Waiting list management in general practice: a review of orthopaedic patients.

OBJECTIVE: To review all patients on a current general practice orthopaedic waiting list for outpatient appointments with regard to accuracy of the list, clinical priority, and need for further radiological investigation before hospital attendance. DESIGN: Record review by one general practitioner and a radiologist, and discussion with patients of management alternatives. SETTING: Six partner city centre urban fund-holding general practice, list size 8651 (29% low deprivation payment status). SUBJECTS: 116 adults on an orthopaedic waiting list. MAIN OUTCOME MEASURES: List accuracy (patient details and status on waiting list); clinical priority (severity of condition); further investigations (results of tests after radiological review). RESULTS: 32 patients (28%) were removed from the waiting list because of inaccuracies. 14 patients were considered to be high priority and referred to other hospitals by utilising waiting list initiative funds. Of these patients, five agreed to referral to another hospital (treatment completed on average within three months of rereferral), six did not wish to be rereferred, and two did not attend to discuss the offer and remained on the original waiting list. One prioritised patient had further radiological investigations, was reassured, and was taken off the waiting list. 10 patients had further investigations. These resulted in six patients being referred to other hospitals, three being taken off the waiting list, and one seeking private care. CONCLUSIONS: Systematic review of patients on an orthopaedic waiting list of one general practice, though time consuming, led to the identification of inaccuracies in the list and changes in management. Costs need further evaluation, but if the findings occur widely substantial benefits could be achieved for patients.     

General practice orthopaedic outpatient referrals in North Staffordshire.

A study was made of 813 orthopaedic referrals by 134 general practitioners in North Staffordshire. The referral rates showed no relation to practice list size or the doctors'' previous orthopaedic experience. The published waiting times did not accurately reflect clinic vacancies, and no effective priority rating of letters by consultants was shown. Less than 1% of patients had an appointment within four weeks. One quarter of the patients failed to attend and, of those who did, 27% received physiotherapy or a "simple" appliance, or both, while 16% received treatment already available from their general practitioner. Patients from high referring doctors showed the same pattern of distribution in body area affected and treatment outcome as those from low referring doctors, but had a significantly longer time to wait for their appointment. A survey of non-attenders showed that 56% of the patients failed to attend because the condition had resolved.     

Waiting times: monitoring the total postreferral wait.

OBJECTIVES--To determine whether the period spent on the true inpatient waiting list is a valid indication of the total time that patients have to wait for an operation; and to assess the feasibility of monitoring the total "postreferral waiting time" by using existing computerised information systems. SETTING--Three randomly selected Scottish hospitals. SUBJECTS--Waiting list patients admitted to hospital for operations during June to August 1993 in six major specialties, separate attention being focused on cataract operations and hip and knee replacements. MAIN OUTCOME MEASURE--The total time that patients have to wait for an operation after the initial general practitioner referral--the postreferral waiting time--compared with that spent at the final stage of the process on the true inpatient waiting list. RESULTS--In the specialties investigated roughly half (58 days; 53%) of the average postreferral wait of 110 days was spent on the true inpatient waiting list, one third (35 days; 32%) being spent on the outpatient waiting list and one sixth (17 days; 15%) waiting between waiting lists. Only a quarter of cataract patients (73/292) were treated within three months of general practitioner referral compared with over three quarters (228/292) within three months of being placed on the inpatient waiting list. Nevertheless, within a year over 99% of patients (290) had been treated whichever date was taken as the starting point. CONCLUSIONS--Monitoring postreferral waiting times would provide a much more accurate picture for purchasers and patients of waiting times for treatment than is obtained by focusing exclusively on the true inpatient waiting list and facilitate fairer comparisons between NHS trusts in national league tables. Stringent national and local monitoring is essential to ensure (a) that future reductions in the time waiting on true inpatient waiting lists are not gained at the expense of longer periods waiting to be placed on the lists, and (b) that no increases occur in the number of patients placed instead on deferred waiting lists or exempted from the normal maximum waiting time guarantees.     

The extent of the two tier service for fundholders.

