SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
August, 2008 - SUPPORT Summary of a systematic review | print this article |
Specialist outreach clinics are planned and regular visits by specialist-trained medical practitioners from a usual practice location (hospital or specialist centre) to primary care or rural hospital settings. Specialist outreach clinics aim to improve access to specialists and hospital-based services, to strengthen the liaison between specialists and primary carer providers, and to give the benefits of consultations in primary care settings, such as familiarity and less stigma for patients.
People making decisions concerning use of specialist outreach clinics in primary care and rural settings.
Gruen RL, Weeramanthri TS, Knight SE, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database of Systematic Reviews 2003, Issue 4.
See in Cochrane Library
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Specialist medical practitioners usually consult in outpatient areas of major hospital facilities or large metropolitan clinics. In some places, visiting specialist services, otherwise known as 'specialist outreach', have been established to improve access to specialist care, enhance primary-specialist care relationships, reduce pressures on hospitals, shift the balance of care to community-based services, or reduce health service costs. Specialist outreach has emerged as specific policy initiatives, as initiatives of individual practitioners or organisations, and as a secondary effect of other policies. “Special outreach” is a term that covers different activities.
Planning specialist outreach services requires detailed knoweldge of the targeted population, the gaps in existing resources and the potential contribution of specialist medical practitioners.
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Review Objectives:
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| / | What the review authors searched for | What the review authors found |
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| Interventions | Specialist outreach clinics (planned and regular visits by specialist medical practitioners to primary care or rural hospital settings). | Nine studies (5 randomised trials, 2 controlled before-after studies and 2 interrupted time series analyses) met the inclusion criteria. |
| Participants |
1. Patients who are eligible for specialist care |
Orthodontics (1 UK), psychiatry (3 USA and 2 UK), orthopaedics (1 Holland), oncology (1 USA) , general surgery, gynaecology, ophthalmology and ENT (1 Australia) |
| Settings |
All primary care and rural hospital settings globally |
Urban non-disadvantaged populations (7 studies), a rural non-disadvantaged population in the USA (1), and a rural disadvantaged population in Australia (1). |
| Outcomes |
Access, quality of care (guideline-consistent referral and treatment; adher-ence to treatment), health outcomes, pa-tient and provider satisfaction, use of hos-pital and primary care services, costs |
No study reported provider satisfaction. The other outcomes were reported by one or more studies |
| Date of most recent search: May 2002 | ||
| Limitations: This is a good quality systematic review with only minor limitations. | ||
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*The descriptive overview included 105 articles reporting 73 outreach interventions. Nine of the descriptive studies were from low and middle-income countries, demonstrating that specialist outreach can be implemented where resources are available. |
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Gruen RL, Weeramanthri TS, Knight SE, Bailie RS. Specialist outreach clinics in primary care and rural hospital settings. Cochrane Database of Systematic Reviews 2003, Issue 4.
See in Cochrane Library
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
This Cochrane review reported both a descriptive overview of all studies of specialist outreach clinics, and a review assessing the effectiveness of specialist outreach clinics compared to usual care. The descriptive overview included 105 articles reporting findings from 73 outreach interventions. Twenty-eight were from the UK, twelve from Australia, eleven from the USA, seven from Canada, four from South Africa, three from East Africa (Kenya, Tanzania and Uganda), three from Israel, and one each from Zimbabwe, Holland, Norway, Ecuador and Hong Kong. A wide range of settings, specialties and interventions were described.
Nine of the 73 studies met the inclusion criteria for the systematic review of effectiveness, 17 were comparative studies that did not meet the inclusion criteria, and 47 were descriptive only. None of the comparative studies were from low or middle-income countries.
One study in a rural population in the USA reported that outreach led to 9% (28% vs. 19%) more breast cancer patients receiving an oncology consultation (difference in absolute change from baseline), and a study from Australia found a large relative increase in numbers of specialist consultations involving remote community patients (390%).
