Mean Waiting Time Research Articles

A Multidisciplinary Hand Clinic Using Physiatrists for the Evaluation of Non-Operative Pathologies.

The purpose of this study was to describe the impact of using a multidisciplinary hand clinic on (1) hand clinic waitlists for urgent operative pathologies and (2) the volume of urgent operative referrals seen by plastic surgery. A retrospective data analysis of all new referrals to the Peter Lougheed Centre hand clinic in Calgary, Alberta, was performed. Data were collected from 6 months before and after the introduction of the multidisciplinary model (ie, between January 2017 and January 2018). Demographics for all new referrals were collected from the clinic database, including wait times, triage type, and volume of referrals triaged to each discipline. Prior to using a multidisciplinary model, 81% (n = 591) of new patient referrals were triaged directly to plastic surgery, 4% (n = 28) to physiotherapy, and 6% (n = 43) to minor surgery (N = 728). However, following the addition of physiatry to the clinic, 62% (n = 451) of new patient referrals were triaged directly to plastic surgery, 24% (n = 173) to physiatry, 2% (n = 17) to physiotherapy, and 4% (n = 31) to minor surgery (N = 730). Overall, the number of urgent operative referrals triaged to plastic surgery proportionally increased by 7%, from 67% to 74%. Mean wait times for urgent referrals to plastic surgery decreased by 1.7 ± 1.0 months (P = .09). Applying a multidisciplinary model to a hand clinic can allow non-operative cases to be triaged directly to physiotherapy and physiatry, allowing plastic surgeons to manage a higher volume of urgent and operative referrals. Implementing a multidisciplinary hand clinic can, therefore, decrease waitlist volumes and shorten the time to assessment by a plastic surgeon. Level II Prognostic Study.

E‐Consultation in Headache Medicine: A Quality Improvement Pilot Study

Access to headache consultations by a headache specialist is limited. E-consultations are an efficient approach shown to reduce costs and improve continuity of care with the primary care provider. Indications, suitability, and uptake in the headache population are not well studied. This quality improvement pilot aims to explore the appropriateness of e-consultations for patients referred to a headache specialist. E-consultation feasibility was explored through (1) retrospective review of completed face-to-face consultations; (2) prospective survey of providers to identify face-to-face consultations appropriate for e-consultation; (3) cross-sectional review of the current waiting list to assess theoretical triaging to face-to-face vs e-consultation; and (4) prospective review of all e-consultations requested from an academic headache clinic to improve the understanding of e-consultation feasibility and referral triage. The retrospective review included 75 face-to-face consultations with a mean (SD) wait time of 33 (39.4) days for consultations, of which 28/75 (37.3%) were deemed to be feasible e-consultations. The prospective survey of providers identified 10 face-to-face consultations that were felt to be theoretically appropriate for e-consultation. The cross-sectional review identified 20 patients on the clinic waiting list, of whom 5/20 (25%) were theoretically triaged to e-consultation. Finally, the prospective review found 12 requested e-consultations, of which 6/12 (50%) were for migraine prophylaxis recommendations. Chart data often lacked details for complete assessments, with 5/12 (41.7%) converted to face-to-face consultations and only 4/12 (33.3%) deemed appropriate for e-consultation. E-consultation in headache medicine could be considered if appropriately triaged. Pathways are needed to reach patients earlier in their disease course to ensure headache care meets guideline recommendations, and e-consultation is 1 option. However, better communication with primary care is required for system optimization.

Association of dermatology wait times with insurance coverage in Michigan.

