Research on lost to follow-up of patients at the outpatient clinic of Nork Marash Medical Center

Abstract

Purpose. The proposed project aimed to examine the factors predisposing to lost to follow-up and explore the reasons for drop out at the Yerevan Nork Marash Medical Center (NMMC). Background information. A follow-up program is an integral aspect of high-quality care in any health care facility. One of the steps for establishing a comprehensive system for patient follow-up is the investigation of causes/determinants contributing to lost to follow-up. Different researches revealed, that low perceived severity of illness, coupled with the costs and inconvenience of care, patient satisfaction from provided services, the patient-provider communication skills have influenced the follow-up status of patients. NMMC provides a wide range of cardiology and cardiovascular surgery services to both adult and pediatric populations of Armenia. Since March 2000 a collaborative project was underway between American University of Armenia and NMMC with the aim is to develop and implement quality improvement program in NMMC. By the physicians of the hospital lost to follow-up was identified as one of the weak points in the NMMC activities. The presented study was carried out at NMMC Adult Cardiology and Arrhythmology Departments in order to examine the predictors for lost to follow-up and discover reasons for them. Methods. The study design was an analytical, cross-sectional group comparison (two groups). The first group was composed of patients remaining in the follow-up and the second group composed of lost to follow-up patients. The needed information on all patients admitted to the Outpatient clinic‘s Adult Cardiology Department or Arrhythmology Department during data collection period was collected and entered into the developed Patient Information Form. Patients who were present on their follow-up visit, were contacted by telephone the next day of the visit and were administered the survey questionnaire designed for them (Questionnaire # 1). The criterion for considering a patient as lost to follow-up was set as the absence of a visit after a week of the recommended date for follow-up. Patients who didn’t come to follow-up were contacted after a week and administered another questionnaire (Questionnaire # 2). Sample. The sample size was calculated considering the prevalence of satisfaction as 90% in the group of patients remaining in the follow-up and it was hypothesized to detect at least 25% lower satisfaction in the group of patients lost to follow-up. It was considered also the fact that the lost patients composed 20 % in the target population. Overall, 112 patients in the group of patients remaining in the follow-up and 30 patients lost to follow-up were interviewed. Ethical considerations. The research proposal was reviewed and approved by the Institutional Review Board (IRB) within the College of Health Science at the AUA. Before the interview an oral consent was provided to patients. Results. Two groups were similar with respect to distributions across age, gender and departments. There was statistically significant association between the outcome (remain in follow-up or lost to follow-up) and type of secondary visit (secondary outpatient versus secondary post-surgical). There was no statistically significant difference between the groups’ current health status distribution as ‘fair/poor’ versus ‘good/very good/excellent’ (p value was 0.08). In the group of patients remaining in the follow-up 94,5% were satisfied with services, while in the group of patients lost to follow-up 89,7% were satisfied. Only type of visit was identified as a predictor of the outcome. The odds of outcome (remain in follow-up versus lost to follow-up) was by 2.5 times higher in the group of patients with secondary post-surgical visit vs. patients with secondary outpatient visit (p value was 0.03). The reasons for not coming to follow-up were explored among the 30 patients lost to follow-up. As the results showed, almost half of the lost patients (n=14) planned to come to follow-up later. Almost one third of the lost patients pointed as a reason that they ‘feel good and have no need to come to follow-up’. The time for recommended follow-up was inconvenient for 33.3% of patients. Conclusions/Recommendations. The study showed that patient satisfaction was enough high at the identified departments. Patients with secondary outpatient visits were more likely to drop out from follow-up than patients with secondary post-surgical visits. The examination of reasons for lost to follow-up from patients’ perspective revealed the areas where the changes are needed. Based on the obtained results it could be recommended: • To develop standardized written follow-up protocols for post-surgical and ambulatory patients with different conditions. • It was recommended to develop an electronic database for patients’ daily flow and follow-up in the Adult Cardiology Department. • The results of the study underlined the importance of the establishment of a follow-up center in the hospital. • To conduct larger scale survey to measure the exact drop out rate and examine other predictors for lost to follow-up (patients’ education, income, traveling time and/or distance, functional assessment for cardiovascular system).