Reducing waiting time for community rehabilitation services: a controlled before-and-after trial

Insights into how universal, tax-funded, single payer health systems manage their waiting lists: A review of the literature

Background: A conspicuous consequence of gatekeeping arrangements in universal, tax-funded, single-payer health care systems is the long waiting times. Besides limiting equal access to care, long waiting times can have a negative impact on health outcomes. Long waiting times can create obstacles in a patient's care pathway. Organization for Economic Co-operation and Development (OECD) countries have implemented various strategies to tackle this issue, but there is little evidence for which approach is the most effective. This literature review examined waiting times for ambulatory care. Objective: The aim was to identify the main policies or combinations of policies universal, tax-funded, and single-payer healthcare systems have implemented to improve the governance of outpatient waiting times. Methods: Starting from 1040 potentially eligible articles, a total of 41 studies were identified via a 2-step selection process. Findings: Despite the relevance of the issue, the literature is limited. A set of 15 policies for the governance of ambulatory waiting time was identified and categorized by the type of intervention: generation of supply capacity, control of demand, and mixed interventions. Even if a primary intervention was always identifiable, rarely a policy was implemented solo. The most frequent primary strategies were: guidelines implementation and/or clinical pathways, including triage, guidelines for referral and maxim waiting times (14 studies), task shifting (9 studies), and telemedicine (6 studies). Most studies were observational, with no data on costs of intervention and impact on clinical outcomes.

Sustainability of an intervention to reduce waiting for access to an epilepsy outpatient clinic

Purpose

Delays in outpatient specialist neurologist care for people with epilepsy are common despite recommendations for prompt access. There is evidence to suggest that there are interventions that can minimise waitlists and waiting time. However, little is known about whether such interventions can result in sustained improvements in waiting. The aim of this study was to determine the extent to which an intervention to reduce waiting in an epilepsy specialist outpatient clinic demonstrated sustained outcomes two years after the intervention was implemented.

Methods

This observational study analysed routinely collected epilepsy clinic data over three study periods: pre-intervention, post-intervention and at two-year follow-up. The intervention, Specific Timely Assessment and Triage (STAT), combined a short-term backlog reduction strategy and creation of protected appointments for new referrals based on analysis of demand. After the initial intervention, there was no further active intervention in the following two years. The primary outcome was waiting measured by 1.) waiting time for access to a clinic appointment, defined as the number of days between referral and first appointment for all patients referred to the epilepsy clinic during the three study periods; and 2.) a snapshot of the number of patients on the waitlist at two time points for each of the three study periods.

Results

Two years after implementing the STAT model in an epilepsy clinic, median waiting time from post-intervention to two-year follow-up was stable (52-51 days) and the interquartile range of days waited reduced from 37 to 77 days post-intervention to 45-57 days at two-year follow-up, with a reduction in the most lengthy wait times observed. After a dramatic reduction of the total number of patients on the waitlist immediately following the intervention, a small rise was seen at two years (n = 69) which remained well below the pre-intervention level (n = 582).

Conclusion

The STAT model is a promising intervention for reducing waiting in an epilepsy clinic. While there was a small increase in the waitlist after two years, the median waiting time was sustained.

An evidence-based demand management strategy using a hub and spoke training model reduces waiting time for children's therapy services: An implementation trial

BACKGROUND

Waiting lists for community-based paediatric therapy services are common and lead to poorer health outcomes, anxiety and missed opportunities for treatment during crucial developmental stages. The Specific Timely Appointments for Triage (STAT) model has been shown to reduce waiting lists in a range of health settings.

AIMS

To determine whether providing training and support in the STAT model to champions within five community health centres using a remote 'hub and spoke' approach could reduce waiting time from referral to first appointment.

METHODS

Representatives from five community health centres providing paediatric therapy services (speech therapy, occupational therapy and other allied health services) participated in five online workshops over 6 months. They were guided sequentially through the steps of the STAT model: understanding supply and demand, reducing backlogs, preserving space for new patients based on demand and redesigning models of care to maintain flow. Waiting time was measured in three consecutive years (pre, during and post intervention) and compared using the Kruskal-Wallis test. Employee satisfaction and perception of the model were explored using surveys.

RESULTS

Data from 2564 children (mean age 3.2 years, 66% male) showed a 33% reduction in waiting time from the pre-intervention (median 57 days) to the post-intervention period (median 38 days, p < 0.01). The total number of children waiting was observed to reduce from 335 immediately prior to the intervention (mean per centre 67, SD 25.1) to 112 (mean 22, SD 13.6) after implementation (t[8] = 3.56, p < 0.01). There was no impact on employee satisfaction or other aspects of service delivery.

CONCLUSION

Waiting lists are a major challenge across the health system. STAT provides a practical, low-cost, data-driven approach to tackling waiting times. This study demonstrates its effectiveness in paediatric therapy services and provides evidence for a 'hub and spoke' approach to facilitate implementation that could be provided at scale.

An innovative model of access and triage to reduce waiting in an outpatient epilepsy clinic: an intervention study

BACKGROUND

Delayed access to outpatient care may negatively impact on health outcomes. We aimed to evaluate implementation of the Specific Timely Appointments for Triage (STAT) model of access in an epilepsy clinic to reduce a long waitlist and waiting time.

METHODS

This study is an intervention study using pre-post comparison and an interrupted time series analysis to measure the effect of implementation of the STAT model to an epilepsy clinic. Data were collected over 28 months to observe the number of patients on the waitlist and the waiting time over three time periods: 12 months prior to implementation of STAT, ten months during implementation and six months post-intervention. STAT combines one-off backlog reduction with responsive scheduling that protects time for new appointments based on historical data. The primary outcomes were the number of patients on the waitlist and the waiting time across the three time periods. Secondary outcomes evaluated pre- and post-intervention changes in number of appointments offered weekly, non-arrival and discharge rates.

