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When it comes to follow-up doctor visits, the variation is wide and evidence slim

Often we raise questions about the value of high tech, expensive specialty services, but we also frequently ask whether all the services we provide as primary care clinicians — screening tests, routine physicals, and other items from the Choosing Wisely campaign — improve care.

This recent JAMA article , which has gotten a lot of attention, raises questions about one of the most basic things we do as clinicians: patient visits. The article asks the question, What is the appropriate follow-up interval for patients?

The answer, of course, is that it depends on the situation. But what struck us about this article was how little is known about this topic. It is clear there are few evidence-based answers here. But we know from the Dartmouth Atlas of Health Care and other data sources that there is a wide variation in how frequently clinicians see their patients, and more frequent visits often do not correlate with better outcomes. In fact, visit frequency seems to be driven most strongly by payment structure, with fee-for-service systems resulting in shorter visit intervals.

Another important message from this article is that there is an opportunity for us to be more efficient as clinicians and to make accessing health care easier for patients by providing more telephone care, email, and patient portal communication. We recently learned that in the Kaiser system, approximately half of patient touches are by phone or portal.

If you have the time, take a look at this article, not because it provides any clear answers but rather because it will get you thinking about whether doctors can provide a bit more of patient care by phone or portal and email. We have found that patients are incredibly appreciative when you call them with test results rather than schedule a follow up visit, which has the added benefit of making our job as clinicians even more rewarding!

Top image by Oliver Symens  via Flickr .

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How Top Doctors Follow Up After an Appointment

You might invest in marketing to attract new patients and provide excellent care during each and every appointment. But if you don’t excel at follow-up, your practice could still be falling short of its potential.

From the patient perspective, follow-up is key to understanding medical care. A study published in Mayo Clinic Proceedings  found that, within four to 18 days after being discharged from the hospital,  just 64 percent of patients could name their new medication(s) or understand their purpose. What’s more, only 56 percent of these patients could remember their medication dosages, and a mere 11 percent could recall being informed about their medications’ potential adverse effects.

High-quality providers understand that follow-up has other benefits, too. It can strengthen the patient-provider relationship, help patients get involved in their own treatment, and even serve as a marketing tool for the practice. If you’re ready to amplify your follow-up game, use these 5 tips to get started.

Follow up every time

Top physicians don’t just follow up when it’s necessary; they touch base with a patient after each appointment. You’re already doing necessary follow-up to share abnormal lab results or schedule additional appointments, b ut what about follow-up after routine examinations? Quickly check in with patients after every visit to see how they’re feeling and answer any lingering questions. The exceptional service and your attention to detail will stand out.

Use this same philosophy when sharing lab results. Most patients think that no news is good news when it comes to medical tests, but a lack of follow-up could signal that the physician hasn’t reviewed the results yet. Not only is this poor practice, but it could pose a serious health risk to patients, as found in a 2012 review paper of 760 articles.  Following up on lab results every time puts your patients at ease and helps ensure you don’t accidentally miss reviewing their results.

Make follow-up interactive

There is a large opportunity to use follow-up as a tool to help patients become more actively engaged in their healthcare. For example, you could  point patients to an app that encourages regular blood pressure checks as a way to keep your treatment plan top-of-mind.

Giving homework after an appointment creates an opportunity for follow-up since you can reach out to ask patients if they have any questions about their assignment. This approach also means that patients will come to their next appointments with additional health information to share.

Use several communication methods

Chatting on the phone is the most appropriate way to follow up after certain appointments, and it may feel most natural to some patients. However, feel free to explore the other options. Consider using email or text messages to follow up after routine appointments so patients can respond at their convenience.

You can even semi-automate the process, crafting a few brief template emails or SMS notifications that can be customized in seconds. A small time investment up front can help streamline your process for years.

Turn follow-up into feedback

Following up isn’t only a great way to enhance the patient experience, it can also be a powerful tool for your practice. Email your patients a satisfaction survey after their appointment to help you identify what you’re doing right (and wrong) and catch any patient complaints early.

You may get a glowing review that you could, with permission, use as a testimonial to bring in more business. Sending a survey may also create an opportunity to smooth over a relationship with an upset patient before you lose them .

Keep the conversation going

A strong plan for following up can turn one-time appointments into long-term patients ,  the lifeblood of a successful specialty practice. Follow up to remind patients about upcoming routine appointments, and keep your client base engaged with a monthly or quarterly email newsletter full of helpful and shareable information.

Ongoing communication merges follow-up with marketing, allowing you to advertise your practice and boost patient retention in a way that feels organic and authentic.

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It's Important to Follow-up with Your Doctor

Some patients, unfortunately, don't get better after the first doctor's appointment, and an estimated 30 percent of patients don't even fill their prescriptions. If your condition doesn't improve, your doctor needs to know. Women's health expert Dr. Kirtly Parker Jones talks about the importance of following up with your doctor after an initial visit.

Episode Transcript

So you went to the doctor for a problem, doctor made a plan, and you may have followed the plan or maybe you didn't, but you never told the doctor that it didn't get better. This is why follow-up is so important.

So it turns out that often people come to their physician, and in this case, for me, it's a gynecologist, and they have a problem. Let's just pick hot flashes. They come in, they have hot flashes, I talk about hot flashes, and I say, "I think you're a good candidate for some estrogen." And I write them a prescription, and I send them home. And I think I'm the best, smartest doctor that ever was because I didn't see them again. Now, what possibly happened?

Statistically, 50% of those patients, they get a prescription for hormones, and this is just this particular kind of problem, but get a prescription for hormones, don't ever fill it. Do I know that? No, I don't know. My system doesn't tell me with a little alert on their electronic health record that she didn't ever fill it. So I don't know she didn't fill it. What happened if she filled it and took it and it didn't help, but she thinks I'm a bad doctor because I gave her something and she didn't come back? I have lots of other tools in my toolkit, but if I don't know from her that she isn't better, then I can't do anything.

