Colorectal cancer is the third most common cancer in the UK with over 40 000 cases in 2016 and the cost to the UK economy is estimated at £1.6 billion per year (White et al, 2018). Many of these cancers are treatable by surgical resection with or without adjuvant chemo- or radiotherapy, depending on the disease stage as well as other tumour and patient characteristics. The National Institute for Health and Care Excellence (NICE) recommends a clinic visit 4-6 weeks after resection for bowel cancer with curative intent (NICE, 2011). This should be followed by at least two CT scans of the chest, abdomen and pelvis in the first 3 years and regular blood tests. Colonoscopy should be offered at 1 year and considered at 5 years (NICE, 2011).
This is because evidence shows that serum carcinoembryonic antigen (CEA) and CT are the two investigations that increase the likelihood of detecting and therefore treating recurrence or metastatic disease (Association of Colproctology of Britain and Ireland (ACGBI), 2017). The Follow-up After Colorectal Surgery (FACS) study was a randomised clinical trial in 39 NHS hospitals that looked at follow-up in patients with bowel cancer who had undergone treatment with curative intent. It found that intensive CT scans or CEA screening compared to minimal follow-up increased the number of recurrences detected at an early stage by three times. The authors concluded that these investigations should be used in follow-up due to the increased number of early and treatable recurrences detected, but survival advantages between different follow-up strategies is likely to be small (Primrose et al, 2014).
Patients are followed-up after bowel cancer resection both to detect recurrence and provide psychological support, which is normally carried out by doctors and specialist nurses in an outpatient clinic. At the Royal Hampshire Hospital in Winchester, an innovative telephone follow-up service, run by specialist nurses, has been in place for approximately 20 years for a subsection of bowel cancer patients. Following surgery, patients are followed-up with routine phone calls at a frequency decided at the multidisciplinary team (MDT) meeting. In addition, yearly CEA blood tests, regular CT scans and colonoscopies are carried out as required, as an outpatient. This follow-up is performed by the surgical team, although patients having adjunctive chemotherapy or radiotherapy are also seen by oncology. Telephone follow-up is becoming more widespread, but remains a relatively underused system and contrasts with the traditional model of being seen regularly in the outpatient clinic that is still in place at many centres.
All patients remain under the care of the MDT with investigations reviewed by clinical staff and patients are phoned with the results. Outpatient clinic follow-up is arranged if necessary following abnormal results or the patient reporting problems. Patients are educated about red flag symptoms such as pain, change in bowel habit or weight loss and are encouraged to call the nurses if they have concerns. Patients followed-up in this way are well enough at presentation that, should the cancer reoccur, further treatment would be likely to be of benefit and they would be motivated to engage with healthcare services.
Aims
This service evaluation is designed to assess patient satisfaction and the cost saving realised for commissioners by use of the telephone follow-up service. There is an emerging evidence base that telephone follow-up is safe after some operations and provides good satisfaction for patients (Murchie et al, 2016; Beaver et al, 2017; Thompson et al, 2019). In addition, it can provide improved efficiency for hospitals in line with the ambition of the NHS Long Term Plan to reduce the number of outpatient visits (NHS England and NHS Improvement, 2019).
Methods
The local Research Ethics and Governance Committee was contacted to confirm that this is a service evaluation and so did not require formal ethical approval. The records of a group of bowel cancer patients, with no known metastases at presentation, who underwent curative surgery in 2012 and 2013, were then accessed. Patients who did not have an operation and those with known metastases not removed at the primary operation were excluded. These dates were chosen as these patients will have by then completed 5 years of follow-up and so most will no longer be under review. Aspects of their follow-up were recorded, such as the number of follow-up phone calls, clinic attendances and the reason for any need to visit the outpatient department.
The tariff for an outpatient clinic appointment and nurse telephone follow-up appointment was used to model the potential cost savings for the commissioners over this 2-year period. This was done by comparing the combined tariff for all telephone follow-ups and subtracting this from the combined tariff had these appointments been face-to-face as they would have been before the introduction of this service. An underlying assumption was that if the patient had not had the telephone call, they would have instead been seen in the outpatient clinic.