RESULTS

A total of 938 patients were offered a first appointment over the study period. The long waitlist was almost eliminated, reducing from 616 during the pre-intervention period to 11 post-intervention (p = 0.002), but the hypothesis that waiting time would decrease was not supported. The interrupted time series analysis indicated a temporary increase in waiting time during the implementation period but no significant change in slope or level in the post- compared to the pre-intervention period. Direct comparison of the cohort of patients seen in the pre- and post-intervention periods suggested an increase in median waiting time following the intervention (34 [IQR 25-86] to 46 [IQR 36-61] days (p = 0.001)), but the interquartile range reduced indicating less variability in days waited and more timely access for the longest waiters.

CONCLUSIONS

The STAT model was implemented in a specialist epilepsy outpatient clinic and reduced a large waitlist. Reductions in the waitlist were achieved with little or no increase in waiting time. The STAT model provides a framework for an alternative way to operate outpatient clinics that can help to ensure that all people referred are offered an appointment in a timely manner.

Exploring the delivery of community rehabilitation services for older people in an urban Canadian setting: Perspectives of service providers, managers and health system administrators

As the global population of older people increases, policies aimed at improving health care delivery for older people often include supports for ageing in place. Living in the community not only reduces institutionalisation but also improves quality of life and reduces health care costs. For older people, community rehabilitation offers the opportunity to preserve and maximise function while maintaining the ability to live in the community. However, limited research examines the delivery, coordination and integration of community rehabilitation services in health systems. Our case study explored the perspectives of service providers, managers and health system administrators on the strengths, limitations and gaps in community rehabilitation for older people in one Canadian urban health region. Using interpretive description and thematic analysis, we analysed interview data from: 16 service providers, eight managers and five health system administrators. Three themes were identified: (a) Limited Access to Programs and Services; (b) Need to Emphasise Promoting, Maintaining and Restoring Function; and (c) Lack of Flow Across the System. Participants highlighted that restrictive eligibility criteria limited access to services. Services were organised around health conditions that did not address the needs of older people. Long waitlists meant that services were delayed. Transportation costs limited participation of individuals from lower socioeconomic status (SES). Age restrictions did not reflect differences in the ageing process and the health inequities individuals from lower SES groups experienced. There was a lack of emphasis in community rehabilitation programs on maintaining or restoring function in older people, which is the primary focus of rehabilitation. Furthermore, key stakeholders stressed the need for strengthening the integration of service delivery across the continuum of care. The findings underscore the need to develop a conceptual framework for community rehabilitation to promote greater system integration, access and availability of services and to optimise functional outcomes for older people.

Effect of inpatient rehabilitation treatment ingredients on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with unplanned admission: an overview review

BACKGROUND

To synthesise the evidence for the effectiveness of inpatient rehabilitation treatment ingredients (versus any comparison) on functioning, quality of life, length of stay, discharge destination, and mortality among older adults with an unplanned hospital admission.

METHODS

A systematic search of Cochrane Library, MEDLINE, Embase, PsychInfo, PEDro, BASE, and OpenGrey for published and unpublished systematic reviews of inpatient rehabilitation interventions for older adults following an unplanned admission to hospital from database inception to December 2020. Duplicate screening for eligibility, quality assessment, and data extraction including extraction of treatment components and their respective ingredients employing the Treatment Theory framework. Random effects meta-analyses were completed overall and by treatment ingredient. Statistical heterogeneity was assessed with the inconsistency-value (I2).

RESULTS

Systematic reviews (n = 12) of moderate to low quality, including 44 non-overlapping relevant RCTs were included. When incorporated in a rehabilitation intervention, there was a large effect of endurance exercise, early intervention and shaping knowledge on walking endurance after the inpatient stay versus comparison. Early intervention, repeated practice activities, goals and planning, increased medical care and/or discharge planning increased the likelihood of discharge home versus comparison. The evidence for activities of daily living (ADL) was conflicting. Rehabilitation interventions were not effective for functional mobility, strength, or quality of life, or reduce length of stay or mortality. Therefore, we did not explore the potential role of treatment ingredients for these outcomes.

CONCLUSION

Benefits observed were often for subgroups of the older adult population e.g., endurance exercise was effective for endurance in older adults with chronic obstructive pulmonary disease, and early intervention was effective for endurance for those with hip fracture. Future research should determine whether the effectiveness of these treatment ingredients observed in subgroups, are generalisable to older adults more broadly. There is a need for more transparent reporting of intervention components and ingredients according to established frameworks to enable future synthesis and/or replication.

TRIAL REGISTRATION

PROSPERO Registration CRD42018114323 .

Strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities: A systematic literature review

Objective

Identifying effective strategies to reduce waiting times is a crucial issue in many areas of health services. Long waiting times for rehabilitation services have been associated with numerous adverse effects in people with disabilities. The main objective of this study was to conduct a systematic literature review to assess the effectiveness of service redesign strategies to reduce waiting times in outpatient rehabilitation services for adults with physical disabilities.

Methods

We conducted a systematic review, searching three databases (MEDLINE, CINAHL and EMBASE) from their inception until May 2021. We identified studies with comparative data evaluating the effect of rehabilitation services redesign strategies on reducing waiting times. The Mixed Methods Appraisal Tool was used to assess the methodological quality of the studies. A narrative synthesis was conducted.

Results

Nineteen articles including various settings and populations met the selection criteria. They covered physiotherapy ( n = 11), occupational therapy ( n = 2), prosthetics ( n = 1), exercise physiology ( n = 1) and multidisciplinary ( n = 4) services. The methodological quality varied ( n = 10 high quality, n = 6 medium, n = 3 low); common flaws being missing information on the pre-redesign setting and characteristics of the populations. Seven articles assessed access processes or referral management strategies (e.g. self-referral), four focused on extending/modifying the roles of service providers (e.g. to triage) and eight changed the model of care delivery (e.g. mode of intervention). The different redesign strategies had positive effects on waiting times in outpatient rehabilitation services.