Although the Affordable Care Act has greatly expanded coverage, the physician workforce has not increased commensurately. Data on wait times, especially among dermatologists who accept Medicaid, are lacking. The objective of this study was to evaluate wait times in dermatology clinics by insurance coverage and chief complaint. A "secret shopper" survey was conducted. Between June and July 2016, 186 dermatology clinics in Michigan were contacted to determine the earliest available appointment for a patient seeking an evaluation of a changing mole, a chronic rash, and botulinum toxin administration. The mean (standard error [SE]) wait time regardless of insurance or chief complaint was 28.8 (1.29) days. Clinics that accept Medicaid had longer wait times (32.9 [2.19] vs 25.4 [1.50] days; P = .024). The mean (SE) wait time for a mole or rash was longer for patients with Medicaid compared with those with private insurance (40.0 [4.08] vs 27.7 [1.54] days; P = .003). The mean (SE) wait time for Medicaid patients compared with patients with private insurance was also longer, even within the same clinic (39.1 [4.11] vs 27.5 [1.57] days; median, 23.5 vs 16.0 days). Patients with Medicaid were able to obtain appointments sooner for botulinum toxin administration (22.5 [2.10] days) compared with evaluation of a mole (40.0 [6.63] days) or rash (40.1 [4.99] days) (P = .004). Wait times for clinic appointments were longer for patients with Medicaid, especially when requesting an evaluation for a medical dermatologic issue compared with a cosmetic consultation. Delay in medical dermatologic care, especially among Medicaid patients, must be addressed.

Medicaid Expansion: Is There a Storm Brewing?: Commentary on an article by Christopher J. Dy, MD, MPH, et al.: "Unmet Need for Total Joint Arthroplasty in Medicaid Beneficiaries After Affordable Care Act Expansion".

Commentary Medicaid eligibility was expanded under the U.S. Affordable Care Act in 2014. This provided coverage in participating states for citizens with incomes up to 133% of the poverty line. Previous large database studies have shown that the expansion option has led to an increase enrollment in Medicaid with a concomitant greater utilization of health-care services, including orthopaedic procedures. With limited providers accepting Medicaid, there is a concern that this influx of new patients will cause further strain on the system and potentially lead to even greater health-care disparities if measures are not taken to ensure appropriate access to care. In their study, Dy et al. attempt to understand the impact that Medicaid expansion may have on the health-care system, specifically in terms of the demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA). The authors hypothesized that patients who were newly enrolled in the Medicaid expansion would proceed to a surgical procedure following enrollment in the plan sooner than traditional Medicaid beneficiaries (Supplemental Security Income [SSI] and Temporary Assistance for Needy Families [TANF]), thereby representing a pent-up demand in these patients that may strain the health-care system. In their study, the authors indeed found a shorter time from enrollment to a surgical procedure in the patients in the expansion group compared with the patients in the SSI and TANF groups. The authors concluded that health-care providers and policymakers should be aware of this earlier demand for a surgical procedure in order to anticipate future needs. Although the study covers the important topic of health-care disparities, it did have several limitations, including the small sample size. Only 663 patients across 4 states were enrolled in the expansion program and underwent a THA or TKA through the managed care company during the study period. This small sample limits the ability of the reader to understand or predict the impact that further expansion of the program will have on the health-care system. Although the authors use the shorter time from enrollment to a surgical procedure to conclude that there is a pent-up demand, this abbreviated wait time also suggests that the health-care systems in participating states are not currently overwhelmed by the new patients. As the authors discuss, the shorter wait times for the patients in the expansion group could be due to several variables, including potential differences in reimbursement between plans by the managed care company, thereby incentivizing providers to offer services to the patients in the expansion group at the expense of the patients in the SSI and TANF groups. It would be interesting to compare the mean wait time for all Medicaid patients prior to, and following, state participation in the Medicaid expansion program, as an overall increased lag time would suggest strain on the system rather than simply shifting resources away from the patients in traditional Medicaid plans to the new patients in the expansion program. Although this article is a good initial step, larger studies will be helpful to better clarify the true impact that the Medicaid expansion program has on the health-care system.

What are the Predictors of Wait Times for Veterans Seeking Care in the VA and the Community through VA‐Purchased Care?

