Patient Initiated Follow-Up in an Irish Dermatology Department: A Pilot Study

Patient initiated follow up (PIFU) is an alternative approach to a traditional, fixed appointment-based system that offers a flexible review for patients when needed. It has successfully been implemented across a range of speciality departments worldwide.1,2 In 2022, the Health Service Executive (HSE) in Ireland announced reforms to introduce ‘Patient Initiated Review’ across the organisation as part of a nationwide strategy to tackle long patient waiting lists.3 Here, we will present our experience of PIFU in an Irish Dermatology Department.

This was a single-centre, prospective pilot study identifying patients who were offered PIFU in a Dermatology department in Ireland between April – June 2021.

Adult and paediatric dermatology patients were identified through electronic clinic reports and data drawn from clinical charts and records. Patients were offered ‘flexible’ review within one year of the original presentation pertaining to the same clinical condition. Patient demographics and clinical details were extracted and analysed, and patients followed for a 12-month period.

A total of 47 patients were identified, 57% (n=27) were female and median age was 23 years (range; 0-83). Clinical diagnoses included: acne (n=13/47), eczema (n=8/47), infection (n=5/47), non-specific rash (n=4/47), non-melanoma skin cancer (n=3/47), urticaria (n=2/47), hidradenitis suppurativa (n=2/47), actinic keratosis (n=2/47), guttate psoriasis (n=2/47), vasculitis (n=2/47) and other (n=4/47).

Twenty-nine percent (n=14/47) of patients activated PIFU within a 12-month period. Median time until PIFU was 213 days (range; 28-413 days). Forty-two percent (n=6/14) of patients had acne, 28.5% (n=4/14) eczema, 14.2% (n=2/14) actinic keratosis 7% (n=1/14), urticaria and 7% (n=1/14) guttate psoriasis. Seventy percent (n=33) had no further episodes of care during the study interval. The background rate of patients who ‘did not attend’ (DNA) in 2021 was 11% (n=823/7093).

Previous research has demonstrated the advantage of a flexible approach to follow-up for patients with chronic conditions who require lifelong management in speciality clinics4. Our findings support the view that PIFU has a role in Dermatology for patients with conditions that display periods of quiescence such as that seen in inflammatory dermatoses. Early review allows for appropriate escalation of treatment to avoid potential complications such as infection, hospitalisation, and reduced quality of life.

This study also shows that PIFU can have a positive impact on patient DNA rates. In 2021, the departmental DNA rate was lower than the estimated annual national rate of 13%4. This study demonstrates that PIFU has a useful role in reducing unnecessary attendance of well-controlled patients at OPD clinics, thus reducing the potential for non-attendance.

Study limitations include a small patient number attending a single institution. Our findings may be affected by the HSE Cyber-attack in May 2021 and the COVID-19 pandemic.

This study suggests PIFU is a useful strategy for the management of patients with conditions that display periods of remission to allow for prompt review by a Dermatologist in the event of an acute deterioration. Further larger studies focusing on client and resource benefits of PIFU can guide speciality specific policies for its use across the HSE in the future.

1 Balhorn J, Su’a B, Jin J et al. Changing the routine: a move to patient initiated follow up to improve surgical outpatient clinic. ANZ Journal of Surgery. 2022;92(6):1394-1400.

2 Newton C, Nordin A, Rolland P et al. British Gynaecological Cancer Society recommendations and guidance on patient-initiated follow-up (PIFU). International Journal of Gynecologic Cancer. 2020;30(5):695-700.

3 The Department of Health, Health Service Executive Ireland. 2022 Waiting List Action Plan [Internet]. Hse.ie. 2022 [cited 6 September 2022]. Available from: https://www.hse.ie/eng/ about/who/board-members/ board-meetings/february2022/4-0-1-department-ofhealth-waiting-list-action-planpdf.pdf

4 Khoury L, Møller T, Zachariae C, Skov L. A prospective 52week randomized controlled trial of patient-initiated care consultations for patients with psoriasis. British Journal of Dermatology. 2018.