Conclusions

This review highlights the positive effects of many service redesign strategies. These findings suggest that there are several effective strategies to choose from to reduce waiting times and help better respond to the needs of persons experiencing physical disabilities.

Current practices, supports, and challenges in speech-language pathology service provision for autistic preschoolers

Background

Speech-language pathology services are among the most frequently accessed services for young autistic children. Therefore, understanding the nature of these services, what challenges these clinicians face, and what supports they value is critical for developing appropriate policies and practices that can maximize positive outcomes for children and families. This study had two primary aims. The first was to examine the self-reported assessment and intervention practices of community-based Speech Language Pathologists (SLPs) and communicative disorders assistants (CDAs; who provide services under the supervision of a SLP) in supporting preschool children with suspected and diagnosed autism. The second aim was to identify barriers and supports (facilitators) to providing services in the community using the Consolidated Framework for Implementation Research (CFIR) as a framework.

Methods

A cross-sectional online survey was used to collect qualitative and quantitative data from clinicians in Ontario Canada who were providing speech and language services to preschool children with suspected or diagnosed autism. Quantitative data were used to describe clinicians" practices, and qualitative data captured their perspectives on barriers and supports to providing services.

Results

A total of 258 clinicians participated in the survey. On average, clinicians reported almost half of the preschoolers on their caseload had either diagnosed or suspected autism. There was consistency across the skill development areas assessed by SLPs, and targeted during therapy sessions, with the top four areas targeted being: foundational social communication, language, play and pragmatics. However, there was wide variation in speech and language assessment and intervention practices reported by this sample of clinicians (i.e., service delivery models, tools or programs used, length and duration of therapy services, level of collaboration with other professionals). Clinicians identified several barriers to providing services: limited funding and time, lack of inter-professional collaboration, difficulty accessing services, community messaging about autism services, family readiness and clinician knowledge. Supports (facilitators) included: access to autism-focused professional development, inter- and intra-professional collaboration, and access to additional supports in the community.

Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec

BACKGROUND

In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models' similarities and differences.

METHODS

We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS's components included in the initially designed program, Mitchell and Lewis (2003)'s logic model framework, and Chaudoir and colleagues (2013)'s framework on contextual factors' influence on an innovation's implementation.

RESULTS

Findings show the APSS-CRDS program's regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists' availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors' influence, like ministerial and medical associations' involvement, collaborations, the context's implementation readiness, physician practice characteristics, and the program's adaptability.

INTERPRETATION

Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

Many inpatients may not be physically prepared for community ambulation on discharge from a publicly funded rehabilitation centre: a cross-sectional cohort study

PURPOSE

We assessed the ability of patients discharging home from inpatient rehabilitation to meet criteria for community ambulation.

METHODS

Cross-sectional observational study design. Participants were assessed, within 48-hours of discharge on their ability to: ascend/descend three steps, walk at a speed of 0.44 m/s, ascend/descend a slope, ascend/descend a kerb, and walk 315 m continuously. Demographic data were collected from medical records. Multiple logistic regression determined factors predictive of meeting criteria.

RESULTS

Of 200 participants (mean 73 years, 66% women, mixed diagnosis), 64 (32%) met all criteria. The least commonly met criteria were walking 315 m continuously (37%) and ascending/descending steps (70%). Participants who were female (OR: 0.27, 95%CI: 0.12-0.61), with a high comorbidity index (OR: 0.71, 95%CI: 0.56-0.91) or a traumatic orthopaedic diagnosis (OR: 0.22, 95%CI: 0.05-0.96) were less likely to meet all criteria. Participants with a higher admission functional independence walk item score (OR: 1.37, 95%CI: 1.05-1.78) or higher ambulatory self-confidence (OR: 1.02, 95%CI: 1.01-1.04) were more likely to meet all criteria.

CONCLUSIONS

Approximately, one-third of inpatients discharged home from a publicly funded rehabilitation centre met the community ambulation criteria, suggesting many may not be physically prepared to participate in their community.Implications for RehabilitationOnly about one in three inpatients discharging home from a publicly funded rehabilitation centre met physical criteria for community ambulation.Patients discharging home from inpatient rehabilitation have most difficulty walking long distances (≥315 m) compared to other criteria required for community ambulation (i.e., walking at a speed of 0.44 m/s, stepping up/down a kerb, ascending/descending a slope and ascending/descending three steps) and rehabilitation during this phase may require an increased focus on improving walking endurance/physical activity.Women with a high co-morbidity index, traumatic orthopaedic diagnosis, low self-confidence with ambulation on discharge and who require more assistance with walking on admission are least likely to meet the physical criteria for community ambulation at discharge, and therefore may require additional rehabilitation or supports.

Reducing the waitlist of referred patients in a medical specialist outpatient clinic: an observational study

PURPOSE

Long waitlists in outpatient clinics are a widely recognised problem. The purpose of this paper is to describe and report the impact of a waitlist reduction strategy for an epilepsy clinic.

DESIGN/METHODOLOGY/APPROACH

This observational study described the local impact of a methodical approach to tackling a long waiting list, using targeted strategies supported by a modest additional budget. The interventions were described using the template for intervention description and replication (TIDieR).

FINDINGS

Over an eight-month period, the waitlist for the epilepsy clinic was reduced from 599 to 24 patients without increasing the number of days until the next available appointment. Most referrals were removed from the waitlist without an appointment. Auditing revealed a high proportion of patients no longer required the service or referrals remained on the waitlist due to administration error. A short-term increase in clinic capacity of 51 extra appointments met the needs of the remaining waiting patients. The additional project funding invested in this process was AUD $10,500 and a time-limited amount of extra work was absorbed by using existing clinic resources.

PRACTICAL IMPLICATIONS

This waitlist reduction strategy resulted in a very small waitlist for the epilepsy clinic, which is now well placed to trial further interventions with the aim of sustaining the service with minimal waiting times. Not every referral on the waitlist, particularly the very long waiters, required an appointment. Other outpatient clinics may be able to apply this process to reduce their waitlists using a modest budget.

