The need for ongoing monitoring of adherence to access targets

Abstract

Sirs, In 2010 the results of our study on waiting times in pediatric nephrology centers, and specifically on wait time one [1], which is defined as the time between referral to a subspecialist by a pediatrician or general practitioner and assessment, were published in Pediatric Nephrology. In that study we also monitored adherence to these access targets and found that 36 % of patients waited longer than the accepted access targets. Since this study, we have had another 1,110 patients referred to our nephrology service and were interested whether recent changes improved adherence to access targets. All referrals to pediatric nephrology clinics of a tertiary referral center in South Western Ontario, Children’s Hospital, London Health Sciences Center, received between October 2007 and March 2012 were analyzed retrospectively. Adherence to the target maximum waiting time, as determined by the actual clinic visit, was determined using the previously published methodology [1]. The institutional research ethics board approved the original study, and the continuing quality improvement study was exempt. A subanalysis was performed on those referrals whose actual waiting time exceeded the target waiting time by 20 % or more to determine the cause of the delay. The percentage of time exceeding the access target was calculated as follows: “percentage exceeding access target0100 × (actual waiting time − access target time)/access target time”. The data obtained were analyzed for normal distribution using the Shapiro–Wilks test. Normally distributed data were presented as mean ± standard deviation (SD), otherwise as the median and range. We compared the adherence to access targets of the 250 referrals between October 2007 and November 2008 (baseline) with the subsequent referrals to the same institution for the time frame December 2008 to March 2012 (follow-up period). A total of 1,110 additional children were referred in the follow-up period, of whom 496 were male (44.7 %). Median total wait time was 73.5 days (range 0– 480 days, interquartile range 28–92 days; Table 1). One hundred and twenty-one patients exceeded the access target by more than 20 % (37.69 % of patients exceeding access targets). Four hundred and twenty six patients required a test prior to the appointment, and 100 of these (23.4 %) waited for the test longer than the total access target, making this the single most important factor for failing to meet the access targets. Despite the changes, median waiting time did not shorten and remained unchanged at 73.5 days (previously 73 days) [1, 2]. In the first two time points after the intervention, the adherence to access targets improved from 64 % to 76.1 %, but then dropped again and remained unacceptably low. While office-handling time was improved, a large number of patients had an unacceptably long waiting time because of long waiting time for diagnostic imaging. The overall objective to achieve sustained and improved adherence to access targets was not met, and the initially positive trend reversed over time. Implementation of priority-setting tools in clinical practice requires linkage to standardized waiting times [3]. The implementation of standardized waiting times has as its goal to improve the fairness and timeliness of the system for G. Filler :M. Chavannes :A. Yasin Department of Pediatrics, Division of Nephrology, Children’s Hospital, London Health Science Centre, University of Western Ontario, London, Canada