Evidence-Based Guidelines to Determine Follow-up Intervals: A Call for Action

Although there are nearly 1 billion outpatient follow-up visits annually in the United States, few data exist documenting evidence-based follow-up intervals for the most common and costly chronic conditions.

• Evidence-based follow-up intervals must be established based on healthcare outcomes.

• Evidence-based follow-up intervals have the potential to reduce healthcare costs per person and improve access without compromising or restricting care.

Public concern regarding access to care combined with increasing pressure to curtail healthcare costs has prompted physicians to think critically about how best to manage chronic disease. Perhaps surprisingly, Americans face long wait times compared with other industrialized nations. A 2010 Commonwealth Fund study of 11 industrialized countries found waiting times were longer in the United States than in all the other countries except Canada, Norway, and Sweden.¹ Moreover, the study showed that only 57% of patients were able to access a same-day or next-day appointment when they were sick or needed care, compared with top-ranking Switzerland, where 93% of patients described being able to secure an appointment under these conditions. Similarly, 19% of patients in the United States waited 6 or more days for an appointment compared with only 2% of patients in Switzerland.¹ Several specialties face a shortage of providers, and geographic inequities also exist in almost all areas.² This problem is confounded by increasing patient demand in an aging population and slow growth in physician supply, which lags behind other countries on a per capita basis, and is further exacerbated by economic disparities.³

Where might there be more room for patients in this system? Notably, a substantial portion of outpatient office visits are follow-up visits. According to the National Health Statistics Report for 2009, there were nearly 1 billion office visits in 2009, 30% of which were for routine follow-up of a chronic problem and an additional 26% of which were for preventive care or follow-up of an acute condition. The remaining 42% were for the evaluation of a new problem or an exacerbation of a chronic condition.⁴

There are 3 obvious questions. (1) Are these follow- up visits and their timing determined scientifically or by convenience and habit? (2) Is there an evidence base to support physicians’ practice patterns? (3) If there is evidence to support physicians’ practice patterns, are physicians adhering to those guidelines? If not, scheduling habits may be unnecessarily contributing to the problems f limited access, excessive utilization, and excessive costs, without improvement in healthcare outcomes.

Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines for performing a systematic review, we used the PubMed database to search for studies discussing evidence-based guidelines for follow-up intervals for the top 5 chronic conditions accounting for the greatest number of outpatient visits in 2010 (mental disorders, back problems, arthritis, chronic obstructive pulmonary disease/asthma, hypertension).⁵ These 5 conditions accounted for approximately $281 billion in healthcare expenditures in 2010.⁶

Table 1

This search yielded 330 studies. Abstracts of these studies were reviewed, and guidelines with recommendations for follow-up interval timing were included. Eight studies recommended specific follow-up times (^7-15).

Some guidelines attempted to recommend specific followup intervals, but the vast majority were not evidence based. Determining the appropriate intervals and modeling their impact are important. For example, patients being medically managed for hypertension are typically seen every 6 months. However, a recent randomized controlled trial determined 6 months to be too short an interval to reflect accurate therapy-induced changes in blood pressure.⁸ Extending the follow-up interval in this case may not only result in cost savings but also improve patient care, as patients appear to be better managed with more accurate assessment of blood pressure and more appropriate adjustments to therapy. Similarly, recent research into optimizing follow-up intervals for melanoma patients demonstrated that frequency of followup intervals did not impact outcomes.¹⁶

Table 2

The next task was to determine the impact on healthcare utilization and expenditures of curtailing inappropriate follow-up visits. With a model that examines the diagnosis of hypertension, the profound effect of small reforms in followup practice becomes substantially clear. Essential hypertension accounted for $47.4 billion in healthcare expenditures in 2008, with outpatient visits accounting for $13.03 billion.¹⁷ There were 79.1 million outpatient visits for hypertension in 2008.18 About 88%, or 69.6 million, of those visits were established patients.16 Using the Medicare national allowable billing amount of $65.30 for a Current Procedural Terminology code 99213 visit, we can estimate the cost savings as a function of the number of visits omitted. If follow-up visits were extended by just 1 month, from 6 to 7 months, there would be a 15% decrease in the number of visits in 1 year. This reduction could correspond to a cost savings of nearly $682 million. If the follow-up interval were extended to 9 months, there would be a 34% reduction in follow-up visits for 1 year and a potential cost savings of $1.5 billion. Decreasing follow-up visits to a yearly interval would result in a 50% reduction in follow-up visit volume and a possible cost savings of about $2.3 billion (). Additionally, patients may be better managed with more accurate assessment of blood pressure and more appropriate adjustments to therapy.

In this era of healthcare reform, managing follow-up visits and intervals is an evidence-based approach that has the potential to reduce costs per person and improve access without compromising or restricting care. In order to implement this plan, appropriate follow-up intervals must first be established based on healthcare outcomes. Physicians should tackle this first step by focusing research efforts and funding on the development of evidence-based follow-up guidelines for common chronic diagnoses. The same scientific rigor that guides therapeutic decision making should be used to optimize chronic disease management. Rational choice of follow-up intervals is a crucial step in adjusting current utilization patterns to maximize the quality of patient care while minimizing unnecessary costs. It’s a win for everyone.Author Affiliations: From University of Massachusetts (EJ, AR), Boston, MA; Harvard Medical School (ABK), Boston, MA.