ORIGINALITY/VALUE

Although there are reports of successful waitlist reduction, few report the intervention in detail. Use of the TIDieR in reporting enables the intervention to be appraised or adapted to other settings where long waitlists are problematic. Considerations related to implementation of policy are discussed and in this case, a locally led and executed change management strategy was a key to achieving the result.

Return on investment of a model of access combining triage with initial management: an economic analysis

OBJECTIVES

Timely access to outpatient services is a major issue for public health systems. To address this issue, we aimed to establish the return on investment to the health system of the implementation of an alternative model for access and triage (Specific Timely Appointments for Triage: STAT) compared with a traditional waitlist model.

DESIGN

Using a prospective pre-post design, an economic analysis was completed comparing the health system costs for participants who were referred for community outpatient services post-implementation of STAT with a traditional waitlist comparison group.

SETTING

Eight community outpatient services of a health network in Melbourne, Australia.

PARTICIPANTS

Adults and children referred to community outpatient services.

INTERVENTIONS

STAT combined targeted activities to reduce the existing waiting list and direct booking of patients into protected assessment appointments. STAT was compared with usual care, in which new patients were placed on a waiting list and offered appointments as space became available.

OUTCOMES

Health system costs included STAT implementation costs, outpatient health service use, emergency department presentations and hospital admissions 3 months before and after initial outpatient appointment. Waiting time was the primary outcome. Incremental cost-effectiveness ratios (ICERs) were estimated from the health system perspective.

RESULTS

Data from 557 participants showed a 16.9 days or 29% (p<0.001) reduction in waiting time for first appointment with STAT compared with traditional waitlist. The ICER showed a cost of $A10 (95% CI -19 to 39) per day reduction in waiting time with STAT compared with traditional waitlist. Modelling showed the cost reduced to $A4 (95% CI -25 to 32) per day of reduction in waiting, if reduction in waiting times is sustained for 12 months.

CONCLUSIONS

There was a significant reduction in waiting time with the introduction of STAT at minimal cost to the health system.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12615001016527).

Effects of a single-entry intake system on access to outpatient visits to specialist physicians and allied health professionals: a systematic review

BACKGROUND

Canada lags behind other countries with respect to wait times for specialist physician and allied health professional consultations. We conducted a systematic review to assess the effects of a single-entry model on waiting time, referral volume and the satisfaction of patients and health care providers.

METHODS

We searched MEDLINE, Embase, Cochrane CENTRAL and CINAHL databases from inception to December 2019. We included studies from countries in the Organisation for Economic Co-operation and Development that reported on the effects of a single-entry model on the time between referral to first assessment by a specialist physician or allied health professional, termed wait time 1 (WT1). Patient volume and the satisfaction of providers and patients were secondary outcomes. We conducted a narrative synthesis using descriptive statistics.

RESULTS

Of the 4637 citations identified, 17 met the eligibility criteria, and we included 10 of these in the final analysis. All of the included studies reported an absolute reduction in WT1 after implementation of the single-entry model. The average percent reduction in WT1 across specialties was greatest for surgical referrals (57%) and urgent internal medicine referrals (40%). Higher initial WT1 was associated with a greater absolute reduction in WT1 after implementation of the single-entry model (p = 0.002). Patient and provider satisfaction with the single-entry model was high in all studies. The effect estimates from all included studies were at high risk of bias.

INTERPRETATION

Single-entry models were associated with an absolute reduction in time from referral from primary care to consultation. These models represent a promising option to improve access to a range of health services, but there is a need for rigorous prospective evaluations to inform policy.

PROSPERO REGISTRATION

CRD42018100395.

A Multi-Faceted Strategy for Evidence Translation Reduces Healthcare Waiting Time: A Mixed Methods Study Using the RE-AIM Framework

Background: Waiting lists are often thought to be inevitable in healthcare, but strategies that address patient flow by reducing complexity, combining triage with initial management, and/or actively managing the relationship between supply and demand can work. One such model, Specific Timely Appointments for Triage (STAT), brings these elements together and has been found in multiple trials to reduce waiting times by 30–40%. The next challenge is to translate this knowledge into practice.

Method: A multi-faceted knowledge translation strategy, including workshops, resources, dissemination of research findings and a community of practice (CoP) was implemented. A mixed methods evaluation of the strategy was conducted based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework, drawing on an internal database and a survey of workshop and CoP participants.

Results: Demonstrating reach, at July 2020 an internal database held details of 342 clinicians and managers from 64 health services who had participated in the workshop program (n = 308) and/or elected to join an online CoP (n = 227). 40 of 69 (58%) respondents to a survey of this population reported they had adopted the model, with some providing data demonstrating that the STAT model had been efficacious in reducing waiting time. Perceived barriers to implementation included an overwhelming existing waiting list, an imbalance between supply and demand and lack of resources.

Conclusion: There is high quality evidence from trials that STAT reduces waiting time. Using the RE-AIM framework, this evaluation of a translation strategy demonstrates uptake of evidence to reduce waiting time in health services.

Sustainable waiting time reductions after introducing the STAT model for access and triage: 12-month follow up of a stepped wedge cluster randomised controlled trial

Background

Timely access is a challenge for providers of outpatient and community-based health services, as seen by the often lengthy waiting lists to manage demand. The Specific Timely Appointments for Triage (STAT) model, an alternative approach for managing access and triage, reduced waiting time by 34% in a stepped wedge cluster randomised controlled trial involving 8 services and more than 3000 participants. Follow up periods ranged from 3 to 10 months across the participating services in accordance with the stepped wedge design. This study aimed to determine whether outcomes were sustained for a full 12 months after implementation of the STAT model at each site.

