Policy strategies to reduce waits for elective care: a synthesis of international evidence

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.

Reducing Waiting Times and Admission Periods through Pre-Admission Testing: A Quality Improvement Study on In-Hospital Renal Biopsy

Background: Admission for renal biopsy is considered the gold standard for diagnosing kidney disease. However, prolonged waiting times for admission can lead to delayed diagnosis. Despite this issue, there are currently no studies demonstrating how to improve the efficiency of renal biopsy procedures. Methods: We initiated a quality improvement project to implement pre-admission testing (PAT) for renal biopsy from 2016 to 2024 (until 15 April). Our evaluation focused on waiting times for admission, length of admission periods, hospitalization expenses, percentage of cases with no renal biopsy performed, incidence of severe bleeding due to renal biopsy, and percentage of cases with adequate tissue samples obtained. Additionally, we highlighted the time periods during the outbreak of SARS-CoV-2. Results: The highest annual case number was observed in time period 1 (168.3/year). Following the outbreak of SARS-CoV-2, there was a notable decrease in case numbers during time period 2 (119.8), which then increased to 143.0 in time period 3 (post-SARS-CoV-2 era). The mean waiting time was 13.72 ± 40.30 days for time period 1 and 10.00 ± 47.80 days for time period 2, without statistical significance. Following the implementation of PAT, patients now only need to wait approximately 0.76 days for admission, representing a significant reduction in waiting time. Subsequently, following the implementation of PAT, the waiting time decreased significantly to 2.09 ± 2.65 days. Additionally, hospitalization expenses per patient significantly decreased from approximately USD 69.62 ± 97.09 to USD 41.66 ± 52.82. The percentage of missed biopsy is significantly low (p < 0.001). Severe bleeding events (indicated as embolization and blood transfusion) were consistent across the three time periods (p = 0.617). Conclusions: The implementation of PAT can improve the pre-admission process for renal biopsy, resulting in decreased waiting times, fewer missed appointments, shorter admission durations, and reduced hospitalization expenses. We propose implementing PAT for outpatient individuals awaiting in-hospital renal biopsy procedures to mitigate delayed diagnosis, reduce pre-admission waiting periods, and streamline admission processes, thereby enhancing overall patient care efficiency.

Study protocol for a cross-sectional online survey investigating patient preferences and experiences of waiting for elective cardiac surgery

INTRODUCTION

Being on a waiting list for elective (planned) cardiac surgery can be physically and psychologically challenging for patients. Research suggests that stress associated with waiting for surgery is dependent on different individual and contextual factors. However, most data on patients' experiences of waiting for surgery and preferences for waiting list management derives from non-cardiac clinical populations. The aim of the current study is to explore patients' experiences of being on a waiting list for elective cardiac surgery, and their views on how the waiting experience could be improved in the future. This work will inform the patient management strategy during the waiting period for surgery across the four major hospitals in London directly involved in this study, and potentially beyond by transferring learning to other services.

METHODS AND ANALYSIS

This is a mixed-methods study that will collect quantitative and qualitative data using a cross-sectional online survey. Patients who are on waiting lists for elective surgery across four major cardiac surgery departments in London hospitals, and are at least 18 years old, will be invited by their healthcare team via text message or letter to complete the survey. The target sample size of non-randomly selected participants will be 268. Bivariable and multivariable regression models will be used to assess associations between survey items measuring the impact of the cardiac condition on specific life domains (eg, daily activities, social and family relationships, hobbies, sexual life), anxiety and depression symptoms as measured by the Patient Health Questionnaire-4 and survey items evaluating experiences of health services. Data on experience and preferences for improvements to the waiting experience will be analysed with qualitative content analysis using an inductive approach.

ETHICS AND DISSEMINATION

This study was reviewed and granted ethical approval by the East of England-East Cambridge Research Ethics Committee. Findings from this study will be disseminated through peer-reviewed journals, a research website and social media and with an online event engaging patients, members of the public, healthcare professionals and other relevant stakeholders.

TRIAL REGISTRATION NUMB

NCT05996640.

'I just need a plan': Consumer perceptions of waiting for healthcare

RATIONALE

Wait lists are common in the provision of publicly funded services in outpatient and community settings.

AIMS AND OBJECTIVES

We aimed to explore the experiences of consumers on wait lists across a broad range of services and to understand the impact of delays in access to services on people's lives.

METHODS

Consumers with experience of being on a wait list for an outpatient or community-based health service participated in one of three focus groups. Data were transcribed and analysed inductively using a thematic approach.

RESULTS

Waiting for healthcare has detrimental impacts on health and well-being. Consumers on wait lists want their health needs addressed, but they also want the ability to plan, clear communication and to feel like someone cares. Instead, they feel forgotten by impersonal and inflexible systems with very little communication, with emergency departments and general practitioners often left to fill in the gaps.

CONCLUSIONS

More consumer-centred approaches are needed for access systems for outpatient and community services, featuring honesty about what services can realistically be provided, early access to initial assessment and information and clear lines of communication.

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.

[Assessment of the implementation of an care teleregulation project in a Brazilian capital city]

This study evaluates the degree of implementation (DI) of the Regulates+ Brazil project and analyzes to what extent the variations in implementation influence the results observed in access to specialized appointments in Recife, Pernambuco, Brazil. This is an evaluative research of implementation analysis. A logic model and an analysis and judgment matrix with indicators for evaluating the degree of implementation and the results of the Project were developed and submitted to expert consensus. The data collection was conducted via a semi-structured questionnaire applied to key informants and secondary data extracted from the official documents from Regulates+ Brazil and Brazilian National Regulation System (SISREG), referring to the period from May/2020 to May/2021, which were consolidated and compared with values defined in the matrix. The degree of implementation of the Regulates+ Brazil project in Recife was considered to be implemented (83.7%), as well as the Structure (81.7%) and Methods (84.6%) dimensions. However, most effect indicators underperformed, which, when confronted, were consistent with bottlenecks observed in some components and subcomponents of the Project, such as the performance of professionals in basic health units, which was indicated as incipient, especially regarding follow-up of returned requests. The results suggest that any intervention in Telehealth requires, for its proper implementation, the adequacy of teams and work processes, practices of Continuing Education, as well as a continuous evaluation process, to achieve the expected results, or else it will become another bureaucratization and barrier to access.

The impact of delayed nonurgent surgery during the COVID-19 pandemic on surgeons in Alberta: a qualitative interview study

BACKGROUND

During the COVID-19 pandemic, nonurgent surgeries were delayed to preserve capacity for patients admitted with COVID-19; surgeons were challenged personally and professionally during this time. We aimed to describe the impact of delays to nonurgent surgeries during the COVID-19 pandemic from the surgeons' perspective in Alberta.

METHODS

We conducted an interpretive description qualitative study in Alberta from January to March 2022. We recruited adult and pediatric surgeons via social media and through personal contacts from our research network. Semistructured interviews were conducted via Zoom, and we analyzed the data via inductive thematic analysis to identify relevant themes and subthemes related to the impact of delaying nonurgent surgery on surgeons and their provision of surgical care.