So follow-up is a difficult thing, because it has to do with failure. It has to do with communication. So in the case of the thing that I know best, which is hot flashes, I may have not really gotten to the bottom of what this patient's primary concern is. Maybe her primary concern is that she's not a woman anymore, or maybe her primary concern is that these hot flashes make her cranky and she's angry at her family, and this is really not about hot flashes, but that's what brought her in. I heard hot flashes. She's a woman of the right age. I prescribed a medication that usually works, and I sent her home happily according to me, but she's not happy. And this is where follow-up is important.

Now, the question is, whose responsibility is it to follow up? I personally think it's my electronic health record, because the electronic health record should give me a ping if my patient didn't follow up the prescription. I think my electronic health record should send out a little reminder to my patient, "Dr. Jones gave you a prescription three days ago for the problem that you saw her for. Did you get better? If you got better, keep taking it. If you didn't get better, please call. If you got better but you're having side effects, make a follow-up appointment so we can talk about alternatives." This is something that would be so easy for an electronic health record to do, and we get all these telephone calls anyway about what we thought about our doctor and what we thought about the clinic. So why not have a little reminder, "Your doctor gave you a prescription. Did you fill it? If you filled it and it didn't work, push 1. If you filled it and it did work, push 2. If you filled it and you had side effects, push 3, which it will get you right to my nurse."

So if your electronic health record doesn't do this, and the vast majority don't, what should you do if it doesn't work? You should let us know. So if you didn't fill it but you're still symptomatic because you had questions that weren't answered, call my nurse, ask those questions on our private email, or come back and see me. If you took it and did fill it and it worked, well, just keep taking it, and I'll see you in a year. If you took it and you had a side effect, I want to hear about that, because it turns out I have a whole bunch of other things in my tool case that we could try.

So I used the paradigm for hot flashes. I could have used it for any one of a number of common problems. But follow-up is important on my part, and follow-up is important on your part. And don't just give up because you tried once, because we have a lot of Plan B's. So keep thinking about it, learn more, come back and see me, and thanks for joining us on The Scope.

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Follow-Up Medical Care

Once you’re done with cancer treatment, you should receive a follow-up cancer care plan from your doctor and keep it with your medical records.

All cancer survivors should have follow-up care . Follow-up care for cancer means seeing a health care provider for regular medical check-ups once you're done with treatment.

These check-ups may include bloodwork, as well as other tests and procedures that look for changes in your health or any problems that may occur due to your cancer treatment. These visits are also a time to check for physical and emotional problems that may occur months or years after treatment ends.

Your follow-up care plan , along with a summary of your cancer treatment, is part of what is called a survivorship care plan . This plan will have all the details that you and your doctor should discuss to ensure that you get regular care after your treatment ends.

Note that the information in this section focuses on follow-up care for your cancer treatment. But it’s important that you keep getting your routine care from your primary care provider in addition to follow-up cancer care.

Getting a Follow-Up Care Plan

Once your cancer treatment ends, you should receive a follow-up cancer care plan from your oncologist or someone on your treatment team. A follow-up care plan is a summary of your treatment, along with recommendations for your cancer care after treatment ends. Your plan may also include suggestions to help meet other needs, such as emotional, social, or financial issues. 

Choose which doctor to see after treatment. For follow-up cancer care, you may see the same doctor who treated you for cancer or you may see another health care provider, such as one who specializes in follow-up care for cancer survivors. Or you may decide to go to your primary care doctor. You can discuss which doctor(s) to see with your health care team.

Ask each doctor you see to share notes with your other doctors. Keep in mind that once you choose which doctor to see, it may be up to you or a loved one to make sure each doctor communicates with the other about your care. Some research has shown that sometimes treatments or tests with one doctor aren't shared with the other doctor. Make sure to ask both your doctors to send clinic visit notes to each other. Although it creates an extra step for you, it's important that everyone taking care of you be on the same page. 

Follow-up care for childhood cancer survivors is very similar to the steps for adults. While most of the information below is equally important for children, see Care for Childhood Cancer Survivors for more tips.

Common Questions after Treatment Ends

When you receive your follow-up care plan from your doctor or other health care provider, answers to the questions below should be provided. Make sure to ask any other questions you may have:

• How long will it take for me to get better and feel more like myself?
• Which doctor(s) should I see for my follow-up care? How often?
• What symptoms should I watch out for?
• What tests do I need after treatment is over? How often will I have them?
• What are long-term health issues I might expect as a result of my cancer treatment?
• What is the chance that my cancer will return?
• What records do I need to keep about my treatment?
• What can I do to take care of myself and be as healthy as possible?
• Can you suggest a support group that might help me?

You might find it helpful to write these questions down. When you meet with the doctor or follow-up care specialist, you can take notes or record your talks to refer to later. Talk about any concerns you have related to your follow-up care plan.

Your Follow-Up Care Schedule

Each patient has a different follow-up care schedule. How often you return for follow-up visits is based on:

• the type of cancer you had
• the treatment you received
• your overall health, including possible treatment-related problems

In general, people return to the doctor for follow-up appointments every 3 to 4 months during the first 2 to 3 years after treatment, and once or twice a year after that.

At these visits, you may have a physical exam along with blood tests and other necessary tests and procedures. Which tests you receive and how often you receive them will be based on what your doctor thinks is best for you when creating your follow-up care plan.

Survivorship Clinics

Some cancer centers and hospitals have programs that specialize in long-term follow-up care for cancer survivors. Many NCI-Designated Cancer Centers and large community treatment centers offer some form of survivorship program or clinic for adults who have been treated for cancer. Also, the cancer education website OncoLink has a searchable database of survivorship clinics across the United States.

For children and adolescents, NCI’s Office of Cancer Survivorship provides information on where to get follow-up care after treatment, in addition to other posttreatment resources. In addition, the National Children's Cancer Society also provides a list of long-term follow-up care clinics for children who have had cancer.

What to Tell Your Doctor during Follow-Up Visits

When you meet with your doctor for follow-up visits, it’s important to talk openly about any physical or emotional problems you’re having. Always mention any symptoms, pain, or concerns that are new or that won’t go away. Or sometimes people have depression that lasts after treatment. Your doctor needs to know about it so they can help you.

