing care for RA (top) other IJD (middle) and NI (bottom) between October 2006 and March 2008. The X-axis indicates the time to next appointment; the Y-axis indicates numbers of patients.

The former two groups show a “shift to the right” implying that patients with IA are being seen less frequently. The latter shows a substantial drop in the total of NI patients remaining in regular follow-up – but represents only 5.6% of the total follow-up group.

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