Research ObjectiveThe Veterans Choice Program (VCP) was passed in August 2014 in direct response to the VA wait time crisis of that year. It expanded the availability of community care (CC) by allowing VA enrollees who have to wait longer than 30 days or live more than 40 miles from a VA clinic to use community providers paid for by VA. While a few studies have evaluated whether VCP improved access to care, little attention has focused on whether VCP differentially affects Veteran subgroups that have historically experienced greater barriers to care (eg, rural Veterans, non‐white Veterans). To examine this, we compared wait times in CC and VA for the five most commonly authorized outpatient specialty services in CC (cardiology, physical therapy, optometry, ophthalmology, and dental) among Veterans since the inception of VCP.Study DesignRetrospective observational study conducted from Fiscal Year (FY) 2015 to FY18 (10/1/14‐9/31/18) using data from the VA’s Corporate Data Warehouse. Our outcome variable was “wait time,” defined as days from consult request to consult completion date. Independent variables included setting of care (VA vs CC), rural/urban status, demographic characteristics (eg, race), and comorbidities. Bivariate and multivariate analyses were used to determine predictors of mean wait times and to assess the probability of waiting >45 days for care.Population StudiedAll Veterans receiving >1 of selected outpatient services in VA and/or CC during the study time period.Principal FindingsIn FY15, black Veterans’ mean wait times were consistently longer than those for white Veterans (eg, mean wait times for PT services among blacks and whites were 28 and 25 days, respectively). Linear regression models, which adjusted for sociodemographic variables and comorbidities, found similar results: black race was associated with 2‐5 days longer wait times across services than white race in FY15. Wait times declined during the study period, but more so for blacks than whites. This eliminated the wait time disparity in FY18 for cardiology and optometry services but not for PT, ophthalmology, and dental (eg, in FY18, black mean wait times for PT were 28 days compared to 25 days for whites). In FY18, the percentage of blacks waiting >45 days for care remained consistently higher than for whites for PT, ophthalmology, and dental, regardless of rurality and setting of care (eg, 31% of blacks compared to 25% of whites waited >45 days for orthopedic services in rural CC). No other independent variables were meaningful predictors of wait times.ConclusionsAlthough we expected that rural Veterans would be at higher risk for delays in care compared to urban Veterans, their mean wait times were relatively comparable. Despite decreases in wait times since VCP implementation, black Veterans continued to have longer wait times than whites for most services.Implications for Policy or PracticeWhile VCP appears to have improved access to timely care for many Veterans, not all Veterans benefited equally from the policy change. Further study is needed to investigate whether the disparities we found in wait times are also present in other outcomes impacted by VCP.Primary Funding SourceDepartment of Veterans Affairs.

Predictors of long-term employment among patients with cystic fibrosis undergoing lung transplantation.

Lung transplantation is an established therapy in selected patients with advanced cystic fibrosis lung disease. Resumption of employment after lung transplantation is generally supported. In Switzerland, there are no data on long-term employment in people with cystic fibrosis undergoing lung transplantation. In a single-centre, cross-sectional study at a Swiss university hospital, clinical data from lung transplant recipients with cystic fibrosis, covering the transplantation period from January 1996 to December 2016, were analysed retrospectively. The potential influence of pre-lung transplantation factors (age, sex, lung function, body mass index, six-minute walk test distance, lung transplantation wait list time, paid employment on the wait list, education, relationship status, housing situation) and post-lung transplantation factors (chronic allograft dysfunction [CLAD], dialysis, cancer diagnosis [except skin cancer]) on paid employment and work percentage after lung transplantation were investigated using mixed logistic and linear regression models. Descriptive analyses of paid employment were performed for various periods after lung transplantation (<1, 1–3, 3–5, 5–10, >10 years). Data are reported as odds ratios (ORs) or coefficients (β) with their 95% confidence intervals (CIs). Eighty-four subjects (46.4% female) with a mean ± SD age of 29.9 ± 8.4 years were included in the study. Mean wait time for lung transplantation was 42.7 ± 40.2 weeks. The number (percentage) of subjects employed <1 year, 1–3 years, 3–5 years, 5–10 years and >10 years after lung transplantation was n = 23 (28%), n = 51 (65%), n = 44 (75%), n = 30 (68%) and n = 21 (75%), respectively. In mixed logistic regression models, pre-lung transplantation paid employment (OR 24.03, 95% CI 6.08 to 164.39, p <0.0001), academic education (OR 7.81, 95% CI 1.66 to 48.66, p = 0.01) and time post lung transplantation (on log scale, OR 5.81, 95% CI 3.15 to 12.78, p <0.0001) were the main factors influencing post-lung transplantation paid employment status. In mixed linear regression models, pre-lung transplantation paid employment (β = 21.40, 95% CI 10.98 to 31.81, p = 0.00014), academic education (β = 12.54, 95% CI 0.48 to 24.55, p = 0.05) and time post lung transplantation (on log scale, β = 8.96, 95% CI 6.17 to 11.82, p <0.0001) were the main factors influencing work percentage post lung transplantation. No evidence for an influence of clinical factors such as CLAD, cancer or dialysis on post-lung transplantation employment and work percentage was found. Pre-transplant employment is the dominant factor influencing lung transplantation employment in people with cystic fibrosis. People with cystic fibrosis undergoing lung transplantation should be encouraged to work for as long as their health status permits. Professional reintegration after successful lung transplantation should be supported by a multi-disciplinary lung transplant team.

