Improving Productivity and Efficiency in Outpatient Clinics

Executive Summary

Aim

A literature review was carried out to determine what evidence was available internationally that could help to inform methods of increased productivity and efficiency in outpatient clinics in the UK.

Objectives

The four main questions were:

  1. What can be done in the primary care or community setting to reduce pressure on outpatient clinics?
  2. What can be done to decrease the numbers of new and return appointments to the outpatient clinics?
  3. How can outpatient appointments be used more effectively?; and
  4. How can efficiency be improved by reducing variation and overall demand and what are the resultant effects on savings and cost containment?

Literature Search

A literature search was carried out and of the 178 papers identified, 22 met the inclusion criteria. The search focused on international evidence and excluded papers referring exclusively to the UK setting as it was considered that this literature was already well known.

Objective 1: Reducing pressure on outpatient clinics

This question aimed to identify how the demand on outpatient services could be transformed in terms of, for example, how people think about these services, their location, their movement towards primary care and by supporting self-care. Research which addresses this is discussed below:

Outreach clinics

Outreach clinics are clinics in the community rather than in the hospital. A recent systematic review explored the international evidence.

The key findings were:

  • Research exploring the use of outreach clinics tended to describe urban, non-disadvantaged areas although the groups which are most likely to benefit from such clinics are disadvantaged groups and those living in rural areas.
  • Such clinics had the potential to improve access to specialist services, improve liaison between specialists and primary carers, and to benefit from the fact that patients tended to find such clinics less stressful and more familiar.
  • At present the research does not suggest that there were increased efficiencies as a result of these services.

Objective Two: Reducing new and return appointments

  • One study aimed to improve efficiency by actively pre-assessing patient charts and pre-specifying management plans before scheduled outpatient visits. Investigations could be ordered in advance and visits cancelled if unnecessary. This was successful and weekly clinic attendance fell by 40%. Urgent referrals could be seen in the same week while maintaining low waiting times for routine referrals.
  • None of the papers identified in the search explored reducing inpatient referrals by other methods: such as working with general practitioners to reduce unnecessary attendance or providing greater education for self care to patients when they are inpatients.

Objective Three: Utilising outpatient appointments more effectively

A number of approaches were discussed in the literature to use outpatient appointments more effectively.

  • Group medical appointments: Patients were given education about their condition as a group and then seen in a shorter individual session. The approach reduced waiting times, increased hourly profit (US system) and resulted in greater patient satisfaction.
  • Electronic Medical Record: Electronic medical records have been used to increase communication between health sectors. Overall it would seem that they are used differently in different settings and their potential is not yet being realised. While they may improve the system process they create new challenges as they are not always easy to use.
  • Reminders: Several methods were tested to decrease the number of patients who failed to attend including text, telephone and letter reminders and all of these were successful.
  • Electronic Consultation: A review of electronic consultation was carried out. The results showed that it could be practiced in a large number of medical specialities and had application in primary consultation, second opinion consultation, telediagnosis and administrative roles (eg e-referral). However much of the literature is descriptive or anecdotal and hence the results are inconclusive. At present they do not replace face to face consultations but augment them. It is possible that this system could be used to triage patients and also so that investigations could be ordered in advance of an appointment.
  • Quick diagnosis clinics: In this Spanish study, patients with severe diseases who would otherwise have been admitted to hospital were assessed in outpatients and then, if there were no contraindications, they were treated as outpatients even for illnesses for which they would usually require admittance. An estimated 4,563 bed days a year were saved, the mean cost was hospitalisation was significantly reduced and overall satisfaction for this approach was high.

Objective 4: How can efficiency be improved and what are the resultant effects on savings and cost containment?

The papers identified in this area largely described theoretical modelling, lean management and six sigma approaches to improve the efficiency of the outpatient clinic. Using these approaches in conjunction with analysing how a clinic works or working with relevant members of staff showed:

  • Modelling was used to reduce queues, estimate ‘failed to attend’ patients and plan accordingly, find bottlenecks in the system, improve flow of patients between areas, improve appointment systems, test different scenarios, reduce length of stay, estimate capacity and so on.
  • These approaches reduced waiting times in clinics, reduced non-attendance, allowed more people to be seen, allowed physicians to spend more time with patients and increased satisfaction.
  • Such methods have the advantage of allowing new approaches to be tested without disruption to current services and the ability to alter one variable and see the implication of this.
  • A risk assessment approach was also used in a sexually transmitted infection clinic which assessed patients in terms of their risk of infection and gave them suitable tests depending on this likelihood. The authors stated that this had significant cost and time savings.
  • None of the papers identified described variation reduction or methods of reducing overall demand

