Management of access to Hong Kong public specialist out-patient services

Abstract

Introduction Accessibility to care is a key measure for quality health care. Waiting list resulted due to disequilibrium between demand and supply. Waiting time is a common issue in public health care services. Long waits and delays dissatisfy patients, affect clinical outcome and increase health care costs. Access management is therefore important to enhance patient safety, increase satisfaction and reduce service inefficiency. In Hong Kong, waiting lists for public specialist out-patient services have been increasing over the past years. Promotion of appropriate referrals and appropriate utilization between primary and secondary care was identified as one of the current strategies for service demand management. Referral guidelines were introduced to define the clinical conditions to be referred. Appropriate work up and trial of treatment was recommended before referral to specialist care. They were translated into standard referral letter templates and built into the existing electronic medical record system as an execution platform to facilitate workflow and enhance compliance. This electronic referral system was piloted since January 2010 in Department of Accident of Emergency and General Out-patient Clinic at one local public hospital in Hong Kong.

Methods The objective of the study was to evaluate the effectiveness of current strategy in access management to public specialist out-patient services. All new case referrals to Medical and Surgical Specialist Out-patient Clinics (SOPC) of the pilot hospital from January 2010 to December 2010 were examined. While, the new case booking data from January 2009 to December 2009 in respective units of the same hospital was used as control group for comparison. Potential changes in number and distribution of new case bookings at medical and surgical SOPC as well as their corresponding waiting time were looked into. Comparison of referral pattern before and after the implementation of new referral system was performed.

Results Changes in referral pattern in terms of distribution of triage categories have been observed. Number of semi-urgent cases was significantly increased in 2010 compared with 2009 in both Medical and Surgical SOPC (p=0.006 and p=0.048). Shortening of overall median waiting time was also seen in both Medical and Surgical SOPC of the pilot hospital in 2010. Consistent reduction with statistically significance was noted in all triage categories of both specialist clinics, except urgent cases in Surgical SOPC. Larger effect was seen in non-urgent cases, with 9 weeks and 4 weeks shortening of waiting time in Medical and Surgical SOPC respectively. For overall distribution of waiting time, persistent multimodal patterns were observed in both Medical and Surgical SOPC during the study period. Major peaks were identified within 2 and 8 weeks time of appointment, while scattered clustered bookings were seen along the timeline with waiting time up to years.

Discussion The observed result was reinforcing the direction on current strategy, despite direct causal relationship could not be established at the moment. Changes in referral pattern could possibly be explained by the behavioral change of clinicians upon referral and triage of patients due to the introduction of the new referral system. Potential Hawthorne effect during the pilot period should therefore be considered. In view of the complexity and interconnectedness of various service components in the health care system, further studies should be of value to identify the change agent in the system and look into the efficiency gain as well as outcome improvement. Long term and regular monitoring mechanism of waiting time with specific set of performance indicators has to be in place for continuous quality improvement. Taking the public health approach by applying operational studies and simulation models should therefore be the way for further improvement of operational efficiency and service planning in the whole public health system.

Conclusion Appropriateness of referrals and utilization between primary and specialist services was introduced for access management of public specialist out-patient services in Hong Kong. Changes in referral pattern with shortening of waiting time were observed. In order to manage the accessibility issue effectively, a balanced approach on demand, queue and capacity management was suggested to be adopted at the organizational level. Collaboration across sectors particularly with the direction to strengthen primary care would also be needed globally at the system level for a healthy, equitable and sustainable system.