OBJECTIVE--To examine possible differential changes in outpatient referrals to orthopaedic clinics, attendances, and waiting times between fundholding and non-fundholding general practitioners. DESIGN--Observational controlled study of referrals by general practitioners to orthopaedic outpatients between April 1991 and March 1995. SETTING--District health authority in south-west England. SUBJECTS--10 fundholding practices with 108,300 registered patients; 22 control practices with 159,900 registered patients. MAIN OUTCOME MEASURES--Changes in age standardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status; changes in outpatient waiting times. RESULTS--In the year before achieving fundholding status both groups were referring more patients than were being seen. Two years later, referral and attendance ratios had increased by 13% and 36% respectively for fundholders and 32% and 59% for controls, and both groups were referring fewer patients than were being seen. Attendances represented 112% of referrals for fundholders and 104% for controls. In 1991-2, a similar proportion of patients in the two groups was seen within three months of referral. The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993-4, as did a third hospital without such clinics by 1994-5. CONCLUSIONS--Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals. Their patients were likely to be seen more quickly, particularly if the hospital provided special clinics exclusively for fundholders. Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients.     

Characterising the nationwide burden and predictors of unkept outpatient appointments in the National Health Service in England: A cohort study using a machine learning approach

BackgroundUnkept outpatient hospital appointments cost the National Health Service £1 billion each year. Given the associated costs and morbidity of unkept appointments, this is an issue requiring urgent attention. We aimed to determine rates of unkept outpatient clinic appointments across hospital trusts in the England. In addition, we aimed to examine the predictors of unkept outpatient clinic appointments across specialties at Imperial College Healthcare NHS Trust (ICHT). Our final aim was to train machine learning models to determine the effectiveness of a potential intervention in reducing unkept appointments.Methods and findingsUK Hospital Episode Statistics outpatient data from 2016 to 2018 were used for this study. Machine learning models were trained to determine predictors of unkept appointments and their relative importance. These models were gradient boosting machines. In 2017–2018 there were approximately 85 million outpatient appointments, with an unkept appointment rate of 5.7%. Within ICHT, there were almost 1 million appointments, with an unkept appointment rate of 11.2%. Hepatology had the highest rate of unkept appointments (17%), and medical oncology had the lowest (6%). The most important predictors of unkept appointments included the recency (25%) and frequency (13%) of previous unkept appointments and age at appointment (10%). A sensitivity of 0.287 was calculated overall for specialties with at least 10,000 appointments in 2016–2017 (after data cleaning). This suggests that 28.7% of patients who do miss their appointment would be successfully targeted if the top 10% least likely to attend received an intervention. As a result, an intervention targeting the top 10% of likely non-attenders, in the full population of patients, would be able to capture 28.7% of unkept appointments if successful. Study limitations include that some unkept appointments may have been missed from the analysis because recording of unkept appointments is not mandatory in England. Furthermore, results here are based on a single trust in England, hence may not be generalisable to other locations.ConclusionsUnkept appointments remain an ongoing concern for healthcare systems internationally. Using machine learning, we can identify those most likely to miss their appointment and implement more targeted interventions to reduce unkept appointment rates.

Sion Phillpott-Morgan and co-workers study occurrence and possible predictors of unkept outpatient appointments in the UK.     

Waiting list for nursing home admission gives limited insight of the problems. Study in handling of the waiting list and the consequences for the patients

The waiting list for nursing home admission is expected to remain unacceptably long. A study of the use and of possibly problematic consequences of the waiting list was described in a thesis. Despite long mean waiting periods and many problems (depressive symptoms, experiences of burden) already at the start of the waiting period, the majority of the informal caregivers were satisfied with the waiting times. This may be explained by a reticence to nursing home admission and by enlistment to the waiting list "out of precaution". Both a long and a short waiting period could be experienced as too long. Waiting list figures give insufficient insight in the "real" demand for nursing home care and in problematic waiting periods.     

Waiting list statistics. III. Comparison of two measures of waiting times.

