Hunter Jo, Claridge Andrew, James Shirley, Chan David, Stacey Bernard, Stroud Mike, Patel Praful, Fine David, Cummings J R Fraser
Department of Gastroenterology, University Hospital Southampton Foundation NHS Trust, Southampton, UK.
Frontline Gastroenterol. 2012 Apr;3(2):76-80. doi: 10.1136/flgastro-2012-100123. Epub 2012 Mar 13.
The follow-up of inflammatory bowel disease (IBD) patients is challenging due to the relapsing remitting nature of the diseases, the wide spectrum of severity and complexity as well as the need for monitoring of long-term complications and drug treatments. Conventional outpatient follow-up lacks flexibility for patients and there are competing pressures for clinic time. Alternative follow-up pathways include telephone clinics, self-management programmes or discharging patients. The IBD virtual clinic (VC) is a further option. Patients with an established diagnosis for >2 years, who have been stable for >1 year, do not have primary sclerosing cholangitis and who give their consent, are entered into the VC system. Two months before their annual follow-up is due patients are sent blood test forms and a simple questionnaire with an information sheet. If they meet any of the criteria on the questionnaire, they are asked to contact the IBD specialist nursing team to discuss their situation. The blood test results and the patient's database entry are reviewed to ensure that they are not due surveillance investigations. The patients and their GPs then receive a letter informing them of their management plan. We currently follow-up 20% of the Southampton IBD cohort using the VC. The VC system is an innovative, efficient and patient-responsive method for following up mild to moderate IBD. It is well liked by patients but is dependent on a well-maintained database with good integration of IT systems and requires both clerical and IBD nurse specialist support.
由于炎症性肠病（IBD）具有复发缓解的特性、广泛的严重程度和复杂性，以及监测长期并发症和药物治疗的需求，对IBD患者进行随访具有挑战性。传统的门诊随访对患者缺乏灵活性，且门诊时间存在竞争压力。替代随访途径包括电话门诊、自我管理计划或让患者出院。IBD虚拟诊所（VC）是另一种选择。确诊超过2年、病情稳定超过1年、无原发性硬化性胆管炎且同意参与的患者被纳入VC系统。在年度随访到期前两个月，向患者发送血液检查表格以及一份带有信息单的简单问卷。如果他们符合问卷上的任何标准，就会被要求联系IBD专科护理团队讨论他们的情况。会对血液检查结果和患者的数据库记录进行审查，以确保他们不需要进行监测调查。然后患者及其全科医生会收到一封信，告知他们的管理计划。我们目前使用VC对南安普顿IBD队列中的20%患者进行随访。VC系统是一种创新、高效且能响应患者需求的轻至中度IBD随访方法。它很受患者欢迎，但依赖于维护良好且IT系统整合良好的数据库，并且需要文书工作和IBD护士专家的支持。
