Powell (2002) undertook a systematic review of UK studies of the benefits of holding specialist outreach clinics in primary care settings. Fifteen studies were included in the analysis. The review found a number of studies that surveyed the opinions of GPs, specialists and patients. Perceived advantages of outreach clinics included improved GP-specialist communication, improved patients' experience and improved access. Disadvantages identified included administrative costs, accommodation costs and inefficient use of specialists' time. Studies involving a comparison of outreach and hospital-based clinics found patients expressed a preference for outreach clinics, with satisfaction and convenience generally were rated higher for outreach clinics. Studies did not demonstrate consistent differences in health outcome between the two settings. Direct costs to the health system were higher for outreach clinics.

Gruen, Weeramanthri, et al. (2004) conducted a systematic review of “[r]andomised trials, controlled before and after studies, interrupted time series analyses of visiting specialist outreach clinics in primary care or rural hospital settings” (p. 1). Outcomes assessed in studies included measures of access, quality of care, health outcomes, satisfaction, service use and cost.

Overall, 105 articles relating to 73 interventions reported outcomes from studies of outreach programs. The majority (47) of these were descriptive studies and a further 17 studies were comparative but did not meet criteria for intervention studies set by the Cochrane Effective Practice and Organisation of Care (EPOC). The nine remaining studies meet the inclusion criteria for the review.

Table 25 – Quality of evidence by population type – Gruen et al (2004) review

Population type

Satisfies EPOC

Comparative, not EPOC

Descriptive only

Total

Urban

7

12

16

35

Urban disadvantaged

0

1

6

7

Rural

1

4

14

19

Rural disadvantaged

1

0

11

12

Total

9

17

47

73


The nine studies that satisfied the EPOC criteria are shown in Table 26. Of these, seven related to outreach services to urban populations, one related to outreach to rural populations and one to rural disadvantaged populations. Six studies related to outreach psychiatry services.

Table 26 – Studies that meet EPOC criteria in Gruen et al (2004) review

Study

Population type

Specialty

1

Gruen & Bailie 2000; Gruen et al. 2001

Rural disadvantaged

General surgery, gynaecology, ophthalmology, ENT

2

Howe et al. 1992; Howe et al. 1994, 1997

Rural

Oncology (breast cancer)

3

Katon et al. 1997; Katon et al. 1995; Simon et al. 1998; Von Korff et al. 1998

Urban

Psychiatry

4

Katon et al. 1999; Simon et al. 2001

Urban

Psychiatry

5

O'Brien et al. 2001

Urban

Psychiatry

6

Roy-Byrne et al. 2001

Urban

Psychiatry

7

Ferguson et al. 1992; Tyrer 1984; Tyrer et al. 1984

Urban

Psychiatry

8

Vierhout et al. 1995

Urban

Orthopaedics

9

Strathdee & Williams 1984

Urban

Psychiatry

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The one high quality study of outreach services to rural disadvantaged populations (Gruen & Bailie 2000; Gruen et al. 2001) examined the effect of an outreach service for general surgery, gynaecology, ophthalmology and ENT in the Northern Territory. The outreach service commenced in 1997 and involved services to a range of small communities, up to 900 kilometres away from Darwin. Outreach visits were scheduled on a three to six monthly basis.

During the evaluation, 5,184 patient consultations were conducted, most commonly for follow-up appointments and new referrals for “colposcopy, retinopathy screening, cataract, abdominal/gastrointestinal conditions, cutaneous surgical conditions, and chronic otitis media with tympanic perforation and hearing loss” (Gruen, Knox, et al. 2004, p. 27). The study was based on a before and after design with comparisons made on the number of consultations for remote community patients (hospital and outreach) and numbers of patients required to travel prior to and after the introduction of the outreach scheme.

Outreach services for gynaecology were most consistent in the period and this was the service analysed for the study. The study found hospital based consultations decreased by 26% per annum and community based consultations increase by 89%. The average cost was decreased by $173 per patient consulted as a result of the intervention, from $450 per patient at Royal Darwin Hospital to $277 per patient in the outreach clinic. The average cost was $357 at the closest regional hospital.

The study by Howe et al. was a retrospective evaluation of the impact of a rural outreach oncology clinics from five rural hospitals in Illinois, USA between 1986 and 1991. The study found that as a result of the outreach model, 8% more women received ‘state of the art’ care. Evidence of the effectiveness and cost effectiveness of outreach services was found in the urban based outreach model.

The Gruen systematic review also drew on some of the descriptive studies in drawing conclusions about outreach services for rural disadvantaged populations. Seven of these studies related to specialist outreach services to rural populations in Africa (including Coetzee et al. 1998; Cotton 1996; Hodges & Hodges 2000; Klein et al. 1996); seven related to remote and Aboriginal and Torres Strait Islander populations in Australia (including Baker & Buttini 1991; Cyna 1993; Humphrey et al. 1993; Kierath et al. 1998; Leaming & Smith 1970) and two to rural populations in Canada (including Baskett 1978, 1979).

Many of these services involved air transport with specialists bringing their own specialised equipment. Some related to major surgical procedures, including cardiothoracic surgery (Klein et al. 1996). Others were principally a consulting service which integrated with treatment in the major hospital. One study (Baskett 1978, 1979) reported local education and joint consultations as major components of the service. The remainder were simple outreach interventions.