The length of time that patients spend on waiting lists is a topic of current concern. Calculating the proportion of patients who have been on a waiting list for a long time by taking a census of patients on the list at a single point in time will tend to yield a higher estimate than that obtained by calculating waiting times of patients admitted to hospital during a period of time. To illustrate this point the waiting times of patients in the Oxford region as measured by SBH 203 returns ("census" data) were compared with those as measured by the Hospital Activity Analysis ("event" data). As expected, the SBH 203 census returns showed a higher proportion of patients who had waited over a year compared with the "event" measure of all admissions. This difference, which is analagous to the difference between prevalence and incidence in epidemiology, should be considered when using data from these sources to calculate waiting times.     

Open access to orthopaedic appliances for general practitioners.

A clinic to which general practitioners can refer patients for some types of orthopaedic appliances was opened in North Clwyd in 1983. During 1985, 956 patients were referred by 82 general practitioners; 860 patients received an appliance, and the average waiting time was less than five weeks. Most referrals were for soft collars (44%), lumbar sacral supports (30%), and dorsilumbar supports (7%). Thirty eight patients failed to attend, 54 declined an appliance, and four referrals were considered to be inappropriate. A few patients were subsequently referred to consultant outpatient clinics, 22 for physiotherapy and 34 were referred simultaneously to the open access clinic. The referral rates for general practitioners with access to community hospitals were low. Such an arrangement merits wider consideration.     

Long distance travel for routine elective surgery: questionnaire survey of patients' attitudes.

OBJECTIVE--To carry out an audit and assess the acceptability of long distance travel to patients on a lengthy surgical waiting list. DESIGN--Audit and questionnaire survey. SETTING--Military hospital in Wiltshire. PATIENTS--116 Patients on a general surgical waiting list at Leighton Hospital near Crewe. INTERVENTIONS--Preselection for medical fitness at a waiting list review clinic. RESULTS--Roughly half of patients offered the facility of travelling 120 miles (190 km) for their routine elective operation at the health authority''s expense accepted. The average waiting list time declared by the patients who travelled was 28 months, and 13 patients stated that their condition prevented them from working. Only four patients regretted their decision to participate in the scheme. Lack of visitors did not cause undue concern. CONCLUSIONS--Some patients did not agree to travel for their operation but almost all of those who did so found the scheme satisfactory. Some minor problems were encountered but these could probably be overcome by ensuring use of appropriate transport, extending the postoperative stay when necessary, and more careful selection of patients for an anaesthetic. For efficient use of theatre time in such schemes it is crucial that the operating consultant surgeon should be in charge of case selection.     

Modeling the impact of integrating HIV and outpatient health services on patient waiting times in an urban health clinic in Zambia

Background

Rapid scale up of HIV treatment programs in sub-Saharan Africa has refueled the long-standing health policy debate regarding the merits and drawbacks of vertical and integrated system. Recent pilots of integrating outpatient and HIV services have shown an improvement in some patient outcomes but deterioration in waiting times, which can lead to worse health outcomes in the long run.

Methods

A pilot intervention involving integration of outpatient and HIV services in an urban primary care facility in Lusaka, Zambia was studied. Data on waiting time of patients during two seven-day periods before and six months after the integration were collected using a time and motion study. Statistical tests were conducted to investigate whether the two observation periods differed in operational details such as staffing, patient arrival rates, mix of patients etc. A discrete event simulation model was constructed to facilitate a fair comparison of waiting times before and after integration. The simulation model was also used to develop alternative configurations of integration and to estimate the resulting waiting times.

Results

Comparison of raw data showed that waiting times increased by 32% and 36% after integration for OPD and ART patients respectively (p<0.01). Using simulation modeling, we found that a large portion of this increase could be explained by changes in operational conditions before and after integration such as reduced staff availability (p<0.01) and longer breaks between consecutive patients (p<0.05). Controlling for these differences, integration of services, per se, would have resulted in a significant decrease in waiting times for OPD and a moderate decrease for HIV services.

Conclusions

Integrating health services has the potential of reducing waiting times due to more efficient use of resources. However, one needs to ensure that other operational factors such as staff availability are not adversely affected due to integration.     