RESULTS

We conducted 12 interviews with 9 adult surgeons and 3 pediatric surgeons. Six themes were identified: accelerator for a surgical care crisis, health system inequity, system-level management of disruptions in surgical services, professional and interprofessional impact, personal impact, and pragmatic adaptation to health system strain. Participants also identified strategies to mitigate the challenges experienced due to nonurgent surgical delays during the COVID-19 pandemic (i.e., additional operating time, surgical process reviews to reduce inefficiencies, and advocacy for sustained funding of hospital beds, human resources and community-based postoperative care).

INTERPRETATION

Our study describes the impacts and challenges experienced by adult and pediatric surgeons of delayed nonurgent surgeries because of the COVID-19 pandemic response. Surgeons identified potential health system-, hospital- and physician-level strategies to minimize future impacts on patients from delays of nonurgent surgery.

Patient, family and professional suggestions for pandemic-related surgical backlog recovery: a qualitative study

BACKGROUND

Surgical shutdowns related to the COVID-19 pandemic have resulted in prolonged wait times for nonemergency surgery. We aimed to understand informational needs and generate suggestions on management of the surgical backlog in the context of the ongoing COVID-19 pandemic through focus groups with key stakeholders.

METHODS

We performed a qualitative study with focus groups held between Sept. 29 and Nov. 30, 2021, in Ontario, with patients who underwent or were awaiting surgery during the pandemic and their family members, and health care leaders with experience or influence overseeing the delivery of surgical services. We conducted the focus groups virtually; focus groups for patients and family members were conducted separately from health care leaders to ensure participants could speak freely about their experiences. Our goal was to elicit information on the impact of communication about the surgical backlog, how this communication may be improved, and to generate and prioritize suggestions to address the backlog. Data were mapped onto 2 complementary frameworks that categorized approaches to reduction in wait times and strategies to improve health care delivery.

RESULTS

A total of 11 patients and family members and 20 health care leaders (7 nursing surgical directors, 10 surgeons and 3 administrators) participated in 7 focus groups (2 patient and family, and 5 health care leader). Participants reported receiving conflicting information about the surgical backlog. Suggestions for communication about the backlog included unified messaging from a single source with clear language to educate the public. Participants prioritized the following suggestions for surgical recovery: increase supply through focusing on system efficiencies and maintaining or increasing health care personnel; incorporate patient-centred outcomes into triage definitions; and refine strategies for performance management to understand and measure inequities between surgeons and centres, and consider the impact of funding incentives on "nonpriority" procedures.

INTERPRETATION

Patients and their families and health care leaders experienced a lack of communication about the surgical backlog and suggested this information should come from a single source; key suggestions to manage the surgical backlog included a focus on system efficiencies, incorporation of patient-centred outcomes into triage definitions, and improving the measurement of wait times to monitor health system performance. The suggestions generated in this study that may be used to address surgical backlog recovery in the Canadian setting.

Procedural Sedation in Minor Procedure Rooms for Pediatric Myringotomy and Tympanostomy: A Quality Improvement Initiative

OBJECTIVE

Lengthy wait times for elective surgery is a widespread health care system conundrum that may increase patient distress and jeopardize health outcomes. The primary aim of this quality improvement project was to reduce the surgical wait time in patients undergoing tympanostomy tube insertion.

METHODS

As of January 2018, our tertiary care institution implemented a novel protocol whereby healthy children may undergo tympanostomy tube insertion in a minor procedure room under ketamine sedation administered by pediatric emergency physicians to address lack of both physical and anesthesia staffing resources. A retrospective study of all children undergoing elective tympanostomy tube insertion was conducted between September 1, 2017, and May 8, 2019, to assess wait time to surgery, as well as anesthesia-related and surgical complications.

RESULTS

Procedural sedation in minor procedure rooms effectively decreased surgical wait times by 53 days (from 134 to 81 days, P < .001) at 16 months postimplementation. This new protocol was found to be safe and effective for healthy children, with no major surgical or anesthesia-related complications noted in 113 patients having undergone the procedure in the novel setting.

DISCUSSION

Although conscious sedation by emergency physicians has been well studied across a variety of surgical procedures, its novel use in pediatric tympanostomy tube insertion requires careful patient selection to enhance accessibility while maintaining anesthetic safety.

IMPLICATIONS FOR PRACTICE

This quality improvement project describes a novel combination of processes, using a minor procedure room space and ketamine-based procedural sedation to address surgical wait times in pediatric patients undergoing tympanostomy tube insertion.

Analysis of Patient Satisfaction through the Effect of Healthcare Spending on Waiting Times for Consultations and Operations

In recent years, public authorities have invested large amounts of public money in trying to reduce waiting times for consultations and operations with the aim of improving the quality of the healthcare system. Our research aims to analyze the effect of these investments on patient satisfaction through the mediating relationship of waiting times for consultations and operations, as well as from a gender perspective. By studying a series of key indicators of the Spanish healthcare system and applying partial least squares structural equation modelling (PLS-SEM), the findings show that the model explains 12.10% of the variance in consultant waiting times, 51.90% in operation waiting times, and 27.00% in patient satisfaction. We found that increased public spending leads to increased patient satisfaction by reducing waiting times. However, no gender-based differences were found. The results provide exciting implications for theory and practice, indicating how policymakers can orient their strategies towards improving patient satisfaction.

A regulação ambulatorial na Atenção Primária do Município do Rio de Janeiro, Brasil, a partir dos médicos reguladores locais

Resumo O artigo teve por objetivo caracterizar o processo de regulação assistencial realizado nas unidades de Atenção Primária à Saúde do município do Rio de Janeiro, com ênfase na dimensão ambulatorial. Foi realizado estudo transversal, por meio de um survey, com participação de 114 médicos reguladores locais, no ano de 2019. Quanto ao perfil dos reguladores locais, destacou-se o alto percentual com formação em Medicina de Família e Comunidade e o tempo de atuação relativamente adequado destes profissionais nas unidades. Para 52,6%, a infraestrutura para regulação é adequada, mas a conectividade apresenta problemas com frequência. No sistema de regulação, os mecanismos e horários de disponibilização de vagas produzem competição entre os reguladores das unidades, com sobrecarga de trabalho e iniquidades de acesso associadas. Observou-se importante envolvimento dos reguladores locais em atividades de avaliação e gestão de filas de espera. A maioria informou haver pouca ou nenhuma interação com a atenção especializada. Apesar do processo de regulação descentralizada ainda apresentar importantes limites, o estudo aponta a factibilidade e contribuição da entrada mais intensa da Atenção Primária na regulação do acesso.

Non-utilization of public healthcare facilities during sickness: a national study in India

Aims

Healthcare utilization is a major challenge for low- and middle-income countries, especially for the publicly funded facilities. The study has tried to explore the women’s opinion behind the non-utilization of public healthcare facilities in India.

