When the Marathon Family Health Team in Northern Ontario tried to improve their availability to patients, it ended up being a bit of a “trial and error” process, says Sarah Newbery, a family doctor on the team and president of the Ontario College of Family Physicians.
The clinic used to offer patients the ability to book appointments a week or two in the future, or to see the physician designated to do urgent care for the team that day. Then they switched to a system where they could offer same- and next-day appointments to all patients with their own providers, no matter the urgency of what they were looking for. But it didn’t work for their office.
“Because we’re in a rural area and all of us also work in our local emergency department, it was quite hard to predict our week-to-week availability,” says Newbery. So the team modified their plans, trying out a different system, called a carve-out model, instead. They now keep about 30% of each doctor’s appointment slots open for urgent care needs.
To Newbery, it’s been a success. “I think it works quite well overall. We’ve improved the continuity – you’re much more likely to see your own doctor. And we’ve seen the numbers of unnecessary emergency department visits decrease as a result.”
More and more clinics are achieving same- and next-day access. According to the The Commonwealth Fund 2015 International Health Policy Survey of Primary Care Physicians, released this morning, 53% of physicians say most of their patients can get a same- or next-day appointment if they request one. That’s up from 39% in 2009, but it still places us second-last of the 10 countries surveyed. In Switzerland, which did the best, 85% of doctors said their patients had access to same- or next-day appointments; in the U.S., 74% of doctors said they did. There’s also significant variation among provinces, with 66% of Ontario’s doctors answering yes – the best of all the provinces – and 53% of physicians in Alberta saying so.
“We’re happy to see the trend [in access to appointments] is upwards,” says Tracy Johnson, director of health systems analysis and emerging issues at the Canadian Institute for Health Information. But “overall our numbers are not where we would want them to be. If you’re in the nearly 50% of patients who call their doctor and can’t get that same- or next-day appointment, 53% likely isn’t good enough for you.”
But improving access isn’t as straightforward as it seems: It can be hard to execute and doesn’t work for every primary care provider. And its touted benefits – including reducing emergency visits and increasing patient satisfaction – aren’t very well supported by studies.
The carve-out model and open access
There are two common models used to speed up access to care. The first is the carve-out model, where many appointments – perhaps 50% to 70% – are booked in advance, and the rest are reserved for urgent, same-day requests. A true advanced access model, or “open access,” goes even further, with the majority of appointments left open for patients who call that day, whether it is for urgent needs or routine care.
Both systems leave room for appointments to be made ahead, which can be better for preventative care such as immunizations and pap smears, and regular follow ups for chronic diseases – or for patients who have an unexpected but non-urgent issue and prefer to book a few days away. In an ideal system, appointments would be available whenever the patient wants them.
Evidence behind same-day and next-day access is mixed
These systems are said to benefit both providers and patients alike. Patients say timely access is one of the most important aspects of primary care to them, and people are happier with faster appointments. Case studies have found it results in fewer no-shows, and front-desk staff have to make fewer confirmation calls and less triage work. As a doctor quoted in a series of case studies in JAMA said, “It is far less effort than handling the daily triage and double-booking chaos of the old system.”
In addition, focusing on faster access should decrease the number of patients who use walk-in clinics and emergency departments –another area where Canada ranks badly, with over a third of older Canadians heading to an emergency department for an issue that could have been dealt with by their primary care provider.
But a 2011 systematic review on advanced access found that while places that introduced it did decrease their wait times, sometimes significantly, they were unlikely to be able to regularly offer appointments within 48 hours.
It also found that while faster access did lower the number of no-shows, it only did so in practices that began with higher no-show rates. Plus, the evidence about it increasing patient satisfaction was mixed, and there wasn’t enough information to judge whether it improved health outcomes. (Though it did find no evidence of harm.) An HQO review of the research around advanced access for patients with chronic diseases found that observational studies in patients with chronic diseases came to similar conclusions.
But since “only a limited number of the studies included in the systematic review were able to achieve same-day access, the mixed results could be attributable to imperfect implementation of the advanced access system as opposed to a failure of the concept itself,” says Johnson.
The evidence that it reduces emergency department visits is also uneven. “It would be lovely if that was true,” says Lee Donohue, chair of the OMA Section on General and Family Practice. “But for family doctors who are taking care of people with complex, chronic diseases, the research doesn’t show that there’s a big dent in emergency use if same- or next-day appointments are available.”
Rick Glazier, a family doctor at St. Michael’s Hospital and senior scientist at the Institute for Clinical Evaluative Sciences in Ontario, attributes the mixed evidence to the fact that there’s no agreed upon method of implementing advanced access, but says it still makes sense to push forward with more timely access. “For me the bottom line is that people need to be seen in a timely way when they feel they need care,” he says. “Turning people [who need care] away because no appointments are available for several days cannot be the foundation of a high functioning health system.”
