Milakovic M, Corrado AM, Tadrous M, Nguyen ME, Vuong S, and Ivers NM. April 16, 2021 9 (2) E413-E423; DOI: https://doi.org/10.9778/cmajo.20200067
Background
Delivering timely access to care is a challenge in many health care systems. Canada lags behind comparator countries in access to specialist physician and allied health professional consultations.
Most outpatient specialists in Canada manage their own referrals and wait lists, meaning they each maintain a separate queue for their own practice—a “multiple-queue” model. Wait times vary by physician, with some specialists having longer wait times than others. Referring physicians choose which of their specialist colleagues they refer to. This choice may be influenced by factors such as longstanding relationships with specialist colleagues, or patients’ preference, and it may be informed by provincial wait time data (such as BC’s Pathways, an online resource for physicians that helps identify the most appropriate specialist with the shortest wait time). The Canadian Institute for Health Information (CIHI) tracks wait times for “priority procedures”, but does not track wait times for non-surgical specialist care. Some provinces, such as Nova Scotia, track and publicly report average non-surgical specialist wait times.
“Single-queue” models for accessing specialty care are an alternative to “multiple-queues”. With single-entry models, patients are triaged and referred to the next available appropriate specialist through either a central intake (i.e. all referrals go through a single door) or a pooled referral system (i.e. multiple physicians’ wait lists are merged). The single-entry model is based on queueing theory and is widely used in, for example, the airline and banking industries. Some believe that single-entry models have the potential to enable faster access to specialist care by decreasing Wait 1 (time from initial referral from the family physician to consultation with a physician specialist or allied health professional).
This study evaluated the effect of implementing of a single-entry model on (a) Wait 1, (b) overall referral volume, and (c) patient and provider satisfaction.
Methods
Systematic review of single-entry models involving allied health professionals and specialist physicians (from database inception to 2019). Inclusion criteria: outpatients referred to specialists for medical, surgical, or allied health services; implementation of single-entry model, and absolute reduction of Wait 1 before vs. after implementation of single-entry model. Exclusion criteria: Studies that did not report original data or were not conducted in OECD countries. Study variables: Wait 1 before and after implementation of the single-entry model, changes in patient volume, and changes in patient and provider satisfaction.
Results
Of 4637 potentially eligible studies, only 10 were included in the analysis: 8 from Canada, 1 from Australia, and 1 from England (all published between 2004 and 2017). Specialties included orthopedics and general surgery (3 studies), internal medicine (5 studies), chronic pain (1 study), physiotherapy (1 study).
All studies reported a reduction in Wait 1 but this statistically significant in only 6 studies. Average reduction in Wait 1 was greatest for surgery, urgent referrals to internal medicine specialties, and for children with complex needs, suggesting that centralized intake may be more helpful for higher-priority referrals, and in situations with longer initial waits. Studies in which implementation of single-entry model was mandatory (3 studies) showed improvements in Wait 1 ranging from 5-47 days. When implementation was optional, improvement in Wait 1 ranged from 6 days to 9 months.
Changes in patient volume (4 studies) varied considerably across studies. Studies assessing patient satisfaction (3 studies) all reported positive or improved satisfaction with single-entry models. Patients felt services was faster and better with a common waiting list. Only one study reported on provider satisfaction after implementation of a single-entry model; providers reported higher quality and more complete referrals after implementation.
Limitations
The main limitation of this review lies in the paucity of eligible studies and the deficiencies of the primary studies included. Studies came from only three countries (i.e. Canada, Australia, and England). Only 3 studies reported on patient satisfaction, and only 1 reported on provider satisfaction. Studies varied with respect to completeness of data, such as sample size, so calculation of weighted averages was not possible. Sustainability of single-entry models was not adequately assessed in any study and few reported on implementation fidelity. All studies had a high risk of confounding because they were either simple before-after studies or cross-sectional, rather than time series. As such, it was not possible to determine whether any differences arose from confounding variables. Risk of bias was high in all studies. Included studies lacked methodological designs that would have improved rigour, such as randomization, matching, and stratification or multiple regression.
Comment
Single entry models are often proposed in Canada as an intervention to help reduce wait times. This systematic review found that implementation of a single-entry model was associated with a decrease in Wait 1 for specialist consultations. This is consistent with other research showing that single-entry models hasten access to elective surgery. However, given significant limitations in the (few) studies included in this review of single-entry models for non-surgical specialty consultations, there remains uncertainty about whether this is the best tool to reduce wait times in that setting. Methodologically robust studies should be designed and undertaken. For elective surgeries/procedures specifically, though, reasonable evidence suggests provinces/territories ought to implement single-entry models, with embedded evaluation to further assess effectiveness.
Long waiting times—in some jurisdictions and for some services—are the main, and in many cases only, reason some Canadians say they might be willing to pay for care outside of the publicly-funded health care system. Yet, since single-entry models reduce patients’ waits for elective surgeries, they may also reduce waits for specialty care. Though equity has not been measured yet, this approach has the potential to improve equitable access to care. As such, single-entry models should be further investigated and, where found to be effective, scaled up and spread. As inferred by the Supreme Court of BC in Cambie Surgeries Corporation v. British Columbia (Attorney General),wait times solutions that preserve and ensure the sustainability of Canada’s publicly-funded system must be implemented, because remedies imported from commerce are likely to be inconsistent with provincial and federal health care law.