Subjects and methods

This was a cross-sectional study using nationally representative samples of 351,625 women of reproductive age (15–49 years) from the 29 States and seven Union Territories. Indian National Family Health Surveys NFHS-4 (2015–2016) was the data source. The respondents were asked why the members of their households do not utilize public healthcare facilities when members of their households are sick. They have options to respond either ‘yes’ or ‘no’. Five reasons for non-utilization of public healthcare were asked: (i) ‘there is no nearby facility’; (ii) ‘facility timing is not convenient’; (iii) ‘health personnel are often absent’; (iv) ‘waiting time is too long’; and (v) ‘poor quality of care’.

Results

The majority of the women in India (88%) said that their family members did not use public healthcare facilities. The reasons behind this were 'no nearby facilities' (42.4%), 'inconvenient facility timing' (29.6%), 'poor quality of care' (52.3%), 'health personnel often absent' (16.8%) and 'long waiting time' (39.9%).

Conclusions

importantly, during the last 10 years, the utilization of public health care facilities has dropped significantly, which should be taken seriously as the Indian Parliament has been placing emphasis on equity.

Exploring wait time variations in a prostate cancer patient pathway—A qualitative study

Norwegian health authorities emphasise that all citizens should have equal access to healthcare and implement cancer patient pathways (CPPs) to ensure medical care for all patients within the same time frame and to avoid unwanted variation. Statistics regarding prostate cancer indicate longer wait times for patients from a local hospital compared to patients from a university hospital. This study describes which health system‐related factors influence variations in wait times. Eighteen healthcare workers participated in qualitative individual interviews conducted using a semi‐structured interview guide. Transcripts were analysed by systematic text condensation, which is a cross‐case method for the thematic analysis of qualitative data. The analysis unveiled four categories describing possible health system‐related factors causing variation in times spent on diagnostics for patients in the local hospital and in university hospital, respectively: (a) capacity and competence, (b) logistics and efficiency, (c) need for highly specialised investigations, and (d) need for extra consultations. Centralisation of surgical treatment necessitated the transfer of patients, with extra steps indicated in the CPP for patients transferring from the local hospital to the university hospital for surgery. The local hospital seemed to lack capacity more frequently than the university hospital. Possible factors explaining variations in wait time between the two hospitals concern both internal conditions at the hospitals in organising CPPs and the implications of transferring patients between hospitals. Differences in hospitals' capacity can cause variations in wait time. The extra steps involved in transferring patients between hospitals can lead to additional time spent in CPP.

Centralisation of surgical treatment necessitated the transfer of patients

The extra steps involved in transferring patients between hospitals can lead to additional time spent in cancer patient pathway

It can be a demanding exercise to comply with the authorities' requirements for specific wait times and simultaneously centralise treatment

Politicians and health authorities should have these implications of contradictory quality indicators in mind when designing patient pathways

Prioritization and surgical wait lists: A cross-sectional survey of patient's health-related quality of life

INTRODUCTION

In many countries, there are waits for elective (planned) surgery. In these settings, processes for triaging patients are applied to determine how long patients wait for their surgery. There are very few instances that evaluate the effectiveness of surgical triage processes.

METHODS

A sample of patients from four acute care hospitals in Vancouver, Canada, completed a number of patient-reported outcomes shortly after being registered on the surgical wait list. Patients' diagnosis was used to triage and determine their expected wait for surgery. The associations between patient-reported outcomes with surgical triage were measured.

RESULTS

The mean wait times for participants were similar across wait times categories. Participants whose expected waits for surgery were the longest reported successively lower levels of self-rated health (p < 0.01) and successively higher levels of pain (p < 0.01.) There was no difference in symptoms of anxiety among participants expected to wait the longest.

DISCUSSION

The diagnosis-based system for prioritizing patients found higher levels of pain and lower health status among those expected to wait the longest for their surgery. Screening waiting patients for treatable mental health conditions should be implemented and the process of surgical triage could be redesigned to allow for a broader set of attributes of health to determine how long a patient waits for their elective surgery.

Challenges to ensuring valid and useful waiting time monitoring - a qualitative study in Swedish specialist care

BACKGROUND

Access to health care is an essential health policy issue. In several countries, waiting time guarantees mandate set time limits for assessment and treatment. High-quality waiting time data are necessary to evaluate and improve waiting times. This study's aim was to investigate health care providers and administrative management professionals' perceptions of validity and usefulness of waiting time reporting in specialist care.

METHODS

Semi-structured interviews (n = 28) were conducted with administrative management and care professionals (line managers and care providers) in specialized clinics in the Stockholm Region, Sweden. Clinic-specific data from the waiting time registry was used in the care provider interviews to assess face validity. Clinics were purposefully sampled for maximum variation in complexity of care, volume of production, geographical location, private or public ownership, and local waiting times. Thematic analysis was used.

RESULTS

The waiting time registry was perceived to have low validity and usefulness. Perceived validity and usefulness were interconnected, with mechanisms that reinforced the connection. Structural and cognitive barriers to validity included technical and procedural errors, errors caused by role division, misinterpretation of guidelines, diverging interpretations of nonregulated cases and extensive willful manipulation of data.

CONCLUSIONS

We identify four misconceptions underpinning the current waiting time reporting system: passive dissemination of guidelines is sufficient as implemented, cognitive load of care providers to report waiting times is negligible, soft-law regulation and presentation of outcome data is sufficient to drive improvement, and self-reported data linked to incentives poses a low risk of data corruption. To counter low validity and usefulness, we propose the following for policy makers and administrative management when developing and implementing waiting time monitoring: communicate guidelines with instructions for operationalization, address barriers to implementation, ensure quality through monitoring of implementation and adherence to guidelines, develop IT ontology together with professionals, avoid parallel measurement infrastructures, ensure waiting times are presented to suit management needs, provide timely waiting time data, enable the study of single cases, minimize manual data entry, and perform spot-checks or external validity checks. Several of these strategies should be transferable to waiting time monitoring in other contexts.

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.

Healthcare Providers and Caregivers' Perspectives on the Quality of Child Health Services in Urban Indonesia: A Mixed-Methods Study

Although Indonesia’s child mortality rate has decreased in tandem with the global trend, healthcare services can be further improved for children. This study aims to explore the perceptions of healthcare providers and caregivers of children aged below five years to improve child health in urban Indonesia. A mixed-methods study design was adopted. Quantitative data were collected via questionnaires from the caregivers. Qualitative data were collected via semi-structured interviews from the healthcare providers. Analysis of 540 caregiver questionnaires regarding the care provided to their child revealed that the majority of them were very satisfied (46.1%) and satisfied (52.2%) with the care received. Analysis of 12 interviews with healthcare providers derived three major themes: (1) importance of one’s role as a healthcare provider; (2) factors affecting the delivery of healthcare; and (3) the way forward in caring for young children. Although caregivers were very satisfied with the care received for their children, the perception of healthcare providers regarding their responsibility in delivering care to children under five years old provides insights into improving the quality of services for children in Indonesia. Our findings suggest that mortality and morbidity of children aged below five years can be best reduced by optimizing primary and secondary preventive measures.

