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

Abstract

BackgroundLong 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.MethodsA 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.ResultsThe 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.ConclusionsBroad-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 registrationAustralian New Zealand Clinical Trials Registry ACTRN12615001016527 registration date: 29/09/2015.

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

“…The perceived advantage of reduced waiting times concurs with the main findings from the stepped wedge cluster randomised controlled trial, which found an average reduction in waiting of 34% (24 days) [12]. In contrast, the perception of an increased wait time to first review appointment is not supported by findings in the trial [12]. While it is possible that there were individual cases where clinicians had difficulty scheduling patients to their first review appointment, there was no difference recorded in the time between the first and second appointment after the STAT model had been implemented across the eight sites.…”

“…The perceived advantage of reduced waiting times concurs with the main findings from the stepped wedge cluster randomised controlled trial, which found an average reduction in waiting of 34% (24 days) [12]. In contrast, the perception of an increased wait time to first review appointment is not supported by findings in the trial [12].…”

“…The aims of the interview were to establish staff perceptions on (1) what aspects of STAT worked well, (2) what aspects had been challenging or failed, (3) how the implementation process could be improved, (4) how much implementation of STAT changed daily practice, (5) the effect of STAT on patient outcomes and (6) the overall perception of the model relative to usual care. All interviews were conducted between July and October 2017, following the end of the STAT trial [12]. This qualitative study received ethics approval from the Eastern Health Human Research Ethics Committee as an amendment to the approval previously obtained for the stepped wedge trial.…”

“…Variability in waiting time was also substantially reduced, suggesting that the greatest benefit of the model was likely to be for patients who were previously judged to be low priority and waited for long periods to access care. This trial was registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12615001016527) and has been reported in detail elsewhere [12].…”

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

“…Waiting for healthcare services is a problem across the care continuum [1] in emergency departments [2], acute hospitals [3] and in ambulatory, community and outpatient settings [4]. Much work has been done on patient flow particularly in the acute setting [5] but there has been increased attention focusing on access, triage and patient flow in non-bed-based services [6–8]. As chronic disease management relies on responsive outpatient services, demand and wait lists for these services has increased [8].…”