Many outreach activities described in these studies related to individuals and non-government groups who had taken the initiative in providing the services. There were examples, particularly in Australia, where the outreach services were part of an institutional strategy related to a regional hospital or academic institutions (including Gruen & Bailie 2000; Gruen et al. 2001; Humphrey et al. 1993; Kierath et al. 1998; Baskett 1978, 1979; Coetzee et al. 1998). The reviewers comment that the literature refers to policy challenges “not just about whether to provide specialist outreach services, but also how much to invest in specialist services at all, as opposed to other services, including primary health care. Although there is little supporting or refuting evidence, multifaceted specialist outreach may in fact be a means for both improving access to specialists and bolstering local primary health care services” (Gruen, Knox, et al. 2004 p.46).

The authors discuss the potential for harm related to outreach services. The principal issue examined in various studies in this respect has been the potential for inefficient use of resources, associated with the additional costs required to provide the clinics and the inefficient use of specialists’ time compared with the primary clinic. It was noted several “UK commentaries and surveys of providers found specialists to be critical of outreach as an inefficient use of scarce specialist resources” (Gruen, Knox, et al. 2004 p.46). However, others found “specialists to be praising the effectiveness of outreach” (Gruen, Knox, et al. 2004 p.46).

One urban study (Katon et al. 1995; Katon et al. 1997; Simon et al. 1998; Von Korff et al. 1998) found outreach services to be a cost effective use of resources. The review authors comment that the question of cost effectiveness remains unanswered for rural and disadvantaged populations “where costs are greater but the potential to benefit is also greater the increased patient throughput in Gruen’s study in a disadvantaged rural population was an indication that an unmet need or demand existed” (Gruen, Knox, et al. 2004 p.46). They found that no study has examined “in detail the opportunity costs associated with specialists being absent from their primary practice. Additionally, no study particularly examined the opportunity costs associated with outreach when compared with investment in other parts of the health care sector” (Gruen, Knox, et al. 2004 p.46).

The overall conclusion from the review is that there is evidence to support the hypothesis that “specialist outreach can improve access to specialist care on a range of patient-based measures, health outcomes to a clinically important degree, and efficiency in the use of hospital-based services by reducing duplication and unnecessary referrals and investigations” (Gruen, Knox, et al. 2004 p.47).

They also observe that outreach services seem “to facilitate engagement between specialists and primary care practitioners, although such engagement cannot be presumed. Interaction is greatest when outreach is part of a complex multifaceted intervention which involves case-conferences, joint consultations, seminars and education sessions, other health professionals or other care enhancements. On the basis of four RCTs, it appears that this can lead to improved health outcomes and more efficient use of services” (Gruen, Knox, et al. 2004 p.47).

They note that outreach required investment of additional resources by service providers and health systems compared with hospital based care, but “these extra costs may be at least partly offset by reduced costs for the patient and greater cost-effectiveness of multifaceted interventions” (Gruen et al 2004 p.47). Higher levels of investment are required in providing services to rural populations, and it is possible that this will generate additional costs associated with uncovering unmet needs. The review authors note the need for ‘tailoring’ of outreach services based on “an intimate understanding of local contexts” (Gruen, Knox, et al. 2004 p.47).

In a subsequent brief on evidence related to visiting outreach services, the Canadian Health Services Research Foundation, relying heavily on the Gruen et al review, concluded that there “are a number of proposed solutions for increasing access to specialist services in rural and remote areas - from telemedicine (interactive video consultations) to expanding the role of family physicians in providing specialist care. Outreach services are a well-evaluated way of enabling patients from rural and remote populations to access speciality care without incurring travel costs and the other inconveniences associated with travel. Importantly, these clinics allow patients to have their families and other loved ones accompany them to their appointments if need be” (Canadian Health Services Research Foundation 2008 p.2).

Smith et al. (2007, 2008) conducted a systematic review to examine whether sharing care across the primary-specialty interface improves outcomes in chronic disease. The reviewers used a classification of shared care developed by Hickman et al. (1994), which include five models:

1. Community clinics: specialists attend or run a clinic in a primary-care setting with primary-care personnel. Communication is informal and depends on the specialists and primary-care team members meeting on site.
2. Basic model: a specific, regular communication system is set up between specialty and primary care. This may be enhanced by an administrator who organizes appointments and follows up and recalls defaulters from care.
3. Liaison: a liaison meeting attended by specialists and the primary-care team where the ongoing management of patients within the service is discussed and planned.
4. Shared care record card: a more formal arrangement for information sharing where an agreed data set is entered onto a record card which is usually carried by the patient.
5. Computer-assisted shared care and electronic mail: a data set is agreed upon and collected in both the specialty and primary-care setting and is circulated between the two sectors using computer systems such as a central repository or email. This system may also include centrally coordinated computerised registration and recall of patients.

(Smith et al. 2007, pp 2-3)

The review included models 3, 4 and 5. Specialist outreach clinics in primary care settings were explicitly excluded. The reviewers found 20 studies that met their criteria of which 19 were randomised controlled trials. Most studies were complex interventions and were evaluated over a short length of time. The studies presented mixed results with no consistent improvement in physical or mental health outcomes, psychosocial outcomes, hospital admissions, default or participation rates, recording of risk factors, and satisfaction with treatment.

Studies that examined prescribing found improvements in this area. Cost data were limited and difficult to interpret across studies. There were shortcomings in the methodologies for many of the included studies, with inadequate length of follow-up a major limitation. The authors conclude “there is insufficient evidence to support the introduction of shared care services into clinical practice". They argue “[f]urther research is needed to test models of collaboration across the primary-specialty care divide both in terms of effectiveness and sustainability over longer periods of time”.Top of page