1.Introduction

This paper reviews evidence on ways of increasing productivity and efficiency in outpatient clinics. The main questions it aims to address are (i) what can be done in the primary care or the community setting to reduce pressure on outpatient clinics, (ii) what can be done to decrease the numbers of new and return appointments to the outpatient clinics, (iii) how can outpatient appointments be used more effectively; and (iv) how can efficiency be improved by reducing variation and overall demand, and what are the resultant effects on savings and cost containment. The project team considered that the UK evidence in this area was already well-known within the government and therefore this review focuses on international evidence.

2.Literature Search

A full literature search was carried out and the details of the search terms and methods can be made available on request. The initial results of the search were scanned by the national lead for primary care, community and outpatients, and as a result the search terms were refined and the search repeated. This second search identified 178 papers and presentations. The abstracts of these were accessed and assessed for inclusion and at this stage 104 papers were excluded. The remaining seventy-four papers were read in full and a further fifty-two of these were excluded on the grounds of relevance, inappropriate methodology or referring only to the UK setting. The present review summarises the remaining twenty-two papers with reference to the four main questions above.

3.Literature Review

3.1What can be done in primary care or the community setting to reduce pressure on outpatient clinics

This question aimed to understand how demand for outpatient clinics could be transformed by, for example, how people think about these services, their location, their movement towards primary care and by supporting self-care. Only one paper was found which was relevant to this area, which was a Cochrane review of outreach clinics.

Outreach Clinics

A Cochrane review published in 2012 examined the cost and benefits of outreach in different specialities and countries including the UK .(1) Of the 73 papers found, nine met the inclusion criteria and the majority of these described non disadvantage populations in developed countries and were set in urban areas. The main types of settings were (1) specialist clinics in urban primary care settings instead of hospital outpatient departments (2) specialist clinics in rural community primary health centres or hospitals where there was no resident specialist, and (3) sub-specialist clinics in major regional centres where there was only a resident ‘general’ specialist service. This meant that outreach services served a range of urban, rural and remote populations of varying degrees of health, healthcare and socioeconomic disadvantage. The authors stated that the aims and potential benefits of these services were (i) to improve access to specialist services, (ii) to improve liaison between specialists and primary carers, and (iii) to benefit from consultation in primary care settings such as the fact that patients tended to find them less stressful and more familiar.

The authors also explored potential costs related to the additional cost of service provision, the cost of the travelling specialist, and the opportunity cost of taking them out of their setting. The review quoted a UK systematic review [Powell, 2002] which included one randomised control trial (RCT) and one other study that controlled for case mix. This concluded that outreach clinics lead to improved communication between GPs and specialists and better access and improved patient access but had increased costs and was a less efficient use of specialists’ time. This review stated that, in the UK, the decision to provide specialist outreach services was made because it was felt to be more convenient for patients and that this convenience was considered to be worth the extra cost. The review authors stated that there had been little analyses of the quality of care compared with hospital clinics, nor of the implications for equity of access. They believed that in different countries, where there were fewer specialists and greater rural population, it was likely that costs and benefits would differ. The authors also commented that there were risks for people who were mentally ill, homeless and so on and that these groups would have different service needs.

This review undertook a descriptive overview of all studies of specialist outreach clinics including those which did not meet the inclusion criteria to estimate their effects on access to specialist care, quality and appropriateness of care, health outcomes, patient and provider satisfaction, use of services and costs and to assess the influence of different contexts and styles of service delivery on their outcomes. The review identified 73 specialist outreach interventions in 14 countries and a wide range of settings was represented, from specialists visiting urban general practice near major hospitals to small aircraft or four wheel drive vehicles to visit remote parts of Africa, Australia and Canada. These had been established to improve access, foster collaboration and improve efficiency and appropriateness of health care service use. Virtually all disciplines were represented. Overall the good quality studies were done in UK, Europe, USA and urban Australia and focused on urban non disadvantaged groups, whereas the studies in rural Australia, rural Canada, Africa, South America and the Middle East were descriptive. In the latter case there may be a greater opportunity to benefit but the quality of the studies made it difficult to draw conclusions. The quality of studies was significantly higher in evaluations of outreach to non-disadvantaged populations and in the areas where the potential to benefit was marginal. In summary: neither the included nor excluded UK studies suggested that outreach in urban non disadvantaged settings provided any significant benefit in health improvement or the effectiveness of healthcare delivery although they may have benefits in terms of patient experience. In addition these clinics were more costly. Some studies found that specialists found them inconvenient and it did not lead to the improved communication that they had hoped. As most studies took place in urban, non-disadvantaged groups, it was not possible to draw conclusion for more disadvantage patients or those in rural areas both of whom may have been expected to benefit from such clinics

