Individuals who have been diagnosed with cancer require frequent follow-up in order to detect recurrent disease and manage the physical and psychological impact of treatment. The US National Cancer Comprehensive Network (NCCN) guidelines direct that these patients attend oncology outpatient clinics, often at frequent intervals, despite evidence in the literature showing that routine follow-up with clinical examination does not contribute to improved survival.^1-4 The frequent follow-up visits of these patients in the outpatient clinic has a significant impact on the oncology service and requires continuous management.  

Background

In Letterkenny General Hospital, in April 2010, it was identified that there were 177 patients on the oncology outpatient waiting list – a number that was growing every month. The oncology team discussed various methods to allocate appointments to these patients to expedite their review. One method that was identified and seemed possible was nurse-led telephone follow-up (NLTFU). 

Literature review

Patient acceptability and satisfaction with nurse-led follow-up is consistently high in the literature.^5-7 Additionally, NLTFU has often been portrayed as a positive and cost-effective means of follow-up. Cox et al, in their study of NLTFU in ovarian cancer, found that the majority of women expressed a preference for NLTFU; the main advantages were reported as the relationship and discussions between the patient and the nurse, and the convenience of having follow-up appointments by phone rather than attending clinic.⁸

Beaver et al conducted a study exploring the views of patients and nurse specialists involved in telephone follow-up after treatment for breast cancer. The study reported positive views on this method.⁹ The researchers concluded that an experienced and skilled practitioner with effective communication skills was required to deliver the intervention and a period of training was recommended. 

Cusack and Taylor found that telephone follow-up meets patient satisfaction, support and information needs, and has the potential to deliver high standards of aftercare when conducted by a nurse specialist.¹⁰ Additionally, they concluded that the option of telephone follow-up could, for some patients, dramatically improve their care experience.  This finding was also reflected in a study by Kimman et al.¹¹

Similarly, Beaver et al found that high levels of satisfaction with the care and delivery by colorectal nurse specialists, and patient acceptance of telephone follow-up, suggest that NLTFU is a viable alternative to traditional hospital-based follow-up.¹²

Kimman et al have identified that NLTFU plus a short educational group programme is an appropriate and cost-effective alternative to hospital follow-up for breast cancer patients during their first year after treatment.¹³ However, in a further study, they point out that an educational group programme does not unequivocally affect positive health-related quality of life outcomes. They concluded that NLTFU seems an appropriate way to reduce clinic visits and represents an accepted alternative strategy.¹⁴

Proposal development

Following a literature review, and identifying that NLTFU could be a safe and effective option for patient care, a proposal was written. This was developed in conjunction with Dr Karen Duffy, a medical oncologist at Letterkenny General Hospital. Her support as the clinical lead was a prerequisite for its introduction. Director of nursing and midwifery support was also secured prior to proceeding. Other nursing colleagues and medical secretaries were consulted to ensure that the practice change was appropriate and feasible. 

The initiative was also discussed at the oncology senior management team meeting to obtain hospital management support. The completed proposal was submitted to the National Council for the Professional Development of Nursing and Midwifery (NCNM) to secure funding, which was successful.

Guideline development

The authors subsequently developed a guideline, which was to direct the holistic assessment for nurse-led telephone follow-up and to ensure that standardised practice and documentation were adhered to. Dr Duffy and other key stakeholders were consulted for their input into this document. It was subsequently ratified at the local nursing policy/guideline committee. 

Patient inclusion/exclusion criteria for involvement in the telephone follow-up were identified and a standardised assessment sheet using Bickley recommendations for assessment was developed.¹⁵

The flow diagram (Figure 1) illustrates the comprehensive care for oncology patients participating in NLTFU. In addition, the decision was made to use the distressometer (www.NCCN.org) to assist patient assessment. It has been incorporated locally into a self-explanatory leaflet that encourages patients to focus on their needs. This leaflet was posted to patients along with the telephone appointment. 

 (click to enlarge)

Results

The first patient assessed in the ‘telephone follow-up clinic’ was in October 2010. To date, the advanced nurse practitioner (ANP) oncology has performed all NLTFU. When this initiative commenced there were 177 patients on the oncology waiting list awaiting routine oncology review, which represented a large backlog. At the time of writing, this number has declined to 22 with the oncology recall clinics operating now about three weeks behind schedule. This 88% reduction in the number of patients on the waiting list cannot be attributed completely to the introduction of NLTFU. 

Ultimately, however, what this project did achieve was to provide the impetus for all the team members to actively try and reduce the waiting list and Figure 2 diagrammatically illustrates how the reductions were achieved.

 (click to enlarge)

By reviewing eligible patients for NLTFU the opportunity was provided to evaluate each patient case. If they had been seen in a surgical clinic recently their oncology appointment could be ‘rescheduled’ rather than having two appointments in close succession. In addition, if patients failed to attend the oncology clinic, rather than resending another appointment the ANP telephoned them. If they ‘declined a review appointment’ they were discharged and a letter dictated to their GP. 

Normal practice is that the medical secretary telephones the patients 24-48 hours prior to their appointment to ensure attendance. Due to the extent of the waiting list, it was decided that if a patient stated they could not attend their scheduled appointment, then another patient would be telephoned, often at short notice – even the morning of the clinic – asking if it suited them to attend. This initiative did appear useful during the icy road conditions of the winter of 2010/2011. Letterkenny General Hospital is situated in the provincial town in Co Donegal and travel time can take over an hour from the peripheries of this area. During the icy conditions many patients were unable to travel to the hospital for review. 

For the clinics of November and December 2010, some patients who met the criteria outlined in the guideline were telephoned by the ANP. A history was elicited, scan results given (provided imaging was negative or stable) and on occasions laboratory tests requested. This ensured that when the weather improved the Oncology Department did not have a backlog of patients needing to attend outpatient clinics.

While NLTFU has contributed to this reduction, it is not the only contributing factor. The guideline requires that patients agree to this manner of follow-up and, to date, there have been no refusals. Anecdotal evidence has shown that patients view this positively, as the literature suggests, and they have provided feedback that indicates they feel comfortable having a telephone call from an ANP who is known to them. 

Future plans

Analysis of prospective clinic lists indicates that the number of patients requiring NLTFU will increase. Future plans include a full audit of the NLTFU documentation and this is proposed for May 2012. The guideline will require review and re-ratification in May 2012. As this project has become well established it is planned to assess the financial impact of this initiative, as it is anticipated that cost savings will be demonstrated. 

Conclusion

It has been demonstrated by research literature that patient satisfaction with NLTFU is equivocal if not superior to routine outpatient review. Advantages to patients include convenience, cost/time saving, and patient reassurance regarding their care. This initiative has confirmed that an advantage to the hospital is reduction of the outpatient waiting list. 

From the perspective of the practitioner performing NLTFU, this new practice requires a guideline-directed approach to ensure standardisation of care. In addition, it is necessary that the patients know the nurse who performs the NLTFU. This approach ensures continuity of care by building upon previously established patient/clinician relationships. 

Consequently, this improves job satisfaction for the nurse and streamlines patient care from hospital to community by making the nurse accessible to the patient in the comfort of their own home.

Acknowledgments

Dr Karen Duffy, medical oncologist, Letterkenny General Hospital; NCNM for funding obtained; management of Letterkenny General Hospital and oncology team members.

References

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