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).

Improving Administrative Outcomes in Physiotherapy by Adopting Open-Access Booking

Purpose: Long wait times for physiotherapy are associated with poorer health trajectories for clients. Clients’ experiences with physiotherapy services in Saint John were suboptimal; thus, this study explored making administrative changes to improve those experiences. All physiotherapy services adopted an administrative model called open-access booking (OAB), which blended elements of advanced access, triage, and centralized wait lists. Method: OAB was instituted in the first week of February 2017 and has been active since. The researcher accessed more than 20,000 anonymized case records spanning 5 years (February 2014–January 2019) and compared the 3-year pre-OAB phase with the 2-year OAB phase using interrupted time series analysis models. Results: OAB appeared to not be associated with changes in client volume, but it was associated with fewer “on-paper” clients, shorter wait times to first appointment, more consistent record keeping, a greater likelihood of being discharged after one appointment, and fewer appointments before discharge. There was less variability in these outcomes after the adoption of OAB, suggesting a more stable client experience with the physiotherapy system. Conclusions: OAB appears to be associated with improved administrative outcomes, but strict causality cannot be assessed. The results are promising but not conclusive.

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.

The impact of public performance reporting on cancer elective surgery waiting times: a data linkage study

Background

Excessive waiting times for cancer elective surgery are a concern in publicly funded healthcare systems. Several countries including Australia have introduced healthcare reforms involving time-based targets and public performance reporting (PPR) of hospital data. However, there is mixed evidence of their benefits. We sought to examine the impact of targets and PPR of cancer elective surgery waiting times on access to breast, bowel and lung cancer elective surgery.

Methods

We analysed routinely-collected linked data on admissions and waiting times for patients aged 15 years or over (n = 199,885) who underwent cancer surgery in a public hospital in Victoria, Australia over a 10-year period. We conducted difference-in-differences analyses to compare waiting times before (2006–07 to 2011–12) and after (2012–13 to 2015–16) the introduction of PPR in meeting these targets.

Results

Across all cancer types, urgent patients were all treated within 30 days before and after PPR. Following PPR, there was a slight increase in the mean waiting times across all cancer types and urgency categories. Patients with lung cancer waited on average two and half days longer for treatment and patients with breast cancer waited on average half-a-day less. There was no effect of PPR on waiting times for patients with bowel cancer across urgency categories.

Conclusions

Our findings suggest that time-based targets and PPR had minimal impact on surgical waiting times. This may be due to reasonable waiting times prior to PPR, improved efficiency being masked by 20% growth in the population, lack of public knowledge that waiting times are publicly reported, or lack of real-time reporting to drive behavioural change. The use of generic elective surgery recommended waiting time measures for cancer is discussed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06132-w.

Using Targets to Reduce Waiting Times for Elective Care: What Can We Learn from the Russian Experience?

This article explores the potential for maximum waiting times targets to improve access to healthcare in a country with limited financial resources. The study combines policy analysis, off-the-record communications, face-to-face interviews, public opinion surveys and open access patient complaints to create a rich picture of how waiting time targets are monitored and implemented in theory and practice. The study found that most waiting time targets in the Russian Federation are unrealistically low, while institutional and operational arrangements for their implementation have not been built in most regions. Estimates of actual waiting times are fragmented and unreliable. The lack of meaningful regulation and monitoring encourages opportunistic behavior among health providers to meet the targets while there is growing uncertainty among patients. Maximum waiting times targets alone are insufficient to reduce excessive waiting times. Successful implementation relies on robust data systems and standardized measurements for waiting times as well as meaningful regulation and monitoring.

Waiting time for short-stay surgery in a paediatric surgery department

AIM

The aim of this study was to assess the waiting time (WT) for a short-stay surgery and determine its possible determinant factors.

PATIENTS AND METHODS

This was a retrospective study conducted in the Department of Paediatric Surgery at the National Hospital of Lamordé of Niamey, Niger. It included patients aged 0-15 years who benefitted from a short-stay surgery (24-48 h of hospitalisation) during a period of 19 months (1st January 2017 - 31st July 2018). Patient, diagnosis and surgical treatment data were gathered. WT was the time elapsed between the indication of a surgical operation and its realisation. The Kruskal-Wallis test was used with a threshold statistical significance of < 0.05.

RESULTS

Short-stay surgery constituted 25.4% of all operating activities (n = 271). Inguinal or inguinoscrotal hernia was the most frequent pathology at 31.38% (n = 85). The mean WT was of 116.6 days (range: 4-491 days) and the median was 114 days. WT was greater than or equal to 3 months for 63.9% of the patients (n = 173). Based on pathology, the mean WT varied between 57.5 days (ovarian hernia) and 163.6 days (5.8 months) for epigastric hernia. A significantly longer WT was observed with the presence of a comorbidity (P = 0.0352) but was not associated with patient residence (P = 0.0951).

CONCLUSION

A long WT for a short-stay surgery should be improved upon by different interventions with respect to the supply and demand of care and the setting of priorities.

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).

How the design and implementation of centralized waiting lists influence their use and effect on access to healthcare - A realist review

CONTEXT

Many health systems have centralized waiting lists (CWLs), but there is limited evidence on CWL effectiveness and how to design and implement them.

AIM

To understand how CWLs' design and implementation influence their use and effect on access to healthcare.

METHODS

We conducted a realist review (n = 21 articles), extracting context-intervention-mechanism-outcome configurations to identify demi-regularities (i.e., recurring patterns of how CWLs work).

RESULTS

In implementing non-mandatory CWLs, acceptability to providers influences their uptake of the CWL. CWL eligibility criteria that are unclear or conflict with providers' role or judgement may result in inequities in patient registration. In CWLs that prioritize patients, providers must perceive the criteria as clear and appropriate to assess patients' level of need; otherwise, prioritization may be inconsistent. During patients' assignment to service providers, providers may select less-complex patients to obtain CWLs rewards or avoid penalties; or may select patients for other policies with stronger incentives, disregarding the established patient order and leading to inequities and limited effectiveness.

CONCLUSION

These findings highlight the need to consider provider behaviours in the four sequential CWL design components: CWL implementation, patient registration, patient prioritization and patient assignment to providers. Otherwise, CWLs may result in limited effects on access or lead to inequities in access to services.

Resolution, access, and waiting time for specialties in different models of care

OBJECTIVE

This study aimed to identify the treatment demands coming from primary health care units and, based on that, the demand for referrals to medical specialties in reference services. This study is justified by the scarcity of scientific literature on the subject.

METHODS

This is a cross-sectional study using secondary data on the treatments and referrals made by the primary health care units, throughout 2014, in a municipality of the State of São Paulo, Brazil. The total population treated in 2014 was considered, resulting in 411,177 treatments.

RESULTS

Out of all treatments performed, the percentage of referrals was of 4.42%, showing that 95,58% of the problems did not need to be referred to another service. A number of 8,897 referrals were made, to 6,850 users, who were mostly women (60.74%). The mean of referrals per patient was 1.3 (min. 1 and max. 8), and 1,604 patients (23.5%) were referred at least twice.