Waiting list for kidney transplant. Some patients wait too long.

The selection of a kidney graft recipient should be made not only taking into account biological and clinical parameters, for assuring the maximum possible clinical success; the ethical objective to allow every patient equal opportunity of receiving a transplant should also be pursued. In every waiting list of transplant candidates a proportion of patients remains in the list for a particularly long time. The present analysis aimed to find out the factors associated with a prolonged waiting time, in order to allow the implementation of patient selection criteria able to balance unfavourable factors. The analysis of the waiting list of our kidney transplant centre allowed to observe that blood group 0, anti-HLA immunisation, presence of rare HLA antigens and, at a lesser extent, HLA homozygosity are associated with a longer waiting time for a kidney transplant.     

Results of Psychotherapy

A controlled double blind study was made of 299 non-psychotic female psychiatric clinic patients divided into six groups, with members of each group dealt with in a different manner from those in other groups. Those in one group had one or two hour-long psychotherapy sessions a week. Four groups were limited to brief visits but were given one of three kinds of drugs or a placebo. One group was merely put on a waiting list and received no therapy. As determined by a variety of independent measures, there was a fairly uniform average improvement of all groups except the one that received no treatment. Follow-up 10 to 18 months after termination of treatment revealed that the average patient had maintained her improvement and that those who had received no treatment showed considerable improvement after they were removed from the waiting list.The findings suggested that the widespread preference for the traditional outpatient psychotherapy is based as much on the physician''s bias as on proven greater effectiveness over briefer treatment methods. There was some confirmation that many things other than the development of understanding enter into much of the so-called psychoanalytically oriented psychotherapy and may have profound effect on the outcome.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

Referrals to hospital by general practitioners: a study of compliance and communication.

To determine the extent of non-attendance at first hospital appointments 269 hospital referrals made in one practice over 14 weeks were analysed retrospectively. Non-attendance was more likely among patients referred to outpatient departments than to casualty or for admission. Fifteen per cent (41/269) of all patients and 20% (33/167) of outpatients failed to keep their initial appointments. Prolonged waiting times from referral to appointment were significantly related to non-attendance. Twenty weeks after the last referral had been made no communication had been received by the practice for 24% (61/252) of all referral letters received by the hospital. Minimum delays to appointments and improved communication between hospitals and general practitioners would help general practitioners to make appropriate referrals and improve compliance.     

Surgery or Consultation: A Population-Based Cohort Study of Use of Orthopaedic Surgeon Services

Background

This population-based cohort study has the objective to understand the sociodemographic characteristics and health conditions of patients who do not receive surgery within 18 months following an ambulatory visit to an orthopaedic surgeon.

Methods

Administrative healthcare databases in Ontario, Canada were linked to identify all patients making an initial ambulatory visit to orthopaedic surgeons between October 1^st, 2004 and September 30^th, 2005. Logistic regression was used to examine predictors of not receiving surgery within 18 months.

Results

Of the 477,945 patients in the cohort 49% visited orthopaedic surgeons for injury, and 24% for arthritis. Overall, 79.3% did not receive surgery within 18 months of the initial visit, which varied somewhat by diagnosis at first visit (84.5% for injury and 73.0% for arthritis) with highest proportions in the 0–24 and 25–44 age groups. The distribution by income quintile of patients visiting was skewed towards higher incomes. Regression analysis for each diagnostic group showed that younger patients were significantly more likely to be non-surgical than those aged 65+ years (age 0–24: OR 3.45 95%CI 3.33–3.57; age 25–44: OR 1.30 95%CI 1.27–1.33). The odds of not getting surgery were significantly higher for women than men for injury and other conditions; the opposite was true for arthritis and bone conditions.

Conclusion

A substantial proportion of referrals were for expert diagnosis or advice on management and treatment. The findings also suggest socioeconomic inequalities in access to orthopaedic care. Further research is needed to investigate whether the high caseload of non-surgical cases affects waiting times to see a surgeon. This paper contributes to the development of evidence-based strategies to streamline access to surgery, and to develop models of care for non-surgical patients to optimize the use of scarce orthopaedic surgeon resources and to enhance the management of musculoskeletal disorders across the care continuum.     