Methods

Routinely collected service data were obtained for a total of 12 months following implementation of the STAT model at each of the 8 services that participated in a stepped wedge cluster randomised controlled trial. The primary outcome was time to first appointment. Secondary outcomes included non-attendance rates, time to second appointment and service use over 12 weeks. Outcomes were compared to pre-intervention data from the original trial, modelled using generalised linear mixed effects models accounting for clustering of sites.

Results

A 29% reduction in waiting time could be attributed to STAT over 12 months, compared to 34% in the original trial. A reduction in variability in waiting time was sustained. There were no significant changes in time to second appointment or in the number of missed appointments in the extended follow up period.

Conclusions

STAT is an effective strategy for reducing waiting time in community-based outpatient services. At 12 months, small reductions in the overall effect are apparent, but reductions in variability are sustained, suggesting that people who previously waited the longest benefit most from the STAT model.

Trial registration

This is a 12-month follow up of a stepped wedge cluster randomised controlled trial that was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12615001016527).

Specific timely appointments for triage to reduce wait times in a medical outpatient clinic: protocol of a pre-post study with process evaluation

Background

Managing demand for services is a problem in many areas of healthcare, including specialist medical outpatient clinics. Some of these clinics have long waiting lists with variation in access for referred people. A model of triage and appointment allocation has been developed and tested that has reduced waiting times by about a third in community outpatient services. This study aims to determine whether the model can be applied in the setting of a specialist medical outpatient clinic to reduce wait time from referral to first appointment.

Methods

A pre-post study will collect data before and after implementing the Specific Timely Appointments for Triage (STAT) model of access and triage. The study will incorporate a pre-implementation period of 12 months, an implementation period of up to 6 months and a post STAT-implementation period of 6 months. The setting will be the epilepsy clinic at a metropolitan health service in Melbourne. Included will be all people referred to the clinic, or currently waiting, during the allocated periods of data collection (total sample estimated n = 975). Data routinely collected by the health service and qualitative data from staff will be analysed to determine the effects of introducing the STAT model. The primary outcome will be wait time, measured by number of patients on the wait list at monthly time points and the mean number of days waited from referral to first appointment. Secondary outcomes will include patient outcomes, such as admission to hospital while waiting, and service outcomes, including rate of discharge. Analysis of the primary outcome will include interrupted time series analysis and simple comparisons of the pre and post-implementation periods. Process evaluation will include investigation of the fidelity of the intervention, adaptations required and qualitative analysis of the experiences of clinic staff.

Discussion

Prompt access to service and optimum patient flow is important for patients and service providers. Testing the STAT model in a specialist medical outpatient clinic will add to the evidence informing service providers and policy makers about how the active management of supply and demand in health care can influence wait times. The results from this study may be applicable to other specialist medical outpatient clinics, potentially improving access to care for many people.

Are wait lists inevitable in subacute ambulatory and community health services? A qualitative analysis

Objectives Wait lists are common in ambulatory and community-based services. The aim of the present study was to explore managers' perceptions of factors that contribute to wait times. Methods A qualitative study was conducted using semi-structured interviews with managers and team leaders of ambulatory and community health services within a large health network. Interviews were transcribed and coded, and the codes were then grouped into themes and subthemes. Results Representatives from 26 services participated in the project. Four major themes were identified. Three themes related to reasons and factors contributing to increased wait time for services (inefficient intake and scheduling processes; service disruptions due to human resource issues; and high service demand). A fourth theme related to staff attitudes towards wait times and acceptance and acknowledgement of wait lists. Conclusions Service providers perceive high demand to be a key driver of wait times, but a range of other factors also contributes and may represent opportunities for improving access to care. These other factors include improving process efficiencies, greater consistency of service delivery through more efficient management of human resources and shifting to more consumer-centred approaches in measuring wait times in order to drive improvements in patient flow. What is known about the topic? Wait times are common in out-patient and ambulatory services. These services experience high demand, which is likely to continue to grow as health service delivery shifts from hospital to community settings. What does this paper add? Although demand is an important driver of wait times, there are other modifiable factors that also contribute, including process inefficiencies and service disruption related to human resource issues. An underlying staff attitude of acceptance of wait times appears to be an additional barrier to improving access. What are the implications for practitioners? The findings of the present study suggest that there are opportunities for improving access to ambulatory and community health services through more efficient use of existing resources. However, a more consumer-focused approach regarding acceptability of wait times is needed to help drive change.

Staff perspectives of a model of access and triage for reducing waiting time in ambulatory services: a qualitative study

Background

Specific Timely Appointments for Triage (STAT) is an intervention designed to reduce waiting time in community outpatient health services, shown to be effective in a large stepped wedge cluster randomised controlled trial. STAT combines initial strategies to reduce existing wait lists with creation of a specific number of protected appointments for new patients based on demand. It offers an alternative to the more traditional methods of demand management for these services using waiting lists with triage systems. This study aimed to explore perceptions of clinicians and administrative staff involved in implementing the model.

Method

Semi-structured interviews with 20 staff members who experienced the change to STAT were conducted by an independent interviewer. All eight sites involved in the original trial and all professional disciplines were represented in the sample. Data were coded and analysed thematically.

Results

Participants agreed that shorter waiting time for patients was the main advantage of the STAT model, and that ongoing management of caseloads was challenging. However, there was variation in the overall weight placed on these factors, and therefore the participants’ preference for the new or previous model of care. Perceptions of whether the advantages outweighed the disadvantages were influenced by five sub-themes: staff perception of how much waiting matters to the patient, prior exposure to the management of waiting list, caseload complexity, approach and attitude to the implementation of STAT and organisational factors.

Conclusions

The STAT model has clear benefits but also presents challenges for staff members. The findings of this study suggest that careful preparation and management of change and active planning for known fluctuations in supply and demand are likely to help to mitigate sources of stress and improve the likelihood of successful implementation of the STAT model for improving waiting times for patients referred to community outpatient services.

A categorisation of problems and solutions to improve patient referrals from primary to specialty care

BACKGROUND

Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated.

METHODS

We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes.

RESULTS

We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies.

CONCLUSION

The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.