Optimal breast reconstruction type for patients treated with neoadjuvant chemotherapy, mastectomy followed by radiation therapy.

To explore the optimal type of breast reconstruction and the time interval to postmastectomy radiotherapy (PMRT) associated with lower complications in breast cancer patients receiving neoadjuvant chemotherapy. We reviewed the medical records of 300 patients who received neoadjuvant chemotherapy, mastectomy with breast reconstruction and PMRT at our institution from 2000 to 2017. Reconstruction types included autologousflaps (AR), single-stage-direct-to-implant and two-stages expander/implant (TE/I). The primary endpoint was therate of reconstruction complications including infection, skin and fat necrosis. Subgroup analysis compared rates of capsular contracture, implant rupture, implant exposure and overall implant failure in single-stage-direct-to-implant to TE/I. The secondary endpoint was identifyingthe time interval between surgerywith immediate implant-based reconstruction and PMRT associated with lower probability of implant failure. Logistic regression models, Kaplan-Meier estimates and Polynomial regression were used to assess endpoints. The median follow-up was 43.5months. 29.3%, 28.3% and 42.4% of the cohort had AR, TE/I and single-stage-direct-to-implant D, respectively. The 5-year cumulative incidence rate of complications was 14.0%, 29.7% and 19.4% for AR, TE/I and single-stage-direct-to-implant, respectively (Log rank p = 0.02). Multivariate analysis showed significant association between TE/I and higher risk of infection (OR 8.1, p = 0.009) compared to AR, while single-stage-direct-to-implant and AR were comparable (OR 3.2, p = 0.2). On subgroup analysis, TE/I was significantly associated with higher rates of implant failure. The mean wait time to deliver PMRT after immediate reconstruction with no adjuvant chemotherapy was 8.4 and 10.7weeks in single-stage-direct-to-implant and TE/I, respectively (p < 0.005). Delivering PMRT after 8weeks of surgery yielded 10% probability of reconstruction failure in single-stage-direct-to-implant versus 40% in TE/I. In comparison to two stages reconstruction, single-stage-direct-to-implant following neoadjuvant chemotherapy has lower complications and offers timely delivery of PMRT.

Field observation and analysis of waiting passengers at subway platform — A case study of Beijing subway stations

As a common human activity in the subway platform, waiting occupies a large amount of passengers’ time and plays an important role in the aggregation, circulation, and segregation of passenger flows. The initial spatial distribution of waiting passengers at the subway platform may contribute significantly to the operational efficiency of the subway station. In this paper, we explore the behaviors of waiting passengers by field observations and video recordings at two of Beijing’s subway stations under normal conditions and intervention of guide. The data, including distribution of waiting pedestrians on waiting zones, percentages of waiting modes under different density levels, as well as distributions of distance headway, movement speed, and mean waiting time are collected and analyzed in two cases. Quantitative analyses of the collected data of waiting passengers under normal and intervention conditions are conducted to assess the impact of the guide on the behavior of waiting passengers by comparing the indicators of the number of passengers in each waiting zone, percentages of waiting modes, distance headway, as well as mean waiting time. Through analyses of the collected data, the behavioral characteristics of waiting passengers under the tactical and operational levels are revealed. The findings of this paper are beneficial to the organization of waiting passengers and the improvement of operational efficiency of subway stations.