Keep in mind that just because you have new symptoms, it doesn’t necessarily mean the cancer has come back. It’s normal to have fears about every ache and pain that arises, but they may just be problems that your doctor can easily address.

Some cancer treatments can cause problems that may not show up for months or years after treatment. These problems, called late effect s, are specific to certain types of treatments and the dose received. When you discuss follow-up care with your doctor, they should talk with you about which late effects to watch for. Early medical attention can help reduce problems that may come from late effects. See Late Side Effects of Cancer Treatment  to learn more.

Other things you should tell your doctor:

• problems with bladder, bowel, or sexual function
• trouble concentrating or memory changes
• trouble sleeping
• weight gain or loss
• any new medicines, vitamins, herbs, or supplements you’re taking
• changes in your family medical history
• any emotional problems you’re having, such as anxiety, excessive worrying, or depression

It’s important to be aware of any changes in your health between scheduled visits . Report any problems to your doctor immediately. They can decide whether the problems are related to the cancer, the treatment you received, or an unrelated health issue.

Your Treatment Summary

Your oncologist or a member of your treatment team should give you a written summary of the treatment you received. Keep this with you to share with your primary care doctor and any other doctors you see. Many people keep their treatment summary in a binder or folder, along with their medical records. This way, key facts about your treatment will always be together.

It's important to always keep your treatment summary somewhere safe in case you need it years later. It's also helpful to keep records of any medical visits you ever have, so you have them in the future. If your primary care doctor keeps electronic medical record s, find out how you can access these when needed.

Types of Health Information in the Treatment Summary

• the date you were diagnosed
• p athology report (s) that describe the type and stage of cancer in detail
• places and dates of each treatment, such as the details of all surgeries, the sites and total amounts of radiation therapy, and the names and doses of chemotherapy and all other drugs
• key lab reports, x-ray reports, CT scans , and MRI reports
• list of signs and symptoms to watch for and possible long-term effects of treatment
• contact information for all health professionals involved in your treatment
• any problems that occurred during or after treatment
• any supportive care you received during treatment (such as medicines for depression or anxiety, emotional support, and nutritional supplements )

Be an active partner. Many cancer survivors say that getting involved with their follow-up care was a good way for them to regain some of the control they felt they lost during cancer treatment. Being an active partner with your doctor and asking for help from other members of the health care team is the first step. Knowing what to expect after cancer treatment can help you and your family make plans, lifestyle changes, and important decisions about the future.

Guidelines and Care Plans for Follow-Up Care

The following programs or organizations provide helpful follow-up care guidelines for some cancers. You can use them to help you talk with your doctor, but they aren't meant to take the place of your doctor's knowledge or judgment.

The American Society of Clinical Oncology (ASCO) provides care plans and follow-up care guidelines for cancer survivors.

The Children’s Oncology Group , an NCI-supported clinical trials group, offers long-term follow-up guidelines for survivors of childhood, adolescent, and young adult cancers. It also has a series of fact sheets called Health Links , which provide information for healthy living after childhood cancer.

The OncoLife Survivorship Care Plan was developed by Livestrong and the University of Pennsylvania. It provides survivors of adult cancers with a personalized survivorship care plan, based on the information they enter into an online program. They also have the  Smart Adult Living After Childhood Cancer (SMART ALACC) , a personalized care plan for childhood cancer survivors. 

The National Comprehensive Cancer Network (NCCN) includes information about follow-up care for cancer and has a series of NCCN Guidelines for Patients® on survivorship topics, including living a healthy lifestyle and cancer-related  late and long-term effects . 

Tips for Healthy Living

Exercise Linked to Better Survival from Breast Cancer

Regular physical activity before or after diagnosis found to be beneficial.

Both during and after cancer treatment, many people want to find ways to reduce the chances of their cancer coming back. Some worry that the way they eat, the stress in their lives, or their exposure to chemicals may put them at risk for recurrence.

Cancer survivors find that this is a time when they look at how they can take care of themselves and what steps to take to live a healthier life.

Talk to your doctor about ways to take care of yourself. Ask your doctor about making a survivorship care plan that includes ways you can take care of your physical, emotional, and spiritual needs. They may also suggest another member of the health care team for you to talk with about wellness, such as a social worker , nutritionist , clergy member, or nurse.

Some General Tips for All Cancer Survivors Include:

Quit smoking.  Smoking after cancer treatment can increase the chances of getting cancer at the same or a different site.

Cut down on how much alcohol you drink.  Drinking alcohol increases the risk of certain cancers.

Eat a balanced diet.  A healthy and balanced diet is important for overall wellness. Talk with your doctor or nurse to find out about any special dietary needs that you may have. You could also ask if you should talk to a nutritionist for guidance on eating a healthy diet. To learn more, see  Nutrition from the National Library of Medicine. 

Stay up to date with screenings and vaccines. Ask your doctor what cancer screenings you should have and when. It's also important to know what vaccines you need. 

Always use sunscreen . To decrease your risk of skin cancer, always use sunscreen and avoid tanning beds.

Exercise and stay active.  Research suggests that staying active after cancer may help lower the risk of recurrence and lead to longer survival. In addition, moderate exercise (walking, biking, swimming) for about 30 minutes every—or almost every—day can:

• reduce anxiety and depression
• improve mood and boost self-esteem
• reduce fatigue, nausea, pain, and diarrhea

It’s important to start an exercise program slowly and increase activity over time. Some people may need to take special care when starting new. Talk with your doctor before you begin any exercise program. You may choose to work with a physical therapist or other specialist for more help.

If you need to stay in bed during your recovery, even doing small activities can help. Stretching or moving your arms or legs can help you stay flexible and relieve muscle tension.

On a broader level, for patients, families, and providers, the American Society of Clinical Oncology's Survivorship Care Compendium offers a collection of resources and tools for survivorship care programs and education. 