The patient records were inputted into an Excel spreadsheet and a random number generator was used to pick a number from one to six. The fourth record was selected using this method and the patient was contacted by telephone. They were asked to complete the European Organisation for Research and Treatment of Cancer questionnaire on Outpatient Satisfaction (Brédart et al, 2018), for which permission to use was granted. Subsequently, every sixth patient on the database was contacted, although if they could not be reached the next one was contacted until a questionnaire was completed. This led to 24 questionnaires being completed. Answerphone messages had been left for patients who did not respond and a further six called back and were included. It was decided by the two primary authors that 30 patients gave a representative sample, which was adequate to assess the service. In addition, all participants rated the service consistently highly with no negative comments, so it felt unlikely that further useful themes would emerge.
The questionnaires contained both quantitative and qualitative data. Quantitative data was analysed using Microsoft Excel, and qualitative data was thematically analysed using a combination of template and emergent coding. Two authors with experience of this methodology read through the free text comments several times, colour coding and drawing out themes with the analysis, then combined to identify common themes.
Findings
A total of 142 patients underwent bowel cancer resection in 2012 and 2013. The cancers were staged using the Dukes' system which ranges from A-D with A representing the least advanced cancers and D metastasis to other parts of the body (Cancer Research UK, 2018). Of these, 20.4% (29 patients) presented as Dukes A, 41.6% (59) as Dukes' B and 35.2% (50) as Dukes’ C, with the remaining as gastrointestinal stromal tumours. One patient included on the cancer pathway had Kikuchi disease (necrotising lymphadenitis) and one patient had no malignant tissue found on histological examination.
The most common operation performed was an anterior resection (59 patients, 41.5%), followed by right hemicolectomy (53 patients, 37.3%) and Hartmann's procedure (8 patients, 5.6%), with abdomino-perineal resection of rectum, left hemicolectomy and sub-total, sigmoid and transverse colectomy also being performed. A total of 45 patients (31.7%) underwent chemotherapy; of these, 11 (7.7%) received pre-operative adjuvant chemotherapy, and 2 (1.4%) underwent chemo-radiotherapy.
Postoperative complications in the follow-up period were uncommon, with the most frequently encountered being hernia (5 patients, 3.5%), followed by fistula formation (1 patient, 0.7%). Polyps (13 patients, 9.2%), hyperplasia (6 patients, 4.2%) and adenomas (4 patients, 2.8%) were detected at follow-up in several patients.
Cancer recurrence (including primary bowel or metastases) was found in 13 patients (9.2%) in the time from initial diagnosis to this study; of these, 5 (3.5%) had liver metastases, 4 (2.8%) were primary bowel, 1 (0.7%) had lung metastases and 3 (2.1%) presented with widespread metastases. Four patients (2.8%) died during the follow-up period, of which one was due to cancer, two from other comorbidities, and one was secondary to overdose.
Table 1 illustrates the average number of phone calls and follow-up investigations per patient over 5 years of follow-up. Total savings for commissioners were £67 840, assuming patients would have been seen in the clinic if not followed-up by telephone.
Table 1. Average number of follow-up calls and investigations during the 5-years of follow-up
| Intervention | Median appointments [IQR] |
|---|---|
| Phone call | 13 (9–16) |
| CEA | 5 (2–7) |
| CT scan | 2 (0–5) |
| Colonoscopy | 3 (2–5)* |
| Outpatient appointments | 1 (1–2) |
* 3 patients declined colonoscopy, 1 patient had their colonoscopy privately after their operation IQR=interquartile range; CEA=serum carcinoembryonic antigen
In total, 30 responses were recorded for the telephone patient satisfaction survey. The quantitative results are summarised in Figure 1.
Table 2 summarises the main themes to emerge from the qualitative element of the questionnaire.
Table 2. Thematic analysis of EORTC questionnaire
| Theme | Quotes |
|---|---|
| Continuity of care | ‘It's absolutely vital to be able to get through to someone who knows your case. It's such a comfort to know I can call Sarah at any time to get advice’ |
| Excellent care from nurses | ‘The nurses are a terrific asset. I recently had a scare, which turned out to be a virus—the nurses were wonderful and on hand to answer all my questions. I know I can ring them whenever I need’‘Service with the two nurses was brilliant; they are very caring and reassuring’‘They always make time for you’ |
| Excellent care from surgeons | ‘Mr Moore did a super job’ |
| Excellent experience overall | ‘They are a great team who go above and beyond’‘I’ve been under their care for 6 years, and it's been absolutely perfect’‘I can't fault them at all, and I owe them my life’‘All been very good and straightforward; the ease of communicating with the team from home is such a great asset’ |
| Convenience | ‘Parking at the hospital is difficult so it was helpful to have the phone calls’ |
Discussion
Specialist nurse telephone follow-up provided excellent patient satisfaction as well as significant savings compared to conventional clinic follow-up in this group of bowel cancer patients (those who had elective, curative surgery, who were eligible for and would want further treatment if recurrence was found).