Outcomes Comparison of the Veterans’ Choice Program With the Veterans Affairs Health Care System for Hepatitis C Treatment

The US Department of Veterans Affairs (VA) has been stressed by the large number of veterans requiring direct-acting antiviral (DAA) medications for hepatitis C virus (HCV) treatment. The Veterans Choice Program provides VA patients more options to receive treatment. This study compared the experience of veterans who received HCV treatment through the Veterans Choice Program and those that received treatment at the VA Loma Linda Healthcare System (VALLHCS) in fiscal year (FY) 2016. A chart review was performed on all veterans referred by VALLHCS to Choice for HCV treatment during FY 2016, and matched to veterans who received treatment at VALLHCS. Data collected included Fibrosis-4 score (Fib-4), platelet count, days elapsed between time of referral and time of appointment (wait time), rate of sustained virologic response at 12 weeks (SVR12), reason for treatment failure, and cost effectiveness. One hundred veterans were referred to Choice; 71 were seen at least once by a Choice provider, and 61 completed a treatment course. Mean Fib-4 and platelet count was 1.9 and 228,000 for the Choice population and 3.4 and 158,000 for the VALLHCS population, respectively. There was no difference in SVR12 rate. Mean wait time was 42 days for Choice vs 29 days for VALLHCS (P < .001). Choice health care providers incurred a mean $8,561.40 in additional costs per veteran seen. While treatment success rates were similar between Choice and VALLHCS, the degree of liver fibrosis was more advanced in the VALLHCS population. The wait time for care was longer with Choice compared with a direct referral within the VA. While Choice offers a potential solution to providing care for veterans, the current program has unique problems that must be considered.

Use of Medicaid Coverage for Abortion Is Associated With Improved Abortion Access [OP03-3C

INTRODUCTION: Low income women disproportionately face barriers to abortion access. It remains unknown whether Medicaid coverage for abortion improves abortion access measures. METHODS: We performed a secondary analysis of the 2014 Guttmacher Abortion Patient Survey. Respondents were included if they selected “Medicaid” as their primary insurance. The exposure was self-report of using Medicaid to pay for the abortion. NARAL state legislative classifications and patient demographics were used as covariates. Chi-square testing and t-tests for unequal variance were used for categorical and continuous variables, respectively. Multivariate regression was performed for the primary outcome of &gt;7 days wait time between decision for abortion and abortion appointment. All statistical analysis was performed in StataSE v15. This study was IRB exempt. RESULTS: Of 2,549 respondents on Medicaid, 1,482 had Medicaid coverage for their abortions and 1,067 did not. Patients with Medicaid coverage had their abortions at an earlier gestational age (8.61 vs. 8.94 weeks, P=.02). Patients using Medicaid for abortion had shorter mean wait times (3.84 vs. 4.37 days, P=.01), traveled less time (32.15 vs. 48.63 minutes, P&lt;.0001) and shorter distances (28.62 vs. 42.91 miles, P=.0003) for their abortions, and were less likely to cross state lines (0.81% vs 7.97%, P &lt; .0001). Patients with Medicaid coverage for abortion were less likely to wait &gt;7 days (83.14% vs. 86.97%, P=.008), which remained true in multivariate regression with OR 0.71 (CI 0.51-0.99). CONCLUSION: Utilization of Medicaid coverage for abortion is associated with increased abortion access, as evidenced by decreased wait times, earlier gestational ages, and decreased travel measures.

Outcomes of liver transplantation by insurance types in the United States.

