April, 2017 - SUPPORT Summary of a systematic review | print this article |

What are the effects of interventions to reduce waiting times for elective procedures?

Long waiting times for non-urgent procedures can cause distress among patients as well as adverse health consequences, and may be perceived as inappropriate healthcare planning. Interventions to reduce waiting times can ration or prioritise demand, expand capacity, or restructure referral or intake assessments of patients.

Key messages

  • Direct/open access and direct booking systems probably slightly decrease median waiting times and may decrease mean waiting times in hospital settings.

− The effects of direct/open access and direct booking systems on mean waiting times in outpatient settings, and on the proportion of patients waiting less than a recommended time are uncertain.

  • The effects of other interventions to reduce waiting times, including increasing the supply of services, are uncertain.
  • The included studies were from high-income countries.

 

Background

Elective health procedures are diagnostic or therapeutic procedures that are not delivered in emergency or urgent situations. Even when long waiting times do not have adverse health effects, they can cause distress for patients. They can also be perceived as inappropriate when patients’ expectations are not met. It is important to keep waiting times at a safe and acceptable level, while ensuring quality, equity and efficient use of resources.

This review assessed the effects of any type of intervention targeted at reducing waiting times. The review authors did not cover all possible interventions (for example resource sharing strategies or remuneration schemes). Also, they considered three categories of interventions: ones that increase supply (expanding capacity of a healthcare provider), ones that reduce demand (rationing or prioritising patients), and ones that improve efficiency by eliminating redundancies or obstacles in the process of care (restructuring the intake assessment/referral process).

 



About the systematic review underlying this summary

Review objectives: To assess the effectiveness of interventions aimed at reducing waiting times for elective care, both diagnostic and therapeutic.
Type of What the review authors searched for What the review authors found
Study designs & interventions Randomised trials, controlled before-after studies, and interrupted time series studies of any type of regulatory/administrative, economic, clinical or organisational intervention aimed at reducing waiting times for access to elective diagnostic or therapeutic procedures
2 cluster-randomised trials, 1 randomised trial, and 5 reanalysed interrupted time series studies of interventions rationing or prioritising demand (1), expanding capacity (1 with a co-intervention), and restructuring the intake assessment/referral process (7)
Participants Healthcare providers of any discipline/area, and patients referred to any type of elective procedure
7 hospitals, 1 outpatient clinic and 135 general practices/primary care, performing elective procedures for ear-nose-throat referrals (1), uncomplicated spinal surgery (1), dermatology (1), elective surgery (1), colposcopy for abnormal cervical cytology (1), any paediatric clinic conditions treated in an outpatient clinic (1), laparoscopic sterilisation (1), and urological interventions (1)
Settings Any setting
Studies in UK (5), US (2), and Australia (1)
Outcomes Number or proportion of participants whose waiting times were above or below a time threshold, mean or median waiting times, safety outcomes (mortality, morbidity, complication rates), and costs
Number and proportion of participants waiting longer (2) or less (2) than a recommended time to be attended or get an appointment, effects on waiting time (5), direct and indirect costs (2)
Date of most recent search: November 2013
Limitations: This is a well-conducted systematic review with only minor limitations.

Ballini L, Negro A, Malton, S, et al. Interventions to reduce waiting times for elective procedures. The Cochrane Database Syst Rev 2015; (2):CD005610.

 

Summary of findings

The eight included studies assessed the effect of two types of interventions: interventions to reduce demand by rationing or prioritising patients; and interventions to restructure referral processes (which includes direct/open access and direct booking systems, distant consultancy and single generic waiting list). The review did not find studies assessing the effect of increasing capacity.

One study measuring the effect of distant consultancy was not reported in this summary, since control group results were not reported.

1) Interventions to reduce or prioritise demand

The review included one interrupted time series study with high risk of bias in patients scheduled for any type of elective surgery in one hospital in Australia.

  • It is uncertain whether prioritising demand decreases waiting times for elective surgery. The certainty of this evidence is very low.

Interventions to reduce demand by rationing or prioritising patients

People                Patients scheduled for elective surgery

Settings              A public hospital in Australia

Intervention       Prioritising demand

Comparison        No intervention

Outcomes

Effect of Intervention

Certainty

of the evidence

(GRADE)

Comments

Number of patients waiting less than a specific time threshold

-

Very low

The authors reported changes in slope, although direction and magnitude of effect is not clear.

GRADE: GRADE Working Group grades of evidence (see above and last page)


2) Interventions to restructure referral processes

Two randomised trials and two interrupted time series studies evaluated the effects of direct/open access and direct booking systems. They were conducted in hospitals (3) and ambulatory settings (1) in the UK (3) and US (1).

 

  • Direct/open access and direct booking systems

- probably slightly decrease median waiting times. The certainty of this evidence is moderate.

- may decrease mean waiting times in hospital settings. The certainty of this evidence is low.