How much day surgery? Delphic predictions.

A list was compiled of 83 of the commonest operations, which according to published reports may be performed on day patients but which in our district were usually performed on inpatients. The results of a national Delphi study among anaesthetists and general surgeons who were known to be in favour of day surgery produced estimates of the probable rates of day surgery for each of those operations under ideal conditions. Comparison of these figures with those from a Delphi study carried out in one district and with figures for day surgery carried out in that district and with waiting list figures enabled two health districts to focus their efforts to increase day surgery. The figures from the national Delphi study could be applied in other districts if the following are taken into account: Hospital Activity Analysis data must be validated; though there was consensus among the national Delphi consultants, personal clinical opinions varied; the case load may grow as waiting lists decrease.     

Waiting for coronary revascularization in Toronto: 2 years' experience with a regional referral office.

OBJECTIVES: To determine the frequency of major adverse events among patients awaiting coronary revascularization; to assess the match between referring physicians'' estimates of urgency, a computer-generated multifactorial urgency rating score and actual waiting times; to determine the changes in waiting times as capacity for bypass surgery increased; and to evaluate the influence of choice of procedure or operator on waiting times. DESIGN: Consecutive case series. SETTING: Greater Toronto region. SUBJECTS: All 571 patients referred to an organized referral office by cardiologists at hospitals without on-site revascularization facilities between Jan. 3, 1989, and June 30, 1991. MAIN OUTCOME MEASURES: Preoperative fatal or nonfatal myocardial infarction; proportions of patients waiting longer than the maximum period recommended for their urgency rating; mean waiting times for various subgroups; and correlations among referring physicians'' urgency ratings, computer-generated multifactorial urgency scores and waiting times. RESULTS: Of the 496 patients accepted for a procedure 5 had fatal cardiac events and 3 nonfatal myocardial infarction. Events occurred three times more often in patients with left mainstem disease than in those in other anatomic categories (relative risk [RR] 3.05, 95% confidence interval [CI] 1.48 to 6.27, p = 0.03). Both the computer-generated scores and the referring physicians'' scores were correlated with the actual waiting time (r = 0.46 and 0.57 respectively). Waiting times and the proportion of patients with excessive waiting times fell during the study period (p < 0.0001). However, urgent cases were much less likely to be done "on time" than those with a recommended waiting time of more than 2 weeks (RR 0.16, 95% CI 0.11 to 0.25, p < 0.0001). The mean wait for coronary artery bypass grafting (CABG) was 22.73 days if the referral office was allowed to find a surgeon or interventional cardiologist and 35.31 days if one was requested (p = 0.002 after adjustment for urgency scores). CONCLUSIONS: Death of a patient on the waiting list is uncommon in an organized referral system. Patients with left main-stem disease are at higher risk of death than those in other anatomic categories. There were significant correlations between referring physicians'' ratings of urgency, multifactorial urgency scores and actual waiting times. Expansion of capacity for CABG led to shorter waiting times, but patients with unstable symptoms continued to wait longer than recommended. Requests for a specific surgeon caused significantly longer delays.     

General Surgical Pre-admission Clinic

Ninety-nine patients from a non-urgent general surgical waiting list were randomly selected for either direct admission to a hospital bed or review at a preadmission clinic. A considerable reduction in subsequent bed occupancy was shown in the latter group. The findings suggest that more detailed review of patients in the outpatient department would result in the more efficient use of hospital facilities.     

Making Hospital Geriatrics Work

The first year''s work at a new geriatric department at Northwick Park Hospital shows that active policies revolutionize the geriatric service and result in high turnover of patients and no waiting list. Comparison with low turnover/waiting list departments shows the effects of a waiting list in terms of diminished therapeutic benefit and less favourable outcome for patients admitted. The requirements for elimination of the waiting list appear to be well directed policies and adequate and enthusiastic staff. Active geriatrics results in high morale and could be widely applicable within the present hospital bed resources given the necessary improvements in staffing.