The outcomes of liver transplantation may vary according to socioeconomic factors such as insurance coverage. The aim of this study was to assess the association between the type of insurance payer and outcomes of liver transplant candidates and recipients in the United States. This was a retrospective cohort study of a national database. The US Scientific Registry of Transplant Recipients was used to select adults (≥18 years) wait-listed for liver transplantation in the United States (2001-2017); patients were followed until March 2018. There were 177,862 liver transplant candidates with payer and outcomes data: The mean (SD) age was 54.1 (10.4) years, 64% were male, 39% had chronic hepatitis C with or without alcoholic liver disease (ALD), 19% had ALD alone, 17% had nonalcoholic steatohepatitis, and 16% had hepatocellular carcinoma. Fifty-nine percent were primarily covered by private insurance, 21% by Medicare, and 16% by Medicaid. After listing, 56% eventually received transplants (mean wait time of 229 days) and 22% dropped off the list. In multivariate analysis, adjusted for demographic and clinical factors, being covered by Medicare (odds ratio [OR], 0.81; 95% CI, 0.78-0.84) or Medicaid (OR, 0.76; 95% CI, 0.73-0.79) was independently associated with a lower chance of receiving a transplant (reference: private insurance). Posttransplant mortality was 11.6% at 1 year, 20.1% at 3 years, 26.8% at 5 years, and 41.6% at 10 years. Having Medicare (adjusted hazard ratio [aHR], 1.24; 95% CI, 1.17-1.31) or Medicaid (aHR, 1.14; 95% CI, 1.06-1.21) was independently associated with higher posttransplant mortality (P <.001) but not with the risk of graft loss (P >.05). Liver transplant candidates covered by Medicare or Medicaid have poorer wait-list outcomes and higher posttransplant mortality.

Causes of long wait time in health consultation services and strategies to reduce them: an observational study in rural Haiti

BackgroundWHO data show that wait times for clinic patients globally vary between 30 min and 2 h, but at Saint Boniface Hospital in Fond-des-Blancs, Haiti, wait times range between 3 h and 8 h. Wait times are important to health-care delivery since patients lose days of work and urgent cases can be delayed. In this study we aimed to analyse wait times during general and specialised medical consultations in order to identify the causes of prolonged waiting times in outpatient clinic as well as potential avenues to reduce future wait times. MethodsWe administered a semi-structured questionnaire to patients in the outpatient clinic recording arrival time, time spent waiting at various check points (eg pharmacy, laboratory), and overall satisfaction with their visit. Patients were welcomed by a research worker at the hospital entrance and then observed until their release from the hospital, noting points of congestion and time spent at each service. The team then implemented three Plan-Do-Study-Act (PDSA) style process improvement interventions that aimed to decrease average wait time for patients and streamline patient flow through hospital outpatient services. We repeated the questionnaire 3 months after implementation of process improvements, capturing changes in baseline measures and outcomes. FindingsBetween January and March, 2014, a total sample of 300 patients completed the questionnaire; 100 patients at baseline and 200 at follow-up. Mean total wait time was 4 h (SD 4). The main contributors to wait time were waiting for laboratory results, lack of knowledge of hospital flow, and lack of staff engagement to resolve barriers. Three PDSA cycles were done on each of these three contributors. After the PDSA cycles, the mean wait time was reduced by 1 h to 3 h (SD 2). InterpretationImproving the clinic process with the use of PDSA cycles resulted in reduced wait times at Saint Boniface hospital. While numerous challenges remain, this study highlighted the importance of implementation of a structured triage system for outpatient clinic visits. As we progressed toward this goal, we later observed a considerable increase in the number of visits per year, which we attribute to improved patient satisfaction. FundingNone

A Bumpy Road: Work Integration of People with Cystic Fibrosis after Lung Transplantation

Lung transplantation (LTX) is an established therapy in selected patients with advanced cystic fibrosis (CF) lung disease. Resumption of employment after LTX is generally supported. In Switzerland, there is no data on long-term LTX employment in patients with CF. In a single center cross-sectional study at our institution, data from LTX patients with CF from 01/1996 to 12/2016 were retrospectively analyzed. Influence of potential pre-LTX factors (i.e., age, sex, lung function, body mass index, 6-min walk distance, education, relationship status, housing situation, LTX wait list time, gainful employment on the wait list) and post-LTX factors on gainful employment after LTX [chronic allograft dysfunction (CLAD), dialysis, cancer diagnosis (except skin cancer)] were investigated using mixed logistic regression models with random effects. Descriptive analyses of gainful employment were performed for various periods after LTX (i.e., >1, 1-3, 3-5, 5-10, >10 years). 99 patients (35±10 years; 49.5% female) were enrolled. Mean wait time for LTX was 42±39 weeks. Employment for <1 (n=93), 1-3 (n=90), 3-5 (n=68), 5-10 (n=53) and >10 (n=32) years post-LTX was 35%, 68%, 79%, 72% and 78%, respectively. Pre-LTX gainful employment (OR 32.16, 95% CI 9.48 - 177.09, p<0.0001), vocational training (academic vs. non-academic, OR 4.40, 95% CI 1.07 - 20.55, p=0.04) and time to LTX (log scale) OR 4.94, 95% CI 2.95 - 9.38, p<0.0001) were main factors influencing post-LTX earning capacity. Clinical factors, such as CLAD, had no influence on LTX employment. Pre-LTX employment is the dominant factor influencing LTX employment in people with CF. Patients should be encouraged to work for as long as possible, where health permits. Professional reintegration after successful LTX should be supported interdisciplinary by the LTX team.