Reducing wait time from referral to first visit for community outpatient services may contribute to better health outcomes: a systematic review

BACKGROUND

Many people wait long periods for community outpatient services. However little is known about the impact of waiting from referral to first visit on patient outcomes. The aim of this systematic review is to investigate whether waiting for community outpatient services is associated with adverse effects on patient outcomes.

METHODS

Medline, Embase, Psych Info and CINAHL databases were searched, combining the key concepts of waiting for healthcare and patient outcomes. Studies were included if they reported data comparing health outcomes for patients with different waiting times for the same period. Three reviewers applied inclusion and exclusion criteria to identified studies and assessed quality using the McMaster Critical Review Forms. Levels of evidence were assessed using National Health and Medical Research Council guidelines. Included studies were analysed using a descriptive synthesis, and summarised according to levels of evidence and clinical significance for key outcomes.

RESULTS

Fourteen studies that included 69,606 adult patients were selected. Selected studies included patients referred for treatment for musculoskeletal disorders (n = 28,722) or to cardiac rehabilitation (n = 40,884). There was low-level evidence that reduced wait time is associated with moderate improvement in workplace participation for patients seeking care for musculoskeletal conditions; and moderate improvement in exercise tolerance for patients referred to cardiac rehabilitation. There was inconsistent evidence that improvements in quality of life, patient satisfaction and psychological symptoms may be associated with shorter wait times. Pain, function and physical activity outcomes were not associated with wait time.

CONCLUSIONS

This review found low-level evidence suggesting an association between early access to community outpatient services and improvement of some patient outcomes. Specifically, shorter wait times from referral to first visit for musculoskeletal pain services may improve patient work participation. Shorter wait times for cardiac rehabilitation may improve patient exercise capacity. The effects of a short wait time for other patient conditions and patient outcomes, including quality of life, psychological symptoms and patient experience, are inconclusive. The modest benefits in health outcomes observed in reducing wait time for community outpatient services suggest that other possible benefits such as increasing patient flow should be explored.

TRIAL REGISTRATION

PROSPERO registration no: CRD42016047003.

A model of access combining triage with initial management reduced waiting time for community outpatient services: a stepped wedge cluster randomised controlled trial

BACKGROUND

Long waiting times are associated with public community outpatient health services. This trial aimed to determine if a new model of care based on evidence-based strategies that improved patient flow in two small pilot trials could be used to reduce waiting time across a variety of services. The key principle of the Specific Timely Appointments for Triage (STAT) model is that patients are booked directly into protected assessment appointments and triage is combined with initial management as an alternative to a waiting list and triage system.

METHODS

A stepped wedge cluster randomised controlled trial was conducted between October 2015 and March 2017, involving 3116 patients at eight sites across a major Australian metropolitan health network.

RESULTS

The intervention reduced waiting time to first appointment by 33.8% (IRR = 0.663, 95% CI 0.516 to 0.852, P = 0.001). Median waiting time decreased from a median of 42 days (IQR 19 to 86) in the control period to a median of 24 days (IQR 13 to 48) in the intervention period. A substantial reduction in variability was also noted. The model did not impact on most secondary outcomes, including time to second appointment, likelihood of discharge by 12 weeks and number of appointments provided, but was associated with a small increase in the rate of missed appointments.

CONCLUSIONS

Broad-scale implementation of a model of access and triage that combined triage with initial management and actively managed the relationship between supply and demand achieved substantial reductions in waiting time without adversely impacting on other aspects of care. The reductions in waiting time are likely to have been driven, primarily, by substantial reductions for those patients previously considered low priority.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12615001016527 registration date: 29/09/2015.

Waiting for a Pediatric Chronic Pain Clinic Evaluation: A Prospective Study Characterizing Waiting Times and Symptom Trajectories

Chronic pain during childhood is prevalent and costly, but the access to interdisciplinary pain care is limited. Studies investigating adults waiting for pain clinic evaluation found that symptoms and quality of life deteriorate over the waiting period, but little is known about the experience of adolescents. Therefore, we aimed to determine wait list times and the longitudinal trends of pain and physical, mental, and social health over a 12-week period. In total, 97 adolescents, aged 10 to 18 years (M = 14.7 years, 82% female), waiting for evaluation at an interdisciplinary pediatric pain clinic completed assessments at enrollment and at 4-, 8-, and 12-week follow-up. We performed a review of the medical record of attendance patterns 12 months later. Twelve adolescents and their parents also completed qualitative interviews, describing their experience of waiting for evaluation. Wait times averaged 197.5 days (range = 69-758 days) from the time of referral to the first-attended appointment, and 86.6% of youths completed appointments. Longitudinal repeated measures analyses demonstrated little improvement in pain or other domains of functioning over the 12-week period. In qualitative interviews, families described anxious anticipation for the upcoming appointment, combined with frustration in waiting. Findings highlight the need to consider approaches to reduce wait times and provide early intervention for youths awaiting pain clinic evaluation. Perspective: This study extends the literature on the characteristics and symptom trajectories of adolescents during the wait period for interdisciplinary pain clinic evaluation, described previously only in adults with chronic pain. Findings demonstrated an average wait time of 6.5 months, during which youths' pain and physical and social health remained impaired.

A modified walk-in system versus scheduled appointments in a secondary-care prosthetic and orthotic clinic

BACKGROUND

Waiting is common in health care, delays intervention, and has negative effects on satisfaction with services.

OBJECTIVES

To evaluate effects of a modified walk-in system, where patients were invited consecutively from the waiting list to attend the clinic on a walk-in basis, on waiting times, services, and work environment.

STUDY DESIGN

Parallel-group trial.

METHODS

In all, 1286 consecutive patients in need of shoe insoles were randomized to waiting lists for modified walk-in ( n = 655) or a scheduled appointment ( n = 631). Seven staff members also participated.