Research in Follow-Up Care

NCI recognizes the importance of follow-up care after cancer treatment. Below are examples of NCI-supported research to improve the lives of cancer survivors.

Childhood Cancer Survivor Study (CCSS) : The CCSS was created to gain new knowledge and educate cancer survivors about the long-term effects of cancer and cancer therapy, and to provide information about follow-up care.

Follow-up Care Use Among Survivors (FOCUS) : The FOCUS survey was created to better understand the many aspects and quality of follow-up care, to document the prevalence of late and long-term effects of cancer and its treatment, to understand survivors’ knowledge of late and long-term effects, and to study health-related quality of life and behaviors in long-term survivors.

Healthcare Delivery Research Program (HDRP) : The HDRP was established by NCI’s Division of Cancer Control and Population Sciences in January 2015 to advance innovative research to improve the delivery of cancer-related care and follow-up care.

Survey of Physician Attitudes Regarding the Care of Cancer Survivors (SPARCCS) : The purpose of the SPARCCS study was to identify perceptions, knowledge, and practices of primary care and oncology specialist physicians about follow-up care of adult cancer survivors after treatment.

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• v.35(6); 2020 Jun

The Relationship Between Follow-up Appointments and Access to Primary Care

Megan e. price.

1 Partnered Evidence-based Policy Resource Center, US Department of Veterans Affairs, VA Boston Healthcare System, Boston, MA USA

Nicolae Done

2 Analysis Group, Boston, USA

3 Department of Psychiatry, Boston University School of Medicine, Boston, USA

Steven D. Pizer

4 Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, USA

Associated Data

Health care operations managers need to balance scheduling frequent follow-ups for patients with chronic conditions and fitting in patients requiring care for new complaints.

We quantify how frequency of follow-up visits corresponds with access to care for patients receiving care from the Department of Veterans Affairs (VA).

We use patient data collected between October 2013 and June 2016 by the Survey of Healthcare Experiences of Patients (SHEP). Our sample is comprised of 94,496 patients. We estimate logistic models with 1-month lagged facility-level predictors.

Main Measures

We calculate monthly measures characterizing facility-level service provision, including the average time between successive primary care visits, the average primary care visit length, the percentage of primary care appointments that are overbooked, the percent of visits that are unscheduled (i.e., walk-ins), and the ratio of patients to providers. We control for economic factors that are associated with health care supply and demand, including median household income, veteran priority status, the Zillow Housing Price Index, and veteran unemployment rates. We also control for patient demographics.

We restrict the data to patients with at least one in-person primary care visit who have provided information on their ability to access urgent and routine care.

Key Results

We find that shorter average follow-up times are associated with better access for patients needing urgent or routine care. A 1-month increase in the average time between successive primary care visits is associated with 10% ( p  < 0.001) lower odds of reporting being able to access urgent care within 1 day and 13% ( p  < 0.001) lower odds of reporting usually or always being able to access routine care when needed.

Facilities with higher average follow-up times are more likely to have patients report that they are unable to quickly access urgent or routine primary care.

Electronic supplementary material

The online version of this article (10.1007/s11606-020-05785-3) contains supplementary material, which is available to authorized users.

INTRODUCTION

Timely access to care is one of the essential features of a high-quality health care system. 1 Wait times in the Department of Veterans Affairs (VA) health care system are strongly associated with patient satisfaction 2 , 3 and local market characteristics. 4 However, primary care clinics balance the provision of care for many patients with a variety of medical conditions, treatment needs, and preferences. US veterans use ambulatory primary care services for a wide-ranging set of reasons, including routine care, mental health, minor but urgent health problems, and referrals to more advanced specialty services. Facilities must optimize operations to provide access for those with chronic conditions who need regular follow-up visits and patients seeking urgent care for more acute complaints. Moreover, facilities face constrained budgets and shortages of primary care providers, which hampers their ability to quickly adapt their supply to fluctuations in service demand.

In this paper, we quantify the relationship between measures of facility operations and patients’ self-reported access to care in VA clinics at the national level. By combining VA facility-level data with nationally representative surveys on patient experiences and local market characteristics, we can assess how several operational metrics are associated with patient access to care. Evidence suggests that patients’ satisfaction with access to care depends on whether care is needed right away or a check-up is needed instead. For example, patients’ willingness to wait for more than 1 day to see their regular physician may differ based on whether they have an acute or a routine problem. 5 Therefore, we use patients’ self-reported access to both urgent and routine appointments to assess whether facility operations variables may have differential associations with these measures. In previous studies, several patient characteristics have also been found to be associated with patient satisfaction including demographic factors, socioeconomic status, and general health status. 6 , 7

Primary care clinics have several ways of adjusting to variations in demand. First, they may schedule shorter appointments. In the VA, this strategy is restricted, as appointments typically can be scheduled for either 30 min (for returning patients) or 60 min (for new patients). Second, VA facilities often allow patients to show up for unscheduled appointments and will provide care in the event of no-shows or canceled appointments from other patients. Third, facilities differ in the extent to which they overbook appointments, thus anticipating no-shows and last-minute cancelations.

We assume that some of the differences in operations variables, such as follow-up time, appointment length, and overbooked/unscheduled appointments, are due to varying congestion and differences between facilities in prioritizing different appointment types. We account for all these factors in our analysis in order to isolate the relationships of interest. Finally, we account for several quality measures based on the HEDIS methodology, 8 also calculated at the facility level.

Patient Sample

Our sample is comprised of patients receiving primary care at one of 127 facilities in the VA who completed a questionnaire on patient experiences delivered through the Survey of Healthcare Experiences of Patients (SHEP). SHEP is an ongoing nationwide survey that seeks to obtain patient feedback on experiences with recent episodes of care in the VA and is modeled after the Consumer Assessment of Healthcare Providers and Systems (CAHPS) family of survey instruments.

The outpatient SHEP component selects a simple random sample of patients with completed appointments at VA facilities each month. We matched the last completed appointment date and location recorded by the VA to match individuals in the SHEP sample to visit month and facility where the visit occurred.