CONCLUSIONS

Primary health care services have been responsible for a large number of treatments, whereas the demand for referrals has decreased, suggesting that such services have established themselves as a gateway to the health system and achieved the expected solvability, although the waiting time for some specialties is very long.

Long Waiting Times for Elective Hospital Care - Breaking the Vicious Circle by Abandoning Prioritisation

Background: Policies assigning low-priority patients treatment delays for care, in order to make room for patients of higher priority arriving later, are common in secondary healthcare services today. Alternatively, each new patient could be granted the first available appointment. We aimed to investigate whether prioritisation can be part of the reason why waiting times for care are often long, and to describe how departments can improve their waiting situation by changing away from prioritisation.

Methods: We used patient flow data from 2015 at the Department of Otorhinolaryngology, Haukeland University Hospital, Norway. In Dynaplan Smia, Dynaplan AS, dynamic simulations were used to compare how waiting time, size and shape of the waiting list, and capacity utilisation developed with and without prioritisation. Simulations were started from the actual waiting list at the beginning of 2015, and from an empty waiting list (simulating a new department with no initial patient backlog).

Results: From an empty waiting list and with capacity equal to demand, waiting times were built 7 times longer when prioritising than when not. Prioritisation also led to poor resource utilisation and short-lived effects of extra capacity. Departments where prioritisation is causing long waits can improve their situation by temporarily bringing capacity above demand and introducing "first come, first served" instead of prioritisation.

Conclusion: A poor appointment allocation policy can build long waiting times, even when capacity is sufficient to meet demand. By bringing waiting times down and going away from prioritisation, the waiting list size and average waiting times at the studied department could be maintained almost 90% below the current level – without requiring permanent change in the capacity/demand ratio.

Elective surgery wait time reduction in Canada: A synthesis of provincial initiatives

In an effort to reduce wait times, Canadian provincial governments have introduced numerous wait time reduction programs and policies. The objective of this study was to provide an overview of elective surgery wait time reduction initiatives across the Canadian provinces from 2000 to 2018. Each of the 10 provincial government web sites were searched. A theoretical framework for elective surgery wait time reduction policies was developed. The final framework is broadly organized into a supply-demand-performance management model. The majority were categorized as supply-oriented initiatives, which have been implemented by all the provinces in some form. Demand-oriented initiatives have been implemented the least. Our conceptual framework may be used to categorize wait time reduction initiatives for the purpose of policy development and evaluation.

'It's all about time': Temporal effects of cancer pathway introduction in treatment and care

In the last decades, increased focus on time optimisation in healthcare services has led to introduction of new standardising technologies that alter the temporal structures of treatment-trajectories and work-practices. This paper presents a qualitative study of the temporal effects of introducing cancer pathways at a university hospital and a cancer rehabilitation centre in Denmark. Building analytically on a combination of Eviatar Zerubavel's and Norbert Elias's sociological studies on time, we show how the introduction of pathways has intensified the separation of cancer treatment and psychosocial support into two decoupled but mutually interdependent temporal orders. We furthermore demonstrate how pathway introduction has increased the focus on time as an overarching quality standard for treatment and care across organisational boundaries. Based on this analysis, we suggest that to understand current standardisation and optimisation processes and their unintended organisational effects, temporality should be treated as a research object of its own. Rather than analytically pre-empting temporal dichotomies or a priori assigning normativity to particular temporal structures, we call for thorough empirical investigation of temporal patterns in and between healthcare organisations.

Improving the quality of care with a single-entry model of referral for total joint replacement: a preimplementation/postimplementation evaluation

OBJECTIVES

We assessed: (1) waiting time variation among surgeons; (2) proportion of patients receiving surgery within benchmark and (3) influence of the Winnipeg Central Intake Service (WCIS) across five dimensions of quality: accessibility, acceptability, appropriateness, effectiveness, safety.

DESIGN

Preimplementation/postimplementation cross-sectional design comparing historical (n=2282) and prospective (n=2397) cohorts.

SETTING

Regional, provincial health authority.

PARTICIPANTS

Patients awaiting total joint replacement of the hip or knee.

INTERVENTIONS

The WCIS is a single-entry model (SEM) to improve access to total hip replacement (THR) or total knee replacement (TKR) surgery, implemented to minimise variation in total waiting time (TW) across orthopaedic surgeons and increase the proportion of surgeries within 26 weeks (benchmark). Impact of SEMs on quality of care is poorly understood.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes related to 'accessibility': waiting time variation across surgeons, waiting times (Waiting Time 2 (WT2)=decision to treat until surgery and TW=total waiting time) and surgeries within benchmark. Analysis included descriptive statistics, group comparisons and clustered regression.

RESULTS

Variability in TW among surgeons was reduced by 3.7 (hip) and 4.3 (knee) weeks. Mean waiting was reduced for TKR (WT2/TW); TKR within benchmark increased by 5.9%. Accessibility and safety were the only quality dimensions that changed (post-WCIS THR and TKR). Shorter WT2 was associated with post-WCIS (knee), worse Oxford score (hip and knee) and having medical comorbidities (hip). Meeting benchmark was associated with post-WCIS (knee), lower Body Mass Index (BMI) (hip) and worse Oxford score (hip and knee).

CONCLUSIONS

The WCIS reduced variability across surgeon waiting times, with modest reductions in overall waits for surgery. There was improvement in some, but not all, dimensions of quality.

Comparison of Referral Pathways in Otolaryngology at a Public Versus Private Academic Center

OBJECTIVE

Delayed medical care may be costly and dangerous. Examining referral pathways may provide insight into ways to reduce delays in care. We sought to compare time between initial referral and first clinic visit and referral and surgical intervention for index otolaryngologic procedures between a public safety net hospital (PSNH) and tertiary-care academic center (TAC).

METHODS

Retrospective cohort study of eligible adult patients undergoing one of several general otolaryngologic procedures at a PSNH (n = 216) and a TAC (n = 161) over a 2-year time period.

RESULTS

PSNH patients were younger, less likely to have comorbidities and more likely to be female, Hispanic or Asian, and to lack insurance. Time between referral and first clinic visit was shorter at the PSNH than the TAC (Mean 35.8 ± 47.7 vs 48.3 ± 60.3 days; P = .03). Time between referral and surgical intervention did not differ between groups (129 ± 90 for PSNH vs 141 ± 130 days for TAC, P = .30). On multivariate analysis, the TAC had more patient-related delays in care than the PSNH (OR: 3.75, P < .001). Time from referral to surgery at a PSNH was associated with age, source of referral, type of surgery, diagnostic workup and comorbidities, and at a TAC was associated with gender and type of surgery and comorbidities.

CONCLUSIONS

Sociodemographic differences between PSNH and TAC patients, as well as differences in referral pathways between the types of institutions, influence progression of surgical care in otolaryngology. These differences may be targets for interventions to streamline care.

LEVEL OF EVIDENCE

2c.

