Patient-initiated follow-up in surgical specialties: meta-analysis and meta-regression

BACKGROUND: Rising outpatient demand has accelerated adoption of patient-initiated follow-up in surgical practice. This review evaluated whether patient-initiated follow-up safely reduces clinic burden while maintaining patient outcomes across specialties. METHODS: MEDLINE, Embase, and CENTRAL were searched (2014-2025) for studies of patient-initiated follow-up, defined as a model enabling clinically stable patients to self-initiate follow-up when new or concerning symptoms arise, rather than attending prearranged appointments. Primary outcomes included outpatient appointment volume and patient-reported quality of life. Where studies reported single-arm utilization data, a random-effects meta-analysis of proportions was undertaken. Exploratory meta-regression examined pathway-level factors associated with utilization. Randomized clinical trials (RCTs) were assessed using the revised Cochrane risk-of-bias 2 tool, observational cohort studies using the Newcastle-Ottawa Scale, and qualitative studies using the Critical Appraisal Skills Programme checklist. RESULTS: Of 1776 manuscripts identified, 34 studies across 6 surgical specialties (breast, colorectal, otorhinolaryngology, orthopaedics, plastics, and urology) were included: 4 RCTs, 17 observational cohort studies, 11 qualitative studies, and 2 mixed-methods studies. Observational studies consistently reported reductions in routine outpatient attendance-including a reduction from 45·0% to 6·0% in first specialist appointments in patient-initiated follow-up in colorectal surgery (P < 0·001) and 52·5% of patients with high-risk cutaneous squamous cell carcinoma not recontacting the clinic-without evidence of increased adverse outcomes. RCTs demonstrated non-inferior patient-reported quality-of-life outcomes with patient-initiated versus standard follow-up, alongside reductions in physician contact, including a 50% reduction in planned consultations in breast cancer (1·9 versus 3·8 per patient; P < 0·001) and a reduction in specialist contacts from 42·0% to 23·0% in rectal cancer. In a meta-analysis (1806 participants), the pooled patient-initiated follow-up utilization proportion was 0·19 (95% confidence interval 0·09 to 0·36; I2 = 95%), indicating substantial context-dependent variation. In oncological settings-particularly breast, colorectal, melanoma, and head and neck cancer-structured surveillance and rapid-access systems were identified as critical safety adjuncts to implementation. CONCLUSION: Patient-initiated follow-up can reduce outpatient burden in selected surgical populations without compromising patient-reported outcomes; however, its effects are dependent on the clinical context and pathway design. Risk-stratified and hybrid models may be the most appropriate, particularly in oncology. Further high-quality trials and robust economic evaluations are required to define optimal implementation strategies.