Overall the authors concluded that the benefits of simple outreach models in urban non-disadvantaged populations seemed small and were often more expensive although they had the potential to improve both access and communication. There was a need for good comparative studies of outreach in rural and disadvantaged settings where outreach might confer most benefit to access and health outcomes.

Based on this Cochrane review the evidence does not exist to support the theory that outreach clinics transform demand on outpatient clinics or that they are more effective or efficient.

3.2Reducing new and return appointments

If reductions could be made in inappropriate visits or return appointment to outpatient clinics then this could reduce pressure on these services as well as increased patient satisfaction. Only one study identified in the literature review addressed this question directly(3). The authors stated that previous research has shown that patients are reviewed unnecessarily in outpatient clinics and outpatient attendance does not reduce hospital readmissions. Moreover inappropriate visits reduce access by increasing waiting times. The aim of this approach was to use the outpatient clinic more efficiently by exploring unnecessary attendance and improving efficiency by actively pre-assessing patient charts and pre specifying management plans before scheduled outpatient visits. All charts were reviewed by a senior clinician two weeks before the clinic and a brief, written management plan was made. This meant that investigations could be ordered in advance so that they would be available on time and clinic visits cancelled if unnecessary, or postponed if the required investigation would not be available in time. Pre-screening for a clinic took about three hours. Over six months 768 patients were scheduled for review in the medical outpatient department, following pre screening, in only 458 of cases was review necessary. Weekly clinic attendance fell by 40% from 32.8 patients to 19.1 patients (p<0.05). This meant that urgent referrals could be seen in the same week while maintaining low waiting times for routine referrals. One of the premises of this study was that Senior House Officers would ask for patients to be reviewed who could have been discharged because they thought it would do no harm, whereas it caused anxiety and time for patients, created opportunity costs, and made this way of seeing patients appear to be standard care. However SHOs do need to see patients for training purposes and patients cannot always be seen by senior clinicians so this method were SHOs make decisions and these are reviewed by . senior clinicians helps to assess whether a further appointment was necessary. In addition by ordering investigations in advance the clinic time could be maximised. Waiting times did not reduce as a result of this approach, but these had already been good. This clinic also had an aggressive discharge policy, a waiting time of only three weeks and open door access. The authors considered that there may be even greater implications for other clinics.

In terms of the review question, regarding the potential for reducing new and return appointments, this study does suggest that one method is by reviewing patient charts in advance of clinics. However this is only one study and no papers identified in the search explored reducing inpatient referrals by other purposes, such as working with general practitioners to reduce unnecessary attendance or providing greater education for self care to patients.

3.3Utilising outpatient appointments more effectively

Productivity and efficiency could also be improved by using outpatient appointments more effectively. The literature search identified several papers that were relevant to this area. They broadly consisted of group medical appointments, electronic records in one form or other, and a reminder system to reduce the number of patients failing to attend. One paper also described a method to use outpatient clinics in order to reduce inpatient numbers. These studies are outlined below.

Group medical appointments

Group medical appointments generally refer to those appointments which are divided into two: the first part being an education session done with patients as a group, and the second part being an individual session, which can be shorter and more focused as information has been given at the group stage. The advantages of this approach are that groups can be taken by a nurse or other clinician, the group appointment gives patients the opportunity to talk to people with similar illnesses and share experiences, and the consultant can spend less time with each patient individually but that this time is more specific to them, rather than repeating the same general information to each patient. Studies have demonstrated improved quality of care, and, as a result of improved education, fewer emergency department and speciality visits. However other studies have shown that these clinics are not always economically viable. Three papers were identified in this review which explored the efficiency of group medical appointments.