The US study of outreach oncology service reported that 7% (5% versus -2%) more breast cancer patients received guideline-consistent care (difference in absolute change from baseline). Self-reported adherence to treatment was greater for outreach in three related studies by a psychiatry group in Seattle, USA. All three studies employed a similar complex collaborative care intervention involving weekly consultations alternating between the primary care physician and the psychiatrist, as well as primary care physician education, case conferences, patient education and individual treatment algorithms. The generalisability of their findings to different populations is unclear, although it seems reasonable to predict that a similar intervention would have benefit in other urban populations for patients with psychiatric disorders.
Quality of care – adherence to treatment |
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| Patient or population: Patients with depression or panic disorder Settings: Seattle, USA Intervention: Specialist outreach involving collaborative care with education of patients and primary care physicians Comparison: Usual care |
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| Outcomes | Illustrative comparative risks | Relative effect (95% CI) |
Number of Participants (studies) |
Quality of the evidence (GRADE) |
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Assumed risk (range) |
Corresponding risk (95% CI) |
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Nonadherence to treatment |
550 per 1000 |
341 per 1000 |
RR 0.62 |
382 |
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| CI: Confidence interval RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) | |||||
One Dutch study of joint consultations between orthopeadic surgeons and primary care physicians reported no improvement in objective clinical assessment or subjective measures of symptoms, other than “disorder free at one year” (35% of intervention versus 23% of control group patients). All three studies from the psychiatry group in Seattle reported substantive improvements in measures of symptom improvement and disease resolution.
Health outcomes |
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| Patient or population: Patients with depression or panic disorder Settings: Seattle, USA Intervention: Specialist outreach involving collaborative care with education of patients and primary care physicians Comparison: Usual care |
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| Outcomes | Illustrative comparative risks | Relative effect (95% CI) |
Number of Participants (studies) |
Quality of the evidence (GRADE) |
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Assumed risk (range) |
Corresponding risk (95% CI) |
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Persisting symptoms |
630 per 1000 |
397 per 1000 |
RR 0.63 |
382 |
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| CI: Confidence interval RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) | |||||
All three studies from the psychiatry group in Seattle reported greater patient satisfaction. No studies reported provider satisfaction.
Patient satisfaction |
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| Patient or population: Patients with depression or panic disorder Settings: Seattle, USA Intervention: Specialist outreach involving collaborative care with education of patients and primary care physicians Comparison: Usual care |
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| Outcomes | Illustrative comparative risks | Relative effect (95% CI) |
Number of Participants (studies) |
Quality of the evidence (GRADE) |
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Assumed risk (range) |
Corresponding risk (95% CI) |
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| Unsatisfied with overall care |
400 per 1000 |
172 per 1000 |
RR 0.43 |
382 |
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| CI: Confidence interval RR: Risk ratio GRADE: GRADE Working Group grades of evidence (see above and last page) |
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It is uncertain whether specialist outreach clinics improve the use of servcies such as other non-hospital services, hospital-based outpatient services, laboratory and radiological tests, medication, planned inpatient services or primary care consultations.
Two studies found outreach to be more expensive to provide per patient, although one of these studies found that, despite being more costly to deliver, the multifaceted outreach intervention was 7.4% more cost-effective than usual care when health outcomes were considered. Two other studies, including the one study in a rural disadvanteged setting, found outreach less expensive to deliver per patient than usual care.
| Findings | Interpretation* |
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| APPLICABILITY | |
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- Capacity of primary care centres or rural hospital settings to accomodate specialist outreach clinics - Financial and administrative support - Demand for specialist outreach clinics
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| EQUITY | |
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| ECONOMIC CONSIDERATIONS | |
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| MONITORING & EVALUATION | |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low- and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm |
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Related literature
Powell J. Systematic review of outreach clinics in primary care in the UK. J Health Serv Res Policy 2002; 7: 177-183.
This summary was prepared by
Signe Flottorp, Norwegian Knowledge Centre for the Health Services, Oslo, Norway
Conflict of interest
None declared. For details, see: Conflicts of Interest
Acknowledgements
This summary has been peer reviewed by: Russ Gruen, Australia; Sasha Shep-perd, UK; Xavier Bosch, Switzerland; Tracey Perez Koehlmoos, Bangladesh; Fu Hongpeng, China
This summary should be cited as
Flottorp S. Do specialist outreach visits in primary care and rural hospital settings improve care? A SUPPORT Summary of a systematic review. August 2008.