Patient-Reported Access

We obtained self-reported indicators of patient experiences with access to care from the SHEP survey. We use the responses regarding the patients’ ability to obtain an appointment for urgent and routine primary care for patients who have completed an in-person visit at one of the VA facilities. Our dependent variables for urgent and routine care are aggregated facility-level survey responses.

The question for urgent care is worded as “In the last 12 months, how many days did you usually have to wait for an appointment when you needed care right away?” Response options are as follows: same day, 1 day, 2 to 3 days, 4 to 7 days, or more than 7 days. We label the “same day” response for urgent care as “could get urgent care same day,” and the union of “same day” and “1 day” responses as “could get urgent care within 1 day.”

The survey question for routine care is worded as “In the past 12 months, when you made an appointment for a check-up or routine care with this provider, how often did you get an appointment as soon as you needed?” Response options are as follows: never, sometimes, usually, always. We label the “always” response as “could get routine care, always,” and the union of the “always” and “usually” responses as “could get routine care, usually/always.”

The survey also collects a comprehensive set of patient characteristics, including age, gender, race and ethnicity, educational attainment, and first spoken language. We control for these characteristics in all our models.

Facility Operation Measures

We used the VA Corporate Data Warehouse (CDW) to extract information on primary care appointments and visits between October 2013 and June 2016. This information included the facility and date of each appointment, as well as indicators for whether the appointment was overbooked or a patient visit was unscheduled. We calculated the monthly mean appointment length at the facility level in minutes by averaging individual appointment length. We obtained monthly mean follow-up time by averaging the time in days between a follow-up appointment and its corresponding initial visit. We also calculated the percent of overbooked appointments and unscheduled visits at the facility level during a given month.

To account for variation in the supply of services at each facility, we controlled for the ratio of full-time-equivalent primary care providers assigned to patient panels 9 and patients enrolled at each facility. To mitigate the potential problem of endogeneity between patient experience with access to care and facility performance indicators, we lagged facility-level operations variables by 1 month. To assess if the relationship varied throughout the distribution, we constructed indicators of quartiles of the lagged facility-level variables and used these indicators as independent variables in the logistic models.

Local Market Characteristics

We controlled for local market characteristics that are related to veteran choice to seek VA care as opposed to community care. 4 These include median household income, the Zillow Home Value Index, 10 and veteran unemployment rates. To assess access to care outside the VA, we added Medicare Advantage Penetration—which signifies the density of private insurers in the area. We also controlled for the percent of veterans at the facility who pay copayments (priority status 7 and 8); copayment eligibility is determined by disability status and a means test. This variable was included both at a facility-level average to account for area economic characteristics, and at an individual level to account for individual attributes within the community.

Health Care Quality Measures

Facilities balancing the trade-off between more frequent follow-ups for existing patients and fitting in new patient and urgent care appointments must do so while trying not to compromise health care quality. We therefore control for a set of quality measures equivalent to the HEDIS measures used in private health plan assessments, adapted for the VA. We include a wide set of measures that capture the complexity of outpatient primary care services in a multi-faceted manner. These measures (defined formally in Appendix Table A1 ) include rates of guideline-concordant blood pressure and cholesterol management, and glycosylated hemoglobin (HbA1c) control for diabetic patients, as well as colonoscopy screening, influenza immunization, and pneumonia immunization rates.

Regression Analyses

We estimated mixed logistic regression models with the patient-reported access indicators as dependent variables and lagged facility-level measures as independent variables. In each model, we controlled for patient-level characteristics, month and year fixed effects, and facility-level fixed effects. In separate models, we used lagged facility-level measures as continuous variables or categorized into quartiles, sextiles, and octiles with the lowest quantile used as the reference group (Tables A3 – A5 ). Standard errors were clustered at the facility level. All analyses were performed in Stata 14.1. 11

Specification Testing

In most economic transactions, including health care services, supply and demand are simultaneously determined. And although we control for several important patient and facility characteristics, we are unable to account for all relevant factors that may affect patient experience with access to care. To establish if such endogeneity biases our results, we tested for endogeneity of the facility operations variables by instrumenting with lagged facility operations variables and then conducting Hausman tests comparing the instrumented and non-instrumented models. The results showed that the instrumented and non-instrumented models were not statistically significantly different (results not shown).

Sample Characteristics

Our sample is comprised of 94,496 patients receiving care at 127 VA facilities. Sample characteristics are shown in Table ​ Table1. 1 . The mean respondent age was 65.9 years, with the majority of the respondents male and white. Most of the respondents (73%) had some college education, and 17.3% were priority status 7 or 8, indicating that their incomes were sufficiently high to be eligible for copays at the VA. Across all facilities, 39.9% of patients reported being able to access urgent care within 1 day, while 67.9% reported always or usually having easy access to routine care.

Patient and Facility Characteristics for the Analytical Sample During the Study Period

Regression Results

Our results suggest that facility mean follow-up time has a statistically significant negative association with access to both urgent and routine care. A 1-month increase in average follow-up time is associated with 10% lower odds of patients reporting that they could get urgent care within 1 day, and 13% lower odds of patients reporting that they could usually or always get routine care when needed.

The secondary model, which breaks the operational variables into quartiles, shows that the effects are stronger at the higher end of the distribution (Fig.  1 ). Patients receiving care in facilities with mean follow-up time in the highest quartile (> 4.4 months) have 16% percent lower odds of always being able to receive a routine appointment, compared with the first quartile of the distribution. For urgent care, patients receiving care in facilities in the highest quartile of the distribution have 8% lower odds of being able to get an appointment within 1 day (Fig. ​ (Fig.1 1 ).]-->

Secondary model: odds ratio estimates of the relationship between quartiles of lagged facility follow-up times and SHEP self-reported access to urgent and routine care, October 2013 to June 2016. Full secondary model results are in Appendix Table A3 .

The results from the logistic regression models (Table ​ (Table2) 2 ) show that mean facility appointment length has a small, but statistically significant association with respondents’ reported ability to access urgent appointments; longer appointments are associated with lower reported access.