Analysis of the State-Dependent Queueing Model and Its Application to Battery Swapping and Charging Stations

This study analyzes the performance of a queue length-dependent overload control policy using a leaky bucket (LB) scheme. This queueing model is applied to the operation of a battery swapping and charging station for electric vehicles (EVs). In addition to the LB scheme, we propose two congestion control policies based on EV queue length thresholds. With these policies, the model determines both EV-arrival and battery-supply intervals, and these depend on the number of EVs waiting in the queue. The queue length distributions, including those at arbitrary epochs, are derived using embedded Markov chain and supplementary variable methods. Performance measures such as blocking probability and mean waiting time are investigated using numerical examples. We study the characteristics of the system using numerical examples and use a cost analysis to investigate situations in which the application of each congestion control policy is advantageous.

A150 ACCESS TIMES TO GASTROENTEROLOGY FOR HIGH-RISK IBD REFERRALS IN THE GREATER CALGARY REGION

Abstract Background Delay in the diagnosis of inflammatory bowel disease (IBD) can lead to adverse outcomes. In 2006, the CAG Wait Time Consensus Group recommended that wait times for patients with symptoms highly suggestive of IBD should be seen within two weeks. In 2007, the greater Calgary region established a central access and triage system to improve access to care as well as the “High-Risk IBD clinic” (HR-IBD) to further expedite the access of patients with IBD alarm symptoms. These included diarrhea, rectal bleeding, weight loss, abnormalities in laboratory and stool investigations. Aims The current study aimed to evaluate whether patient access to the HR-IBD clinic in the Calgary region was within recommended wait times. Methods We conducted a cross-sectional study of charts from consented patients pulled from the EMR of five Gastroenterologists in the Calgary region that received HR-IBD referrals from Feb 2014 to Jan 2018. Of the 206 patients included, the majority were female (139 vs 65) and the mean age was 34.4 y, with no statistical difference in age between genders (p=0.81). Data analysis was done with Stata (StataCorp 2019). Results The mean time to initial consult was 74.8 days (median 64), whereas time to endoscopy was 85.5 days (median 77). There was no statistical difference in the mean wait times between genders. Of the patient charts reviewed, 27% of referrals had a confirmed diagnosis of IBD (CD 17%, UC 11%). Patients with a diagnosis of UC waited a mean of 60.1 days (median 60) until initial consultation and patients with a diagnosis of CD waited 77 days (median 63.5), although this was not statistically different (p=0.27). The mean time to endoscopy for patients with UC was 77 days (median 67), and 85.4 days for patients with CD (median 78.5), again not statistically different. These wait times are below the reported wait times for all GI complaints, of 92 days from referral to consultation and 155 days from referral to procedure, as reported in the SAGE survey (2012). Although there were no differences in time to consult and endoscopy between groups, there were notable differences in alarm symptoms reported in the referral. For example, rectal bleeding was reported in 81.8% of referrals that culminated in a diagnosis of UC, as compared to 50% in CD and 47.6% of non-IBD patients. Further analysis in which alarm symptoms correlate with a final diagnosis of IBD may guide triaging of referrals to decrease the time to diagnosis. Conclusions Timely access for consultation and endoscopy for patients presenting with high-risk features for IBD by Gastroenterology in the Calgary region remains above the CAG recommended wait times. Further correlation of high-risk features with a final diagnosis of IBD will help risk-stratify referrals in order to decrease time to IBD diagnosis. Funding Agencies CIHRAlberta Innovates Health Solutions

Impact of legislative change on waiting time for women accessing surgical abortion services in a rural hospital in the Northern Territory.

