Effect of Advanced Access Scheduling on Processes and Intermediate Outcomes of Diabetes Care and Utilization

Abstract

BACKGROUND:The impact of open access (OA) scheduling on chronic disease care and outcomes has not been studied. OBJECTIVE:To assess the effect of OA implementation at 1 year on: (1) diabetes care processes (testing for A1c, LDL, and urine microalbumin), (2) intermediate outcomes of diabetes care (SBP, A1c, and LDL level), and (3) health-care utilization (ED visits, hospitalization, and outpatient visits). METHODS:We used a retrospective cohort study design to compare process and outcomes for 4,060 continuously enrolled adult patients with diabetes from six OA clinics and six control clinics. Using a generalized linear model framework, data were modeled with linear regression for continuous, logistic regression for dichotomous, and Poisson regression for utilization outcomes. RESULTS:Patients in the OA clinics were older, with a higher percentage being African American (51% vs 34%) and on insulin. In multivariate analyses, for A1c testing, the odds ratio for African-American patients in OA clinics was 0.47 (CI: 0.29-0.77), compared to nonAfrican Americans ]. For urine microablumin, the odds ratio for non-African Americans in OA clinics was 0.37 (CI: 0.17-0.81). At 1 year, in adjusted analyses, patients in OA clinics had significantly higher SBP (mean 6.4 mmHg, 95% CI 5.4 -7.5). There were no differences by clinic type in any of the three health-care utilization outcomes.CONCLUSION: OA scheduling was associated with worse processes of care and SBP at 1 year. OA clinic scheduling should be examined more critically in larger systems of care, multiple health-care settings, and/or in a randomized controlled trial.

Primary Care Access and Emergency Room Use Among Older Veterans

“…First, they are consistent with prior research suggesting that simple interventions like advanced-access scheduling may not solve the problem of ER overuse. 20,21 Our results suggest that the challenge of improving primary care access is more complex than simply increasing appointment availability, and may only work in certain settings where patients rely on a single PCP for their care. As the VHA implements the medical home model nationwide, it will be important to remember that open access alone may not effectively reduce ER use.…”

“…While one study found a decrease in urgent care visits with the implementation of open-access scheduling, 20 neither it or another study found a consistent effect of open access on ER visits. 20,21 Thus, the relationship between primary care access and ER use remains questionable.…”

What Are the Consequences of Waiting for Health Care in the Veteran Population?

“…There was a statistically significant, yet modest effect of visiting an OA clinic on HbA1c levels that was similar to the effect found in the Prentice et al study. 15,31 The effect of more timely access to care in these two studies is roughly a quarter to a third of the effect seen for the most successful multi-faceted quality improvement programs aimed at glycemic control. These quality improvement programs implement a wide range of interventions, such as patient registries, clinician education or case management but do not usually focus on improving timely access to care, [32][33][34] More work also needs to be done to identify patient populations most adversely affected by delays in access to health care.…”

“…Studies outside of the VA have also found an effect of delayed access to care on HbA1c levels. For example, Subramanian et al 31 compared private sector primary care clinics that had implemented OA to control clinics using patients diagnosed with diabetes. There was a statistically significant, yet modest effect of visiting an OA clinic on HbA1c levels that was similar to the effect found in the Prentice et al study.…”

Designing a System for Patients Controlling Providers’ Access to their Electronic Health Records: Organizational and Technical Challenges

“…The study clinic follows an open-access model 10 where patients have an assigned primary care provider (PCP) but are cared for by other physicians, nurse-practitioners, physician assistants, nurses, and other staff. Because these providers often refer patients to other Eskenazi Health providers and clinics, we had to decide which providers would be included.…”