Implementing same- and next-day access
The first step towards more timely access is ensuring that a doctor’s office doesn’t have too many patients. There are ways to calculate this, but a good informal sign is to look at whether the practice’s backlog – the number of days the average patient waits to see the doctor – is stable or growing. If it’s stable, that’s a sign that there is probably a manageable number of patients.
“It could be that you have the right number of patients, but that you have a long queue because you’ve just gotten behind,” says Diane Bischak, co-director of the Healthcare Operational Excellence Laboratory at the University of Calgary. Eating away at that backlog requires increasing your capacity temporarily, but typically only by about 5% to 10%, she says.
On the other hand, doctors who are simply overbooked may find that the ever-growing queue is a symptom of the fact that they may have too many patients to make advanced access work. “If you’ve worked through your backlog and then you go back to your schedule and it starts building up again, then you just have too little capacity for the demand, so there’s not much you can do about that,” she says.
However, roster size “could be a [limiting] factor, but it’s unlikely it’s the main factor,” says Johnson, pointing out that Canada ranks 5th in highest number of family docs per capita among the countries in the Commonwealth Fund rankings.
After the hard work of clearing a backlog, there’s also ongoing work around making sure the schedule stays clear. That requires a fair bit of administration work, especially around high-demand times and vacation needs.
There are also a few best practices to help reduce the time spent on appointments over time. Tara Kiran, quality improvement program director in the Department of Family and Community Medicine at St Michael’s Hospital, covered some of the issues in a recent article in Canadian Family Physician. To reduce appointment demand, she says, providers could question routine appointments that aren’t evidence based; use email or phone to answer patient questions; consider group appointments; and use non-physician professionals, such as nurse practitioners, in their practice. Maximizing appointments can also help, by offering preventative care at the same time as visits for other issues.
Suggestions like these are difficult in our system, says Donohue. “We don’t have fundamental structural support for it; we don’t have the infrastructure,” she says, adding that if you’re in a practice and you have no additional nurses (unlike the situation in the other Commonwealth countries) or no EMR (unlike places like New Zealand) it’s difficult to implement some of these changes. “If it were easy, we would all be doing it.”
Collecting more data on patient quality of care is also important. “I think public reporting at a practice level, with a patient experience survey that’s centrally administered, would help,” says Kiran.
The largest potential problem from same- and next-day access is that it will affect continuity of care. While seeing a different doctor or nurse practitioner at your own clinic is obviously preferable to going to a walk-in or an emergency department, it still may be worse than waiting a bit longer to see your own doctor.
“There’s lots of literature associating patient continuity with good outcomes,” says Kiran. “So it’s important for us to push towards access and continuity together, or the push towards access might come at a cost.”
That’s what happened in the UK. After the government asked for patients to be able to access their physicians within 48 hours, many practices kept 70% of their appointments open. That resulted in patients being told to call in the mornings to book appointments, and often being seen by “duty doctors” instead of their own providers. The shift was widely disliked, earning the nickname “access by denial.”
For providers, there’s also a potential issue around predictability. James Dickinson, Professor of Family Medicine and Community Health Sciences at the University of Calgary, moved to a carve-out model in his clinic and found that the unpredictability of urgent visits affected his hours. “Often urgent care people have problems that are more than just a 10-minute thing,” he says. “I ended up working Friday afternoons, and inevitably people would come in because they’d been putting off seeing the doctor, and then the timing would be blown completely by someone with an acute care problem. My wife got very upset about my hours. It really is a problem.”
That said, he is in favour of the change. “It’s not such a big deal for patients who are fit and healthy who just have an acute problem [to go to the emergency department or to a walk-in clinic]. But when there’s a whole lot of background that has to be taken into account, it’s really important for the doctor seeing them to look at that background and interpret whatever’s happening to them in light of that,” he says.
A concern of some people is that patients will come in for small problems and make more appointments. That’s unfounded, argues Brian Hutchison, who was senior advisor to the Quality Improvement and Innovation Partnership and HQO. “It’s a frequently raised concern – will patients abuse health care if you make it accessible to them? But there isn’t good evidence that people do. People don’t want to go to the doctor, really.”
Ultimately, “Moving to an advanced access type model requires a real paradigm shift,” says Kiran. “Doctors have to go from thinking about their appointment slots to thinking about caring for all their patients.”
It seems to be worth it, says Newbery. “One of the things that we hear from members about this is that it’s a lot of work to put in place upfront, but once you’re through to the other side, it’s a really wonderful way of working. Most physicians who have gone through it wouldn’t go back.”