Right care, right place, right time: improving the timeliness of health care in New South Wales through a public-private hospital partnership

Objective The overall aim of the study was to investigate and assess the feasibility of improving the timeliness of public hospital care through a New South Wales (NSW)-wide public-private hospital partnership. Methods The study reviewed the academic and professional grey literature, and undertook exploratory analyses of secondary data acquired from two national health data repositories informing in-patient access and utilisation across NSW public and private hospitals. Results In 2014-15, the NSW public hospital system was unable to deliver care within the medically recommended time frame for over 27400 people who were awaiting elective surgery. Available information indicates that the annual commissioning of 15% of public in-patient rehabilitation bed days to the private hospital system would potentially free up enough capacity in the NSW public hospital system to enable elective surgery for all public patients within recommended time frames. Conclusions The findings of the study justify a strategic whole-of-health system approach to reducing public patient wait times in NSW and highlight the need for research efforts aimed at securing a better understanding of available hospital capacity across the public and private hospital systems, and identifying and testing workable models that improve the timeliness of public hospital care. What is known about the topic? There are very few studies available to inform public-private hospital service partnerships and the opportunities available to improve timely health care access through such partnerships. What does this paper add? This paper has the potential to open and prompt timely discussion and debate, and generate further fundamental investigation, on public-private hospital service partnerships in Australia where opportunity is available to address elective surgery wait times in a reliable and effective manner. What are the implications for practitioners? The NSW Ministry of Health and its Local Health Districts have the potential to realise a key objective, namely to deliver the 'right care, in the right place, at the right time', through the core value of collaboration, using available infrastructure.

Effects of waiting for outpatient physiotherapy services in persons with musculoskeletal disorders: a systematic review

PURPOSE

This systematic review aimed to assess the scientific evidence on the effects of waiting for outpatient physiotherapy services in persons with musculoskeletal disorders.

METHODS

A literature search was conducted in three databases (Medline, CINAHL, and Embase) for articles assessing the effects of waiting for outpatient physiotherapy services in persons with musculoskeletal disorders. Clinical and health system outcomes were analyzed.

RESULTS

Sixteen studies met the inclusion criteria for this review. The studies varied in designs, settings, and populations. The definition of waiting also varied between studies. The studies were of low to high methodological quality. Waiting for outpatient physiotherapy services was shown to have mixed results on clinical and health system outcomes. Results from included studies suggest the possible detrimental effects of waiting on pain, disability, quality of life, and psychological symptoms in persons with musculoskeletal disorders. There was also evidence of higher healthcare utilization and costs for patients who wait longer before physiotherapy services.

CONCLUSIONS

This review provides mixed evidence that suggest potential detrimental effects on the health of individuals with MSDs and at the health system level. Further high-quality studies are needed, such as longitudinal studies specifically addressing the effects of waiting due to lack of access to physiotherapy services.IMPLICATIONS FOR REHABILITATIONThe findings from this review suggest potential detrimental effects on health outcomes when patients wait longer before receiving physiotherapy services.The findings also suggest higher healthcare utilization and costs for patients with longer wait times compared to those who receive physiotherapy services more rapidly.This review suggests the need to assess and implement strategies and policies to ensure timely access to physiotherapy.

Decision making tools for managing waiting times and treatment rates in elective surgery

BACKGROUND

Waiting times for elective treatments, including elective surgery, are a source of public concern and therefore are on policy makers' agenda. The long waiting times have often been tackled through the allocation of additional resources, in an attempt to reduce them, but results are not straightforward. At the same time, researchers have reported wide geographical variations in the provision of elective care not driven by patient needs or preferences but by other factors. The paper analyses the relationship between waiting times and treatment rates for nine high-volume elective surgical procedures in order to support decision making regarding the availability of these services for the citizens. Using the framework already proposed for the diagnostic services, we identify different patterns that can be followed to align the supply with patient needs in the Italian context.

METHODS

After measuring the waiting times and the treatment rates for nine procedures in the 34 districts in Tuscany, we performed correlation analyses. Then, we plotted the results in a matrix cross-checking waiting times and rates. By doing so, we identified four different contexts that require a second step analysis to tackle unwarranted geographical variations and ensure timely care to patients. Finally, for each district and elective surgical procedure, we measured the economic impact of the different treatment rates in order to evaluate whether there are any supply criticalities and eventually some room for maneuver. We also included active and passive mobility of patients.

RESULTS

The results show a high degree of variation both in treatment rates and waiting times, especially for the orthopaedic procedures: knee replacement, knee arthroscopy and hip replacement. The analysis performed for the nine interventions shows that the 34 districts are in varying positions in the waiting time-treatment rate matrix, suggesting that there is no straightforward relationship between rates and waiting times. Each combination in the matrix may have different determinants that require healthcare managers to adopt diversified strategies. The decision making process needs to be supported by a two-level analysis: the first one to put in place the matrix that cross-checks waiting times and treatment rates, the second one to analyse the characteristics of each quadrant and the improvement actions that can be proposed.

CONCLUSIONS

In Italy, waiting times in elective surgical services are a main policy issue with a relevant geographical variation. Our analysis reveals that this variation is due to multiple elements. In order to avoid simplistic approaches that do not solve the problem but often lead to increased expenditure, policy makers and healthcare managers should follow a two-step strategy firstly identifying the type of context and secondly analysing the impact of elements such as resource productivity, resource availability, patients' preferences and care appropriateness. Only in some cases it is required to increase the service supply.

The stipulation-stimulation spiral: A model of system change

This paper proposes a general model, based on what is known about the nature of (complex) systems, of how systems-in particular, health care systems-respond to attempted change. Inferences are drawn from a critical literature review and reinterpretation of two primary studies. The two fundamental system-change approaches are "stipulation" and "stimulation": stip(ulation) attempts to elicit a specific response from the system; stim(ulation) encourages the system to generate diverse responses. Each has a unique strength: stip's is precision, the ability to directly impact the desired outcome and only that outcome; stim's is resonance, the ability to take advantage of behavior already present within the system. Each approach's inherent strength is its complement's inherent weakness; thus, stip and stim often clash if attempted simultaneously but can reinforce each other if applied in alternation. Opposite patterns (the "stip-stim spiral" vs "stip-stim stalemate") are observed to underpin successful vs failed system change: The crucial difference is whether decision-makers respond to a need for precision/resonance by strengthening the appropriate approach (stipulation/stimulation, respectively), or merely by weakening its complement. With further validation, the model has the potential to yield a more fundamental understanding of why system-change efforts fail and how they can succeed.

Policy strategies to reduce waiting times for elective surgery: A scoping review and evidence synthesis

OBJECTIVES

The purpose of this evidence-based review is to identify and describe the interventions that have been implemented to reduce waiting times for major elective surgery.

METHODS

Scoping review and presentation of the results according to the SUPPORT tools. We searched MEDLINE/PubMed, Embase, Cochrane Library, SciELO, DARE-HTA, and Google Scholar. The inclusion criteria for research design were comprehensive.