RESULTS

The median indirect waiting time to first appointment was 40 days shorter for modified walk-in (135 days) than for scheduled appointment (175 days; p < 0.001); 17% of those randomized to modified walk-in did not attend the clinic compared to 6% for scheduled appointment ( p < 0.001). Mean direct waiting time in the waiting room was 9.9 min longer for modified walk-in than for scheduled appointment ( p < 0.001). Patients attending modified walk-in or a scheduled appointment reported similar levels of satisfaction with services. Staff reported more support from co-workers with modified walk-in than with scheduled appointment ( p = 0.041).

CONCLUSION

The modified walk-in can reduce indirect waiting times without any substantial worsening of direct waiting times, service quality, or work environment. Studies are needed to investigate why many patients drop out from modified walk-in. Clinical relevance A modified walk-in system can cut the queues and create more timely interventions by reducing indirect waiting times. This system can therefore be recommended in secondary-care prosthetic and orthotic clinics to reduce patients' suffering from their health condition.

Changes in health-related quality of life (EQ-5D) dimensions associated with community-based musculoskeletal physiotherapy: a multi-centre analysis

Purpose

To determine the changes in each of the five dimensions of the EuroQol 5-dimension index associated with community-based physiotherapy.

Methods

Four thousand one hundred and thirty-six patients that received community-based musculoskeletal physiotherapy across five NHS centres completed the EQ-5D on entry into the service and upon discharge. Patients were categorised on symptom location and response to treatment based on their EQ-5D index improving by at least 0.1 (“EQ-5D responders”). For each symptom location, and for responders and non-responders to treatment, the mean (± SD) were calculated for each dimension pre- and post-treatment as well as the size of effect.

Results

The mobility dimension improved (p < 0.05) in all symptom locations for EQ-5D responders (d = 0.26–1.58) and in ankle, knee, hip and lumbar symptoms for EQ-5D non-responders (d = 0.17–0.45). The self-care dimension improved (p < 0.05) in all symptom locations for EQ-5D responders (d = 0.49–1.16). The usual activities dimension improved (p < 0.05) across all symptom locations for EQ-5D responders (d = 1.00–1.75) and EQ-5D non-responders (d = 0.14–0.60). Despite the pain/discomfort dimension improving (p < 0.05) across all symptom locations for both EQ-5D responders (d = 1.07–1.43) and EQ-5D non-responders (d = 0.29–0.66), the anxiety/depression dimension improved (p < 0.05) from higher starting levels in EQ-5D responders (d = 0.76–1.05) with no change seen for EQ-5D non-responders (d = − 0.16 to 0.06).

Conclusions

Clinicians should not assume that a patient presenting with pain but expressing high anxiety/depression is unlikely to respond to treatment, as they may show the best HRQoL outcomes. For patients presenting with pain/discomfort and low levels of anxiety/depression, the EQ-5D index is perhaps not a suitable tool for sole use in patient management and service evaluation.

Operationalizing wait lists: Strategies and experiences in three hospital outpatient physiotherapy departments in Montreal

In Canada, limited resources and increasing demand place pressure on the public healthcare system, something that is likely to increase. In this context, wait lists in outpatient physiotherapy departments (OPD) will get longer, system inefficiencies will arise, and frustrations and ethical concerns will be experienced by patients and staff. To better understand the perceptions of OPD staff regarding priority setting, treatment frequency, treatment duration, and wait list management strategies, we conducted an Interpretive Description study involving semi-structured interviews in three OPDs in Montreal. Participants discussed factors that influenced their decision making about who was prioritized to receive care, strategies that were used to respond to an imbalance between needs and resources in the OPDs and procedures to manage wait lists to help improve access to care. While clinical needs are central in approaches to prioritization, other non-clinical factors relating to the patient, the physiotherapist, and the institution also influence decisions. We examine these findings through the lens of complexity theory, providing insight into opportunities and obstacles for the implementation of management strategies in OPDs. These strategies will need to be carefully evaluated in order to create evidence-based guidelines for wait list management in other settings.

Access to publicly funded outpatient physiotherapy services in Quebec: waiting lists and management strategies

PURPOSE

Problems with access to outpatient physiotherapy services have been reported in publicly funded healthcare systems worldwide. A few studies have reported management strategies aimed at reducing extensive waiting lists, but their association with waiting times is not fully understood. The purpose of this study was to document access to public outpatient physiotherapy services for persons with musculoskeletal disorders in hospitals and explore organizational factors associated with waiting time.

METHODS

We surveyed outpatient physiotherapy services in publicly funded hospitals in the province of Quebec (Canada).

RESULTS

A total of 97 sites responded (99%) to the survey. The median waiting time was more than six months for 41% of outpatient physiotherapy services. The waiting time management strategies most frequently used were attendance and cancelation policies (99.0%) and referral prioritization (95.9%). Based on multivariate analyses, the use of a prioritization process with an initial evaluation and intervention was associated with shorter waiting times (p = 0.008).

CONCLUSIONS

Our findings provide evidence that a large number of persons wait a long time for publicly funded physiotherapy services in Quebec. Based on our results, implementation of a prioritization process with an initial evaluation and intervention could help improve timely access to outpatient physiotherapy services. Implications for Rehabilitation Access to publicly funded outpatient physiotherapy services is limited by long waiting times in a great proportion of Quebec's hospitals. The use of a specific prioritization process that combines an evaluation and an intervention could possibly help improve timely access to services. Policy-makers, managers, and other stakeholders should work together to address the issue of limited access to publicly funded outpatient physiotherapy services.

Improving access for community health and sub-acute outpatient services: protocol for a stepped wedge cluster randomised controlled trial

Background

Waiting lists for treatment are common in outpatient and community services, Existing methods for managing access and triage to these services can lead to inequities in service delivery, inefficiencies and divert resources from frontline care. Evidence from two controlled studies indicates that an alternative to the traditional “waitlist and triage” model known as STAT (Specific Timely Appointments for Triage) may be successful in reducing waiting times without adversely affecting other aspects of patient care. This trial aims to test whether the model is cost effective in reducing waiting time across multiple services, and to measure the impact on service provision, health-related quality of life and patient satisfaction.