- have uncertain effects on mean waiting times in outpatient settings. The certainty of this evidence is very low.

- have uncertain effects on the proportion of patients waiting less than a recommended time. The certainty of this evidence is very low.

 

  • It is uncertain whether distant consultancy decreases mean waiting times. The certainty of this evidence is very low.
  • It is uncertain whether single generic lists increase the number of participants waiting less than a recommended time. The certainty of this evidence is very low.

Interventions to restructuring referral processes

People             Patients needing elective specialist ambulatory visits, surgery, or procedures

Settings           Hospital and ambulatory care in UK and USA

Intervention    Direct/open access and direct booking systems, single generic waiting list and distant consultancy

Comparison      No intervention

Outcomes

Impact or Absolute effect of intervention

Certainty

of the evidence

(GRADE)

Comments

Without Intervention

With Intervention

Direct/open access and direct booking systems

Mean waiting time

127 days

108 days

Low

1 randomised trial with high risk of bias and important indirectness in laparoscopic sterilisation

Difference: 19 days

-

Very low

1 reanalysed interrupted time series study with high risk of bias in a paediatric outpatient clinic. Authors reported an effect favouring the intervention

Median waiting time reduction

70 days

55 days

Moderate

1 randomised trial in patients with urinary tract symptoms

Difference: 15 days

24 days

18 days

Moderate

1 randomised trial in patients with microscopic haematuria

Difference: 6 days

Proportion of patients waiting less than specific time threshold

-

Very low

1 reanalysed interrupted time series study with high risk of bias of colposcopy for abnormal cervical cytology

Distant consultancy

Mean waiting time

-

Very low

1 reanalysed interrupted time series study with high risk of bias and serious imprecision, in ear, nose, and throat patients

Single generic waiting list

Number of patients waiting less than a specific time threshold

-

Very low

1 reanalysed interrupted time series study with high risk of bias in patients with spinal cord injury

GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

Findings Interpretation*
APPLICABILITY
The studies included in the review were from high-income countries (UK, US and Australia) for selected conditions or type of patients.

The effect of the interventions included in the review would likely depend on several factors, including:

- Waiting list length

- Resource availability

- Healthcare workers availability

- IT development

- Health system structure


EQUITY
The studies included did not report any differential effect of the interventions on disadvantaged populations.

Interventions might increase inequity if they are not focused on resources-disadvantaged people or underserved areas.

Interventions might be more difficult to design and implement for disadvantaged populations due to a lack of available resources.


ECONOMIC CONSIDERATIONS

The review did not report the cost-effectiveness of interventions.

Two studies incorporated direct and indirect costs as outcomes, but no data were reported in the review.


Both the effects and the costs of the interventions are uncertain.

Costing studies should be considered before implementing interventions.


MONITORING & EVALUATION
There were no studies or the certainty of the evidence was very low for most interventions and outcomes.

There is a need for more research in the evaluation of effectiveness of different antibiotic regimens in the treatment of late onset neonatal sepsis taken in count local characteristics of the population and microbiological surveillance.

 Monitoring of microorganisms responsible for sepsis in different countries and settings is vital for the election of the right antibiotic therapy in specific neonatal populations.

 Security of different antibiotic regimens most be carefully evaluated given that the therapy is often empiric and many neonates are nor actually infected.


*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods


 

Additional information

Related literature

Olisemeke B, Chen YF, Hemming K, Girling A. The effectiveness of service delivery initiatives at improving patients' waiting times in clinical radiology departments: a systematic review. J Digit Imaging 2014; 27:751-78.

 

Siciliani L, Borowitz M, Moran V. Waiting Time Policies in the Health Sector: What Works? OECD Health Policy Studies, OECD Publishing, 2013.

 

Kreindler SA. Policy strategies to reduce waits for elective care: a synthesis of international evidence. Br Med Bull 2010; 95:7–32.

 

Appleby S, Boyle N, Devlin M, et al. Sustaining reductions in waiting times: identifying successful strategies. Final report to the Department of Health. London: The King’s Fund, 2005.

 

This summary was prepared by

Cristian Mansilla, EVIPNet Chile, Ministry of Health, Santiago, Chile

 

Conflict of interest

None declared. For details, see: www.supportsummaries.org/coi

 

Acknowledgements

This summary has been peer reviewed by: Luciana Ballini, Cristian Herrera, Lama Bou Karroum, and Racha Fadlallah.

 

This review should be cited as

Ballini L, Negro A, Malton, S, et al. Interventions to reduce waiting times for elective procedures. The Cochrane Database Syst Rev 2015; (2):CD005610.

 

The summary should be cited as

Mansilla C. What are the effects of interventions to reduce waiting times for elective procedures? A SUPPORT Summary of a systematic review. April 2017. www.supportsummaries.org

 

Keywords

evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, elective surgical procedures, time to treatment, waiting lists, queues, waiting times



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