RESULTS

We identified 5200 records. After eliminating duplicates and screening by title and abstract, 171 records remained for full-text assessment, of which 12 were ultimately included for this review because they reported specific interventions and 96 records were included for further reference. The included studies show significant variability regarding elective procedures, population, and type of provider, as well as in the characteristics of the interventions and the settings. All the studies had methodological limitations. We graded the certainty of the evidence as very low.

CONCLUSIONS

According to the evidence found for this review, interventions most likely should be multidimensional, with prioritization strategies on the waiting lists to incorporate equity criteria, together with quality management improvements of the surgical pathways and the use of operating rooms, as well as improvements in the planning of the surgical schedule.

Reducing ear, nose and throat (ENT) waitlists: Implications of a referral audit

INTRODUCTION

Many specialist waitlists in Australian hospitals are long. One reason anecdotally reported for this is poor alignment of referrals with current recommended guidelines. This paper reports the findings of an audit undertaken in 2017 for ear, nose and throat (ENT) surgeon referrals submitted by primary health centres within Cape York, Australia.

MATERIALS AND METHODS

54 long-wait ENT referrals were reviewed against referral criteria for ENT presentations using the Clinical Prioritization Criteria (CPC) and two routinely applied clinical primary health care guidelines; with findings reported alongside patient demography.

RESULTS

All of the long wait ENT referrals in the sample were for remote living Indigenous Australians, most were children (93%). One fifth of referrals fulfilled all referral criteria and were appropriate (22%); one third required further informaiton to support the referral, either audiology or clinical history (30%); and half were inappropriate referrals (48%).

CONCLUSION

Although many referral submissions did not adhere to CPC or routine guidelines, this audit enabled the identification of improvements to the referral system including the development of a checklist and flow-chart, plus patient information resources aimed at improving patient adherence. A case can be made for a new service delivery model that provides ongoing primary health education and facilitates improved ENT access. These strategies may improve ENT referral quality and decongest current ENT specialist waitlists, while offering improved primary health care management of ear presentations.

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.

Pooling and patient satisfaction in non-instrumented lumbar decompressive surgery

OBJECTIVES

To determine the effect of pooling of patients for elective non-instrumented lumbar decompression on patient satisfaction and waiting times.

MATERIALS AND METHODS

We performed a retrospective review of Spine Tango and Theatre Databases of our Neurosurgical unit for patients who underwent elective primary non-instrumented lumbar decompression between January 2012 and 2016. Patient satisfaction scores at 3 and 12 months post-surgery were collected from the Spine Tango Registry, and patients categorised as pooled/non-pooled by searching theatre databases to determine their named listing and operating consultants. Results were analysed numerically and by performing chi-squared testing to determine if pooling affected patient satisfaction. Theatre records were analysed between January 2004-2006, January 2009-2011 and 2014-2016 to determine what effect implementation of the 18-week wait target system (2009) and of our pooled system (2012) had on waiting times to operation for patients undergoing elective primary non-instrumented lumbar decompression.

RESULTS

There is no significant difference in patient satisfaction levels between pooled and non-pooled patients at 3 (p = .052) and 12 months (p = .5) post primary elective lumbar decompression (significance p < .05). There was no difference in average waiting time between the pooled and non-pooled groups. Both setting of 18-week targets and pooling improved waiting times. Setting of 18-week targets affected average waiting times markedly while pooling most notably reduced the variability in waiting times between patients for the same procedure.

CONCLUSIONS

Pooling of patients for elective non-instrumented lumbar decompression in our unit has improved waiting times, particularly the variability in them, with no detriment to patient satisfaction. We would recommend other units to consider developing a system of pooling such as ours, to help maximise use of their current resources and avoid highly variable waiting times for patients for the same procedure within the same department.

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.

Quantifying Patient-Reported Disability and Health While Waiting for Bunion Surgery

BACKGROUND

Many patients with hallux valgus progress to experiencing pain and loss of function that requires corrective surgery when nonoperative treatments fail. The primary goal of this study was to measure changes in participants' health while patients waited for their operative correction.

METHODS

Patients were prospectively recruited to complete a number of patient-reported outcome measures preoperatively. Baseline data collection was initiated in October 2014, and participants' second surveys were returned by August 2017. The setting of the study was Vancouver, Canada. There were 80 participants in the study. The participation rate among eligible patients was 52.7%.

RESULTS

The average wait time for surgery exceeded 8 months, with a mean wait of 35.7 weeks. Baseline pain among participants was high. Only in the domain of foot- and ankle-related quality of life was the duration of wait time associated with participants' change in health. The other 4 domains of foot function remained stable over the preoperative period.

CONCLUSION

Preoperative health in this study was consistent with other research showing high pain and compromised foot function among patients failing nonoperative therapies for treatment of hallux valgus. This study found high pain and compromised foot function among patients waiting for hallux valgus surgery but only minor relationships between participants' duration of wait time for operative correction of the first metatarsophalangeal joint and changes in patient-reported outcome scores.

LEVEL OF EVIDENCE

Level III, comparative study.

Optimizing Electronic Consultation Between Primary Care Providers and Psychiatrists: Mixed-Methods Study

Background

The use of electronic consultation (e-consult) between primary care providers (PCPs) and psychiatrists has potential, given the high prevalence of mental health issues in primary care and problematic access to specialist care. Utilization and uptake, however, appears to be lower than would be expected.

Objective

This study aimed to examine actual utilization of e-consult between PCPs and psychiatrists and investigate the perceptions of PCPs about this form of psychiatric advice to inform how to optimize the utility and thereby the uptake of this service.

Methods

In this mixed-methods study, we conducted a chart review of psychiatry e-consults (N=37) over 2 platforms during early implementation in Ontario, Canada, as well as 3 group interviews and 1 individual interview with PCPs (N=10) with variable experience levels and from a range of practice settings. The chart review assessed response times and referral content including the type of request, referral attachments, and consultant responses. Interviews explored the perceptions of the PCPs about the uses and barriers of psychiatry e-consult. Thematic content analysis of interview data identified common themes as well as themes unique to different provider profiles (eg, experienced PCPs vs new PCPs and rural vs urban practice). On the basis of interpretation of the quantitative and qualitative findings, we developed recommendations for the optimization of psychiatry e-consultation services.

Results

During the study period, psychiatry e-consults comprised 3.66% (49/1339) of all e-consults submitted on the studied platforms. Among the e-consults reviewed, different psychiatric diagnoses were represented: 70% of requests (26/37) queried about medication safety or side effects, whereas 59% (22/37) asked about psychiatric symptom management. Moreover, 81% (30/37) of e-consults were answered within 24 hours, and 65% (24/37) were addressed in a single exchange. Themes from the interview data included psychiatry having a complexity that differentiates it from other specialties and may limit the utility of e-consult, other than for psychopharmacology advice. Variability in awareness exists in the way e-consultation could be used in psychiatry, with new PCPs feeling unsure about the appropriateness of a question. In general, new PCPs and PCPs practicing in rural areas were more receptive to psychiatry e-consult. PCPs viewed e-consult as an opportunity to collaborate and desired that it be integrated with other available services. Recommendations include the need for appropriate specialist staffing to address a wide range of requests, adequate education to referrers regarding the use of psychiatry e-consult, and the need to integrate psychiatry e-consult with other geographically relevant services, given the complexity of psychiatric issues.