Logistic Regression Model Estimates of the Relationship Between 1-Month Lagged Facility Operations Measures, Market Characteristics, and SHEP Self-reported Access to Urgent Care, October 2013 to June 2016

Robust Z -statistics in parentheses. *** p  < 0.01, ** p  < 0.05, * p  < 0.1. Models also control for HEDIS quality indicators, patient age and age squared, health, patient gender, race, ethnicity, first language, education level, and facility, month, and year fixed effects. Full model results are in Appendix Table A2

Higher staffing levels are also associated with better access to care—although the results are only statistically significant for routine care. An increase of one primary care provider per 1000 enrollees is associated with 24% higher odds of a patient reporting being usually or always able to access routine care when needed (Table ​ (Table2). 2 ). Overbooked and unscheduled appointments have no association with access to care (Table ​ (Table2 2 ).

For both urgent and routine care, individual-level priority status 7 or 8 is strongly associated with increased patient access to care. Patients with priority status 7 or 8 have 7% higher odds of being satisfied with access to urgent care, and 20% higher odds of being satisfied with access to routine care (Table ​ (Table2 2 ).

This contrasts with facility-level averages of the priority 7 and 8 population, where a higher proportion of patients in priority 7 and 8 are associated with decreased patient access to care, although the results are not statistically significant. Priority status 7 and 8 indicate that a veteran patient is expected to pay copayments due to income status—thus, this is an indication of veterans with relatively higher incomes. Area income and home prices are controlled for in this analysis—thus, this priority status indicator measures the relative income of veterans in comparison to the general population.

This study provides evidence on the relationship between measures of facility operations and access to care. We find that facilities with higher average follow-up times are more likely to have patients report that they are unable to access urgent or routine primary care. However, the associations with routine care are mostly concentrated at the higher end of the distribution, suggesting that facilities with more frequent follow-up times may be able to space patient visits further without much of an impact on patient access, while facilities with the most infrequent follow-up intervals may improve patient access by scheduling patients for more frequent return visits.

One potential explanation for the association between priority 7 and 8 veterans and higher access to care is that veterans in priority status 7 and 8 are more likely than the typical veteran to have access to a private health insurance plan, and specifically choose the VA because they are satisfied with it. In contrast, lower income veterans may not have access to other sources of health care and may continue to use the VA even if they are not satisfied.

Our study has several important limitations. First, this is an associative study. In future work, we would like to get causal estimates through instrumental variable estimation.

Second, we are not able to observe the exact reasons for which patients are scheduled for follow-up, and whether physicians are following guidelines established for conditions like diabetes or heart failure. We are assuming that some of the observed variation in follow-up time is due to differences in patient to staff ratios and differences in facility priorities between managing chronic conditions and addressing acute needs.

Third, our measures may suffer from measurement error. The facility operations metrics are calculated at the facility level for each month and do not correspond exactly to each individual’s experience. However, individual-level metrics suffer from simultaneous determination of health status and access, 12 so these metrics must be constructed at the facility level. Finally, our study relies on the assumption that patients’ response to the SHEP survey is dominated by their experience during the last appointment with a VA primary care provider.

The next step for future research is to extend these results to directly address how facilities can optimize operation resources in order to improve patient-reported access and care. One such step would be to review clinically appropriate follow-up times and specific clinic adherence to these follow-up times. Additional areas for future research include the relationship between patient access and clinic operations, how variations in provider workload impact the quality of care, and the relationship between telehealth and access to care.

There has been some research associating patient satisfaction to patient care and clinic operations, but more is needed. For example, there is a negative relationship between length of patient waiting times and satisfaction with access to care. 12 Legler and colleagues found an association between patient satisfaction and provider’s use of an integrated viewer of multiple electronic health records. 13

Regarding workload, Kabdiyeva found an association between patients seen per provider and burnout. 14 Based on her work, we can postulate that increasing provider workload by requiring providers to see patients more often may result in increased provider burnout.

The VA is investing heavily in telehealth, which has the potential to impact access, and thus also patient satisfaction with access. Hantke and colleagues showed that 90% of geriatric psychiatry patients who received care via video conference were at least as satisfied with their telehealth experience as with an in-person appointment. 15 The VA is also expanding community care due to Mission Act requirements, 16 and it is possible that pressure to change follow-up intervals would impact who is referred to community care, as a change in follow-up frequency would affect appointment demand. Feyman and Griffith showed that lower staffing levels at specialty care clinics at the VA are associated with reduced reliance on the VA and higher reliance on community care. 17 We expect that this relationship may be different for primary care because veterans generally need to first be seen in primary care before they can be referred to community care. Opportunities to extend research in all of these areas will expand in the near future.

Our results, measuring the relationship between follow-up time after primary care appointments and patient-reported access, are likely to carry over into the private sector. Clinic managers may wish to increase the follow-up time to get new patients seen more quickly, but if follow-up times are too long, then patient reported with access may suffer. There is no published work on this relationship between follow-up times and patient-reported access in the private sector—thus, this study is the only available evidence. It would be valuable for a research group in a large private sector health organization to repeat this study with private data. As a VA research group, we are mostly limited to working with VA data. This may change as VA community care expands going forward.

These results could have important implications for clinic management policy. Based on patient-reported access alone, it appears that most clinics could increase follow-up times without adversely affecting patient experience. Patient experience, as measured by CAHPS scores, is a key metric for health organizations; Hospital CAHPS scores influence hospital reimbursements from CMS through their input into value-based payment metrics. 18 For outpatient care, ACOs receiving CMS funds are also required to participate in CAHPS. 19

Of course, our results are silent on the optimal follow-up time for chronic disease management, so individual providers will have to weigh patient access as one factor in follow-up timing. If increased follow-up time is compatible with sound medical management, it could create much needed additional space in the schedule to more promptly address concerns of new patients.

Electronic Supplementary Material

(DOCX 77 kb)

Acknowledgments

The authors wish to thank Michael Davies, MD, Mary Fields, and Manuel Alvillar for helpful comments on prior versions of this work and for logistical assistance.

