title: Reforming respiratory outpatient services: a before-and-after observational study assessing the impact of a quality improvement project applying British Thoracic Society criteria to the discharge of patients to primary care.
abstract: BACKGROUND
  Secondary care physicians caring for people with long-term conditions (LTCs) are under increasing pressure to discharge long-term follow-up patients to primary care. In respiratory medicine, the 2008 British Thoracic Society (BTS) statement on criteria for specialist referral, admission, discharge, and follow-up for adults with respiratory disease remains the only available basis for this dialogue. There is widespread concern about reforming outpatient clinics to meet these demands and the impact of discharging people with respiratory LTCs to primary care.
  
  
  OBJECTIVE
  To examine the impact of implementing BTS guidance on secondary care follow-up of patients with respiratory disease.
  
  
  METHODS
  We undertook a clinic reform project, which included one-stop medical reviews, providing more open access appointments, and implementing the BTS criteria. The impact on patients was assessed by patient survey, and the impact on GPs was assessed by an analysis of referral patterns pre- and post-reform.
  
  
  RESULTS
  There was a significant improvement in commissioner-mandated performance through reduction in follow-up (p=0.006) and the unscheduled hospital admission rate decreased significantly (p=0.021). However, many patients were dissatisfied with the process and re-referral rates rose.
  
  
  CONCLUSIONS
  Our findings suggest that the delivery of a responsive service capable of sustainable management of respiratory LTCs can be achieved using the BTS criteria. It seems to be efficacious within secondary care, increasing the quality and value of the clinic activity, although hidden impacts on primary care will require further prospective studies.
authors: University of Birmingham, QEHB Research Laboratories, QEHB, Birmingham, UK. a.m.wood@bham.ac.uk
authors: Alice M
authors: AM
authors: Turner
authors: Satinder Kaur
authors: SK
authors: Dalay
authors: Ambika
authors: A
authors: Talwar
authors: Catherine
authors: C
authors: Snelson
authors: Rahul
authors: R
authors: Mukherjee
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000592:standards*; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000592:standards*; D058996:Quality Improvement; D012120:Respiration Disorders / Q000175:diagnosis / Q000628:therapy; D012189:Retrospective Studies; D006113:United Kingdom