For all the questions regarding follow-up, including ease of speaking to a health professional, the average score was between 4.5 and 5, with 4 representing very good and 5 representing excellent. A possible reason for such high scores is that there were only two specialist nurses providing the telephone follow-up during this period, which led to a high level of continuity of care. In addition, there is a dedicated telephone number that is regularly checked, which increases ease of access for patients when contacting the hospital service. It is unsurprising that the highest score, with an average of 4.93, was achieved in response to the question regarding the ease of accessing hospital services from home, which was also highlighted in the qualitative results. This finding agrees with an earlier study by Murchie et al (2016) which found that patients accept follow-up care from specialist nurses if continuity of care was improved, and one-to-one counselling offered.
This system of follow-up is innovative and complies with recommended guidelines regarding follow-up of patients who have had bowel cancer resection. The benefits to commissioners are that the agreed tariff for a nurse telephone follow-up is significantly less than the outpatient tariff. In addition, there is benefit for the hospital as this increases outpatient capacity to see patients with serious pathology and new patients, which carries the largest tariff. Telephone follow-up appointments also reduce problems with parking at the hospital and carbon emissions (Naylor and Appleby, 2012).
The greatest benefit of this system seems to be for patients. The median number of follow-up phone calls was 13 (first quartile 9, third quartile 16), had patients attended the outpatient department instead, they would have incurred a huge inconvenience and the service, cost. This is reflected in the patient satisfaction survey of 30 patients, in which all respondents gave extremely positive quantitative and qualitative feedback.
Limitations
There were several limitations of this study, such as not including all clinical parameters although this was deemed not relevant to assessing the telephone follow-up service. There was also no comparator group, so although patients were clearly very pleased with the service, it could not be compared to traditional outpatient follow-up in a clinic. As the concept of outpatients is broadened from the traditional model of a clinic to include virtual appointments (Healy et al, 2019) and telephone follow-up, further studies to compare satisfaction with different models could provide valuable information.
As this service is run by two very experienced specialist nurses, it may not be directly transferable to other departments unless the same expertise is available. The only negative identified by the nurses was that they initially found the service difficult to adjust to. One area identified was learning to assess risk over the telephone. This may be because telephone assessment is unlikely to be covered in training, meaning a new skill set needs to be learnt once such a system is implemented. Finally, the study examines a specific group of patients (ie those who have had curative primary surgery, who would be eligible for, and would want, further treatment if recurrence occurred), and telephone follow-up may not be suitable for other groups.
Conclusion
Having a specialist nurse follow-up patients who have had curative resection for bowel cancer by telephone has worked well in this unit for approximately 20 years with minimal problems reported. This can generate significant savings for local commissioners as the tariff charged is significantly less than for outpatient appointments. More importantly, patients are highly satisfied with this service and there are also benefits through increased outpatient resources for other uses and reduced carbon emissions as patients are not travelling to hospital so frequently (Naylor and Appleby, 2012). This model, if replicated elsewhere could provide part of the solution to reducing outpatient appointments as set out in the NHS Long-Term Plan (NHS England and NHS Improvement, 2019). Once established, the service may be enhanced through the use of newer technologies such as video calling or commercial apps. This may allow better communication as well as a greater range of diagnoses through visualisation of reported problems, such as a hernia. The greatest barrier to this is likely to be the availability of staff with the expertise to provide this service.
CPD reflective questions
- Why might reducing the number of outpatient services be beneficial for an NHS Trust?
- What challenges might there be in implementing this approach in your Trust?
- How might the multidisciplinary team in your service be best utilised to improve patient experience?
- Other than telephone follow-up, what other methods might be implemented to reduce the number of outpatient appointments?
KEY POINTS
- The NHS Long Term Plan has called for a reduction in outpatient appointments to reduce pressure on hospital services and improve access for patients
- A nurse-led telephone follow-up service for elective bowel cancer patients following surgery was evaluated
- Feedback on the service was overwhelmingly positive, with patients praising continuity of care, ease of access and convenience, and the standard of care received from specialist nurses
- The service creates significant savings for commissioners, increases capacity to see patients and leads to reductions in carbon emissions
- However, the service is only generalisable to other units where staff have appropriate expertise