Funding Information

This research was supported by Grant No. PEC 16-001 from the VA’s Quality Enhancement Research Initiative (QUERI) and by the VA Office of Veterans’ Access to Care.

Compliance with Ethical Standards

The authors declare that they do not have a conflict of interest.

Opinions and conclusions expressed are those of the authors and do not reflect the official position of the US Department of Veterans Affairs or Boston University.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The Importance of Hospital Follow-Up: Ensuring Continued Care and Recovery

Hospitalization plays a significant role in managing acute illnesses, injuries, or surgical procedures. However, the journey towards complete recovery does not end upon discharge from the hospital.  In this blog post, we will explore the importance of hospital follow-up, its benefits, and how it contributes to optimal post-hospitalization care.

The Purpose of Hospital Follow-Up:

Monitoring Recovery Progress: Hospital follow-up visits allow healthcare professionals to assess a patient's progress after their initial treatment or surgery. This monitoring ensures that the patient is healing as expected and helps identify any potential complications or concerns early on.

Medication Management: Follow-up appointments provide an opportunity for healthcare providers to review and adjust medication regimens. They can assess the effectiveness of prescribed medications, address any side effects or interactions, and make necessary modifications to ensure optimal medication management.

Preventing Complications: Hospital follow-up visits enable healthcare professionals to detect and manage any potential post-hospitalization complications promptly. They can identify signs of infection, monitor healing processes, and provide guidance on wound care or other specific post-operative instructions.

Addressing Concerns and Questions: Patients may have lingering questions or concerns after their hospital stay. Follow-up appointments provide an opportunity to discuss these issues, address any uncertainties, and provide additional information or support to ensure the patient feels informed and empowered throughout their recovery.

Rehabilitation and Therapy: In many cases, hospital follow-up care includes referrals to rehabilitation services or therapy sessions. These sessions can aid in restoring physical function, mobility, and overall well-being. Follow-up visits allow healthcare providers to assess the effectiveness of these interventions and make adjustments as needed.

The Benefits of Hospital Follow-Up:

Continuity of Care: Hospital follow-up visits foster continuity of care by maintaining the connection between the patient and their healthcare provider. This ongoing relationship ensures that the patient's medical history, treatment plans, and progress are properly monitored and managed.

Personalized Treatment: Each patient's recovery journey is unique. Hospital follow-up visits allow healthcare professionals to tailor treatment plans and interventions based on the individual's progress, needs, and specific health conditions. This personalized approach enhances the effectiveness of post-hospitalization care.

Early Detection of Issues: Regular follow-up appointments enable healthcare providers to detect any potential issues early on, before they develop into more significant problems. This early detection allows for prompt intervention, reducing the risk of complications and promoting a smoother recovery.

Patient Education and Empowerment: Hospital follow-up visits provide an opportunity for patients and their families to receive valuable education and guidance on post-hospitalization self-care. Patients can learn about lifestyle modifications, symptom management, medication adherence, and strategies to support their recovery, empowering them to take an active role in their own well-being.

Conclusion:

Hospital follow-up care is a vital component of the recovery process, ensuring continued care, monitoring, and support for patients after their hospital stay. Through regular follow-up appointments, healthcare professionals can assess progress, address concerns, manage medications, detect complications early, and provide the necessary guidance and interventions for optimal recovery. By actively engaging in hospital follow-up, patients can enhance their chances of a successful and complete recovery, ultimately improving their overall health and well-being. Remember, your journey towards full recovery does not end at the hospital discharge – it continues with dedicated follow-up care.

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The Importance of Follow-Up Care after an Emergency Room Visit

When a medical emergency strikes, the first instinct is often to rush to the nearest emergency room for immediate care. 

The emergency room serves as a crucial lifeline in times of crisis, providing prompt and essential medical attention. 

However, many overlook the importance of follow-up care after an emergency room visit. 

Beyond the initial treatment, a well-structured and consistent follow-up plan ensures sustained recovery and prevents potential complications.

The Immediate Aftermath:

Emergencies are unpredictable, and the situation’s urgency often leaves little room for comprehensive examinations. 

Emergency room physicians focus on stabilizing the patient, addressing the immediate concerns, and initiating necessary treatments. 

While this initial care is essential, it may not cover all aspects of a patient’s health, especially underlying conditions that could contribute to the emergency.

The Need for Follow-Up Care:

Comprehensive assessment:.

Follow-up care allows a more thorough examination of the patient’s health. 

It will enable healthcare professionals to conduct comprehensive assessments, identify underlying issues, and develop a more accurate diagnosis. 

This is particularly crucial for conditions that may have been apparent during the emergency.

Monitoring Recovery:

Following an emergency room visit, patients are often given specific instructions for recovery. 

These recommendations are essential for ongoing healing, whether it’s medication management, lifestyle changes, or additional tests. 

Follow-up care ensures patients adhere to these guidelines and allows healthcare providers to monitor progress, making adjustments as needed.

Preventing Complications:

Without proper follow-up care, there is an increased risk of complications.

Some medical issues may not manifest immediately but can develop over time. 

Regular check-ups and monitoring can help detect and address potential difficulties before they escalate, ultimately preventing the need for further emergency interventions.

Medication Management:

Many patients receive prescriptions after an emergency room visit. 

Follow-up care ensures that patients understand the importance of medication adherence, manage potential side effects, and allow healthcare providers to adjust medications based on the individual’s response.

Psychological Support:

Medical emergencies can be traumatic, impacting not only the physical but also the mental well-being of individuals. 

Follow-up care provides an opportunity for healthcare professionals to offer psychological support, addressing the emotional aftermath of the emergency and helping patients cope with the stress and anxiety associated with their experience.

Managing Chronic Conditions:

For individuals with pre-existing chronic conditions, emergency room visits may be a result of exacerbations or complications. 

Follow-up care is crucial for managing these chronic conditions, adjusting treatment plans, and implementing preventive measures to reduce the likelihood of future emergencies.

Educating Patients:

Follow-up care serves as a platform for educating patients about their health. 