Methods/design

A stepped wedge cluster randomised controlled trial has been designed to evaluate the impact of the STAT model in 8 community health and outpatient services. The primary outcome will be waiting time from referral to first appointment. Secondary outcomes will be nature and quantity of service received (collected from all patients attending the service during the study period and health-related quality of life (AQOL-8D), patient satisfaction, health care utilisation and cost data (collected from a subgroup of patients at initial assessment and after 12 weeks). Data will be analysed with a multiple multi-level random-effects regression model that allows for cluster effects. An economic evaluation will be undertaken alongside the clinical trial.

Discussion

This paper outlines the study protocol for a fully powered prospective stepped wedge cluster randomised controlled trial (SWCRCT) to establish whether the STAT model of access and triage can reduce waiting times applied across multiple settings, without increasing health service costs or adversely impacting on other aspects of patient care. If successful, it will provide evidence for the effectiveness of a practical model of access that can substantially reduce waiting time for outpatient and community services with subsequent benefits for both efficiency of health systems and patient care.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12615001016527. Approved 15/9/2015.

Impact of the single point of access referral system to reduce waiting times and improve clinical outcomes in an assistive technology service

The introduction of a single point referral system that prioritises clients depending on case complexity and overcomes the need for re-admittance to a waiting list via a review system has been shown to significantly reduce maximum waiting times for a Posture and Mobility (Special Seating) Service from 102.0 ± 24.33 weeks to 19.2 ± 8.57 weeks (p = 0.015). Using this service model linear regression revealed a statistically significant improvement in the performance outcome of prescribed seating solutions with shorter Episode of Care completion times (p = 0.023). In addition, the number of Episodes of Care completed per annum was significantly related to the Episode of Care completion time (p = 0.019). In conclusion, it is recommended that it may be advantageous to apply this service model to other assistive technology services in order to reduce waiting times and to improve clinical outcomes.

Waiting list management practices for home-care occupational therapy in the province of Quebec, Canada

Referral prioritisation is commonly used in home-based occupational therapy to minimise the negative impacts of waiting, but this practice is not standardised. This may lead to inequities in access to care, especially for clients considered as low priority, who tend to bear the brunt of lengthy waiting lists. This cross-sectional study aimed to describe waiting list management practices targeting low-priority clients in home-based occupational therapy in the province of Quebec, Canada, and to investigate the association between these practices and the length of the waiting list. A structured telephone interview was conducted in 2012-2013 with the person who manages the occupational therapy waiting list in 55 home care programmes across Quebec. Questions pertained to strategies aimed at servicing low-priority clients, the date of the oldest referral and the number of clients waiting. Results were analysed using descriptive statistics and non-parametric tests. The median wait time for the oldest referral was 18 months (range: 2-108 months). A variety of strategies were used to service low-priority clients. Programmes that used no strategies to service low-priority clients (n = 16) had longer wait times (P < 0.0001) and a greater number of people on the waiting list (P = 0.006) compared with programmes that applied a maximum wait time target (n = 12). In conclusion, diverse strategies exist to allocate services to low-priority clients in home-based occupational therapy programmes. However, in programmes where none of these strategies are used, low-priority clients may be denied access to services indefinitely.

Specific timely appointments for triage reduced waiting lists in an outpatient physiotherapy service

OBJECTIVES

Waiting lists with triage systems are commonly used in outpatient physiotherapy but may not be effective. Could an alternative model of access and triage reduce waiting times over a sustained period with no additional resources?

DESIGN

Observational study comparing retrospective data for 11 months prior to the introduction of a new model of access compared with data for the equivalent 11 months afterwards.

PARTICIPANTS

Patients referred to a physiotherapy outpatient department at an outer metropolitan hospital before (n=721) and after (n=707) the introduction of the new model.

INTERVENTION

A model of access and triage known as 'specific timely appointments for triage' (STAT), in which appointment slots are preserved in advance specifically for new patients based on calculation of average demand.

OUTCOME MEASURES

Time from referral to first assessment, number of appointments per patient, occasions of non-attendance and total length of stay in the service.

RESULTS

Median time from referral to first appointment was 18 days [interquartile range (IQR) 11 to 33 days] in the pre-intervention group, compared with 14 days (IQR 9 to 21 days) in the post-intervention group (P<0.01). The number of physiotherapy appointments also reduced (IQR 2 to 6 vs IQR 1 to 4; P<0.01). There were no changes in non-attendance rates or total time in the service.

CONCLUSION

Waiting time for outpatient physiotherapy was 22% lower in the year following the introduction of the STAT model. While acknowledging the limitations of a pre- and post-measurement design, this model may have potential for reducing waiting times for outpatient physiotherapy without additional resources.

Old tool, new tricks? A new adaptation of the Modified Falls Efficacy Scale

Aim:

Measuring outcomes is important in community rehabilitation programs (CRPs), both at the individual and service level. Identifying global outcome measures that can be used for all patients is challenging given the diversity of this client group.

Method:

This observational study explored measurement properties of the Modified Efficacy Scale (MES), which is an adaptation of the Modified Falls Efficacy Scale. The MES was used to assess patient confidence in performing activities without reference to falls and was trialled with 221 CRP patients. Floor and ceiling effects, responsiveness to change and minimal clinically important difference (MCID) scores were measured and compared with scores for the same sample of patients using the Lawton Instrumental Activities of Daily Living (IADL) scale.

Results:

The MES showed evidence of convergent validity and was responsive to change. Both scales showed ceiling effects on discharge, although this was more pronounced with the Lawton IADL scale (40%) than the MES (21%). Both scales had small values for MCID relative to scale width.

Conclusions:

The MES demonstrated evidence of validity and has a less pronounced ceiling effect compared with the Lawton IADL scale. The implications of a ceiling effect should be considered in the context of the assessment purpose.