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

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.

Self-management strategies for people with epilepsy: An overview of reviews

OBJECTIVE

This overview of systematic reviews aimed to appraise evidence regarding self-management strategies on health-related quality of life, self-efficacy, medication compliance, seizure status and psychosocial outcomes compared to usual care for people with epilepsy.

METHODS

Databases were searched until September 2022 using MeSH terms included OVID Medline, Embase and Cochrane. Following application of eligibility criteria, data were extracted and quality of articles was assessed using the AMSTAR2 checklist. A narrative synthesis of evidence included certainty of evidence evaluated using a Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

The 12 selected reviews contained three meta-analyses and 91 unique primary studies. One review considered only epilepsy with intellectual disability and three considered paediatrics. Interventions included technologically-based interventions, small group discussion, or counselling and educational programs. There was high certainty evidence to suggest self-management is associated with improvement in health-related quality of life and moderate certainty evidence to suggest improvement in depression symptoms. There was low certainty evidence to suggest a modest reduction in negative health events and a minimal increase in the satisfaction with life. There was no evidence of benefit favouring self-management on measures of adherence epilepsy self-management, perception of self-efficacy, medication adherence or seizure status.

SIGNIFICANCE

Despite high certainty evidence to suggest that self-management strategies for people with epilepsy improve health-related quality of life, benefits have not been demonstrated for outcomes that would be expected to be associated with these improvements, such as seizure status. These results provide support for self-management strategies to supplement usual care for people with epilepsy.

'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.

What is the effect of delays in access to specialist epilepsy care on patient outcomes? A systematic review and meta-analysis

OBJECTIVE

To determine the association between delays in access to specialist epilepsy care and patient outcomes.

METHODS

Three databases were searched using eligibility criteria related to the concepts of timely access, epilepsy, and clinical outcome. Comparative data on patient outcomes by time to treatment was required for inclusion. Studies were selected independently by two researchers who reviewed title/abstract, then full text articles. Data were extracted and risk of bias was evaluated. Results were synthesized in random effects model meta-analyses, and strength of the body of evidence was evaluated. Descriptive analysis was conducted for studies not included in meta-analyses.

RESULTS

Thirty-five studies, reported in 40 papers, were included. The studies investigated impact of delays in diagnosis, commencement of medication, or surgery for children and adults. Early diagnosis and access to specialist neurology care was associated with improvements in seizure status, development, and/or intelligence quotients. Meta-analyses provided low to high certainty evidence of increased odds of improved seizure outcome with early commencement of medication depending on follow-up period and individual risk factors. There was moderate certainty evidence that people with favorable seizure outcomes wait less time (MD 2.8 years, 95% CI 1.7-3.9) for surgery compared to those with unfavorable outcomes.

SIGNIFICANCE

This review provides evidence that earlier access to specialist epilepsy care for diagnosis, commencement of medication, and surgery is associated with better patient outcomes.