It allows healthcare providers to discuss preventive measures, lifestyle modifications, and healthy habits that can contribute to long-term well-being.

Extended Monitoring and Diagnostic Tests:

Follow-up care allows for extended monitoring through diagnostic tests that may not have been possible during the emergency. 

These tests could include blood work, imaging studies, or specialized screenings to uncover underlying health issues. 

By conducting these tests, healthcare providers can gain valuable insights into the patient’s health, enabling them to tailor their approach to meet individual needs.

Rehabilitation and Physical Therapy:

For recovering from injuries or surgeries, follow-up care often involves rehabilitation and physical therapy. 

These sessions are designed to restore mobility, strength, and function. 

They play a critical role in the recovery process, helping patients regain independence and improve their overall quality of life. 

Follow-up care ensures rehabilitation plans are adjusted based on progress and emerging issues.

Coordination of Care:

Follow-up care facilitates better coordination among various healthcare providers. 

In complex medical cases, a patient may require the expertise of different specialists. 

Follow-up appointments allow these specialists to collaborate, share information, and develop a cohesive care plan. 

This coordination ensures that all patient health aspects are considered, leading to more effective and personalized care.

Addressing Medication Adjustments:

Medication management is dynamic, and adjustments may be necessary based on a patient’s response and evolving health conditions. 

Follow-up care provides the opportunity to discuss any issues or changes in the patient’s medication response. 

Healthcare providers can then make informed decisions about dosage adjustments, changes in prescription medications, or the introduction of additional therapies.

Patient Education and Empowerment:

Follow-up care is an invaluable platform for patient education. 

It empowers individuals with the knowledge they need to participate in their healthcare actively. 

Patients can make informed decisions that positively impact their well-being by understanding their condition, treatment plan, and the importance of lifestyle modifications. 

This education extends beyond the immediate recovery period, fostering a culture of proactive health management.

Insurance and Financial Guidance:

Emergency room visits and subsequent follow-up care can have financial implications. 

Follow-up appointments provide an opportunity to discuss insurance coverage, clarify billing questions, and explore potential financial assistance programs. 

This aspect of follow-up care is essential in alleviating the stress associated with healthcare costs and ensuring that individuals can access the care they need without undue financial burden.

Long-Term Health Maintenance:

Follow-up care is not just about addressing the aftermath of an emergency; it’s a commitment to long-term health maintenance. 

Regular check-ups and ongoing monitoring can identify emerging health issues before they become critical. 

This proactive approach can lead to early interventions, reducing the likelihood of future emergencies and promoting a sustained, healthy lifestyle.

Community Resources and Support:

Usually, follow-up care may involve connecting patients with community resources and support networks. 

This could include support groups, counseling services, or educational programs aimed at helping individuals manage chronic conditions or navigate lifestyle changes. 

These resources play a vital role in fostering resilience and enhancing patients’ overall well-being.

In conclusion, follow-up care is a multifaceted process that extends far beyond the immediate aftermath of an emergency room visit. 

It encompasses ongoing monitoring, rehabilitation, care coordination, patient education, financial guidance, and a commitment to long-term health. 

By recognizing the diverse aspects of follow-up care, individuals can actively participate in their recovery journey, supported by healthcare professionals dedicated to their well-being. 

If you or a loved one have recently experienced an emergency room visit and would like to schedule follow-up care, please visit MoveUp Healthcare . 

Our team is here to provide comprehensive and compassionate support tailored to your unique needs.

Why is follow-up care necessary after an emergency room visit?

Follow-up care is crucial for a variety of reasons. It allows healthcare providers to conduct a more comprehensive assessment, monitor recovery, prevent complications, manage medications, address psychological aspects, and ensure patients’ overall well-being. This ongoing care is essential for sustained healing and the prevention of future emergencies.

How soon should I schedule a follow-up appointment after an emergency room visit?

The timing of follow-up appointments can vary based on the nature of the emergency and individual health needs. Healthcare providers often recommend scheduling a follow-up appointment within a week or two to assess recovery progress and address any emerging issues. It’s essential to follow the specific guidance the emergency room staff provides.

What can I expect during a follow-up appointment?

Follow-up appointments typically involve a thorough examination, discussion of symptoms and recovery progress, and, if necessary, additional diagnostic tests. Healthcare providers may also review and adjust medications, discuss rehabilitation plans, and provide guidance on lifestyle modifications. It allows open communication between the patient and the healthcare team.

Does insurance cover follow-up appointments?

In many cases, follow-up appointments are covered by insurance, but it’s essential to check with your specific insurance provider to understand the details of your coverage. Our healthcare professionals can assist in navigating insurance-related questions and provide information on potential financial assistance programs.

How long does follow-up care continue after an emergency room visit?

The duration of follow-up care varies depending on the individual’s health condition, the nature of the emergency, and the recovery progress. Some individuals may require more extended monitoring, while others may transition to routine check-ups over time. Healthcare providers will tailor the follow-up plan based on each patient’s unique needs.

Can I address mental health concerns during follow-up care?

Absolutely. Follow-up care is not solely focused on physical health; it also addresses mental and emotional well-being. If you have concerns about your mental health following an emergency, our healthcare professionals are here to provide support, discuss coping strategies, and, if necessary, refer you to additional mental health resources.

What if I have questions or concerns between follow-up appointments?

We encourage open communication. If you have questions or concerns between follow-up appointments, don’t hesitate to contact our healthcare team. Many issues can be addressed through phone consultations, and we are here to provide the guidance and support you need throughout your recovery journey.

Can I request a different healthcare provider for follow-up care?

We understand the importance of a comfortable and trusting patient-provider relationship. While we strive to maintain continuity of care, if you have specific preferences or concerns, please communicate them with our scheduling team. We will do our best to accommodate your needs and support you during follow-up care.

What should I bring to a follow-up appointment?

It’s helpful to bring any relevant medical documents, a list of current medications, and a record of any symptoms or changes you’ve noticed since the emergency room visit. This information assists healthcare providers in gaining a comprehensive understanding of your health status.