Funding Source: None.

Author Disclosures: The authors (ABK, EJ, AR) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ABK); acquisition of data (AR, EJ); analysis and interpretation of data (ABK, EJ, AR); drafting of the manuscript (ABK, EJ, AR); critical revision of the manuscript for important intellectual content (ABK, EJ, AR); administrative, technical, or logistic support (ABK); and supervision (ABK).

Address correspondence to: Alexa Boer Kimball, MD, MPH, Department of Dermatology, Harvard University School of Medicine, 50 Staniford St, #240, Boston, MA 02114. E-mail: akimball@partners.org. 1. Schoen C, Osborn R; for the Commonwealth Fund. 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries. http://www.commonwealthfund.org/Surveys/2010/Nov/2010-International-Survey.aspx. Published November 2010. Accessed October 30,2012.

2. US General Accounting Office. Physician Workforce: Physician Supply Increased in Metropolitan and Nonmetropolitan Areas but Geographic Disparities Persisted. http://www.gao.gov/new.items/d04124.pdf. Published October 2003. Accessed June 11, 2012.

3. Simoens S, Hurst J. The Supply of Physician Services in OECD Countries. OECD Health Working Papers No. 21. http://www.oecd.org/dataoecd/27/22/35987490.pdf. Published January 2006. Accessed June 11, 2012.

4. Centers for Disease Control and Prevention. National AmbulatoryMedical Care Survey: 2009 Summary Tables. Fact Sheet: Physician Office Visits. http://www.cdc.gov/nchs/data/ahcd/NAMCS_Factsheet_All_2009.pdf. Accessed June 11, 2012.

5. Agency for Healthcare Research and Quality. Table 2: Number of events for selected conditions by type of service: United States, 2010. Medical Expenditure Panel Survey Household Component Data. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Accessed June 11, 2012.

6. Agency for Healthcare Research and Quality. Total expenses and percent distribution for selected conditions by type of service: United States, 2010. Medical Expenditure Panel Survey Household Component Data. Rockville, MD: Agency for Healthcare Research and Quality; 2010. Accessed June 11, 2012.

7. Quinn RR, Hemmelgarn BR, Padwal RS, et al; Canadian Hypertension Education Program. The 2010 Canadian Hypertension Education Program recommendations for the management of hypertension: part I—blood pressure measurement, diagnosis and assessment of risk. Can J Cardiol. 2010;26(5):241-248.

8. Keenan K, Hayen A, Neal BC, Irwig L. Long term monitoring in patients receiving treatment to lower blood pressure: analysis of data from placebo controlled randomised controlled trial. BMJ. 2009;338:b1492.

9. British Thoracic Society Standards of Care Committee. BTS statement on criteria for specialist referral, admission, discharge and follow-up for adults with respiratory disease. Thorax. 2008;63(suppl1):i1-i16.

10. van den Bemt L, Schermer T, Smeele I, et al. Monitoring of patients with COPD: a review of current guidelines’ recommendations. Respir Med. 2008;102(5):633-641.

11. Schulberg HC, Katon W, Simon GE, Rush AJ. Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. Arch Gen Psychiatry. 1998;55(12):1121-1127.

12. Francken AB, Hoekstra HJ. Follow-up of melanoma patients: the need for evidence-based protocols. Ann Surg Oncol. 2009;16(4): 804-805.

13. Francken AB, Thompson JF, Bastiaannet E, Hoekstra HJ. Detection of the first recurrence in patients with melanoma: three quarters by the patient, one quarter during outpatient follow-up [in Dutch]. Ned Tijdschr Geneeskd. 2008;152(10):557-562.

14. Francken AB, Shaw HM, Accortt NA, Soong SJ, Hoekstra HJ, Thompson JF. Detection of first relapse in cutaneous melanoma patients: implications for the formulation of evidence-based follow-up guidelines. Ann Surg Oncol. 2007;14(6):1924-1933.

15. Einwachter-Thompson J, MacKie RM. An evidence base for reconsidering current follow-up guidelines for patients with cutaneous melanoma less than 0.5mm thick at diagnosis. Br J Dermatol. 2008; 159(2):337-341.

16. Turner RM, Bell KJ, Morton RL, et al. Optimizing the frequency of follow-up visits for patients treated for localized primary cutaneous melanoma. J Clin Oncol. 2011;29(35):4641-4646.

17. Agency for Healthcare Research and Quality. Total expenses and percent distribution for selected conditions by type of service & number of events for selected conditions by type of service: United States, 2008. Medical Expenditure Panel Survey Household Component Data.Rockville, MD: Agency for Healthcare Research and Quality; 2008. AccessedJune 11, 2012.

18. Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2008 Summary Tables: Table 8: Continuity-of- Care Office Visit Characteristics, by Specialty Type: United States, 2008.