Conclusions

E-consult is a viable and timely way for PCPs to get much-needed psychiatric advice. For optimizing its utility and uptake, e-consult needs to be integrated into reliable care pathways with adequate referrer and consultant preparation.

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.

Insights from the design and implementation of a single-entry model of referral for total joint replacement surgery: Critical success factors and unanticipated consequences

BACKGROUND

Single-entry models (SEMs) in healthcare allow patients to see the next-available provider and have been shown to improve waiting times, access and patient flow for preference-sensitive, scheduled services. The Winnipeg Central Intake Service (WCIS) for hip and knee replacement surgery was implemented to improve access in the Winnipeg Regional Health Authority. This paper describes the system's design/implementation; successes, challenges, and unanticipated consequences.

METHODS

On two occasions, during and following implementation, we interviewed all members of the WCIS project team, including processing engineers, waiting list coordinators, administrators and policy-makers regarding their experiences. We used semi-structured telephone interviews to collect data and qualitative thematic analysis to analyze and interpret the findings.

RESULTS

Respondents indicated that the overarching objectives of the WCIS were being met. Benefits included streamlined processes, greater patient access, improved measurement and monitoring of outcomes. Challenges included low awareness, change readiness, and initial participation among stakeholders. Unanticipated consequences included workload increases, confusion around stakeholder expectations and under-reporting of data by surgeons' offices. Critical success factors for implementation included a requirement for clear communication, robust data collection, physician leadership and patience by all, especially implementation teams.

CONCLUSIONS

Although successfully implemented, key lessons and critical success factors were learned related to change management, which if considered and applied, can reduce unanticipated consequences, improve uptake and benefit new models of care.

An innovative approach to improve ear, nose and throat surgical access for remote living Cape York Indigenous children

INTRODUCTION

On a background of high rates of severe otitis media (OM) with associated hearing loss, children from the Torres Strait and Cape York region requiring ear, nose and throat (ENT) surgery, faced waiting times exceeding three years. After numerous clinical safety incidents were raised, indicating a failure of the current system to deliver appropriate care, the governing Hospital and Health service opted to deliver surgical care through an alternate process. ENT surgeries were performed on 16 consented children from two remote locations via the private health care system, funded by a health provider partnership.

METHODS

We examined the collaboration processes alongside clinical findings from this ENT surgery. Collated patient data, included patient demographics, clinical and audiometry presentation features were reviewed and compared pre and post-operatively. Cost savings associated with the use of TeleHealth post-operatively were briefly examined.

RESULTS

Surgeries were successfully completed in all 16 children. The reported mean waitlist time for ENT surgery was 1.2 years. Pre-surgery pure-tone average hearing thresholds were reported at left: 30.9 dB, right: 38.2 dB. The majority of presentations were for bilateral OM with Effusion (69%). Post-surgical follow up indicated successful clinical outcomes in 80% of patients and successful hearing outcomes in 88% of patients. Mean difference pure-tone average hearing thresholds, left: 8.4 dB and right: 11.2 dB. Furthermore, the majority of patients reported improved hearing and breathing. The use of TeleHealth for post-operative review enabled a minimum cost saving of AUD$21,664 for these 16 children. Overall, a high level of staffing resources was required to successfully coordinate this intense surgical activity.

CONCLUSION

This innovative approach to a health system crisis enabled successful ENT surgical and hearing outcomes in 16 children, whose waitlisted time grossly exceeded state health recommendations. Using private health facilities funded by a health partnership, while unlikely to be a suitable model of care for routine service delivery; may be applied as an adjunct service model when blockages and delays lead to sub-standard service provision. This approach may be applicable to other health care facilities when facing extended elective surgery wait times in ENT or other specialty areas.

A quality improvement project to reduce waiting time for pediatric outpatient referral clinics in Singapore

Background:

The long waiting time in our General Pediatric Clinic results in the delay in diagnosis and treatment leading to increase in morbidity and dissatisfaction rate among sick children who seek treatment at KK Women’s and Children’s Hospital, Singapore. The mean ± SD waiting time in our General Pediatric Clinic increased from 40 ± 4 days in 2008 and 45 ± 7 days in 2009 to 50 ± 5 days in 2010.

Objectives:

To reduce long waiting times in our General Pediatric Clinic by 20%.

Methods:

The Reducing Waiting Time Working Group was formed to tackle the waiting time problem in the General Pediatric Clinic. Extensive literature was searched and reviewed, brainstorming and discussions were carried out and strategies were developed. A series of implementations were carried out sequentially including clearing of the backlog of cases, development of general and fast track referral guidelines, triaging system and ‘5 Days SMS and 48 Hours Call’ system.

Results:

By clearing the backlog cases, waiting time was reduced from 57 days to 44 days. Through effective triaging system and ‘5 Days SMS and 48 Hours Call’ system, the mean ± SD waiting time was further reduced by 30% from 50 ± 5 days to 35 ± 7 days. By June 2012, the mean waiting time was 27 days.

Conclusions:

Waiting time is one of the important indicators of healthcare quality provided by any healthcare institution. Through these implementations, waiting time was successfully reduced by 30%. These methods may serve as viable options to improve waiting time in other healthcare settings.

What is the influence of single-entry models on access to elective surgical procedures? A systematic review

BACKGROUND

Single-entry models (SEMs) for the management of patients awaiting elective surgical services are designed to increase access and flow through the system of care. We assessed scope of use and influence of SEMs on access (waiting times/throughput) and patient-centredness (patient/provider acceptability).

METHODS

Systematic review of articles published in 6 relevant electronic databases included studies from database inception to July 2016. Included studies needed to (1) report on the nature of the SEM; (2) specify elective service and (3) address at least 1 of 3 research questions related to (1) scope of use of SEMs; (2) influence on timeliness and access; (3) patient-centredness and acceptability. Article quality was assessed using a modified Downs and Black checklist.

RESULTS

11 studies from Canada, Australia and the UK were included with mostly weak observational design-2 simulations, 5 before-after, 2 descriptive and 2 cross-sectional studies. 9 studies showed a decrease in patient waiting times; 6 showed that more patients were meeting benchmark waiting times; and 5 demonstrated that waiting lists decreased using an SEM as compared with controls. Patient acceptability was examined in 6 studies, with high levels of satisfaction reported. Acceptability among general practitioners/surgeons was mixed, as reported in 1 study. Research varied widely in design, scope, reported outcomes and overall quality.

CONCLUSIONS

This is the first review to assess the influence of SEMs on access to elective surgery for adults. This review demonstrates a potential ability for SEMs to improve timeliness and patient-centredness of elective services; however, the small number of low-quality studies available does not support firm conclusions about the effectiveness of SEMs to improve access. Further evaluation with higher quality designs and rigour is required.