Women face challenges when accessing abortion, including varied legislation and reduced access to services in rural and remote settings. There are limited clinical guidelines in Australia and little information regarding the patient journey, particularly the timeframe between referral to abortion procedure. Legislation reform in the Northern Territory (NT) legalised early medical abortion (EMA) in primary health care, providing an opportunity to review service provision of elective surgical abortion prior to and after these changes. To review the waiting time to access abortion, percentage eligible for EMA based on ultrasound gestation alone, percentage of Indigenous women accessing abortion in the NT and the effects of the legislation change. Retrospective audit-analysed surgical abortion data from 354 patient files who underwent suction curettage of uterus between 2012-2017 in one NT public hospital. Mean wait-time ranged from 20 to 22days in 2012-2016 and dropped to 15days in 2017 following the law reform. Sixty-two percent of women waited longer than that in the recommended clinical guidelines. Indigenous women represented approximately 25% of patients accessing surgical abortion services. Average gestation at surgical abortion procedure increased following reform. Prior to reform up to 95% of patients accessing surgical abortion would have been eligible for EMA at time of referral. Results demonstrate potential for changes in service provision of abortion in the NT with increased choice, patient-centred care and reduced waiting times. This audit demonstrated the possibility to move the majority of abortion services into primary health care leading to cost savings.

The Impact of a New Triage and Booking System on Renal Clinic Wait Times.

Background:Prolonged wait times are known barriers to accessing nephrology care for patients needing more urgent specialist services. Improved process and standardized triage systems are known to minimize wait times of urgent or semi-urgent care in health care disciplines. In Central Zone (CZ) renal clinic, mean wait times for urgent (P1) and semi-urgent (P2) referrals were prolonged before 2014. We also observed prolonged wait times for elective (P3-P5) categories. Improving wait times was identified as an access to care quality improvement focus in CZ renal clinic of the Nova Scotia Health Authority (NSHA).Objectives:To describe our new referral process and new triage system, and to examine their effect on number of referrals wait-listed and mean wait times.Design:A quasi-experimental design was used.Setting:Halifax, Nova Scotia, Canada.Participants:Patients referred to Central Zone Renal Clinic between 2012 and 2018.Measurements:A time series of referral counts and wait times for each triage category were measured before our interventions and after implementing our interventions.Methods:We reviewed our referral processes to identify gaps leading to prolonged wait times. On January 1, 2014, we implemented new administrative procedures: pretriage (standardized referral information form and staff training), triage (standardized clinic intake criteria and new triage guidelines), posttriage (protecting clinic spots for urgent and semi-urgent referrals, wait-list maintenance, and increasing new referral clinic capacity). Data were collected prospectively. Descriptive analysis on mean wait times was done using run charts.Results:A 33% reduction in total number of referrals wait-listed was observed over 4.5 years after intervention. Descriptive analysis of the urgent and semi-urgent categories (P1 and P2) revealed a significant shift of mean wait times on run charts after the interventions. Target wait time was achieved in 94% of P1 category and 78% of P2 category.Limitations:This type of study design does not exclude confounding variables influencing results. We did not explore stakeholder satisfaction or whether the new referral process presented barriers to resending referrals that had insufficient triage data. The long-term sustainability of adding demand-responsive surge clinics and opportunity cost were not assessed. Our referral process and triage system have not been externally validated and may not be applicable in settings without wait-lists or settings that use electronic, telephone or telemedicine consults.Conclusion:Our selective intake of referrals with adequate triage information and referrals needing nephrology consult as defined by our clinic intake criteria reduced number of referrals wait-listed. We saw improved wait times for urgent and semi-urgent referrals with these categories now falling within target wait times for the vast majority of patients. The work of this improvement initiative continues especially for the lower-risk triage categories.Trial registration:Not applicable as this was a Quality improvement initiative.

Promoting hospital and primary care collaboration for timely and effective care for chronic hepatitis B in western Melbourne.

Objective The aims of this study were to: (1) identify the characteristics of patients with chronic hepatitis B (CHB) who do not attend their hospital liver clinic appointments; and (2) raise awareness among general practitioners (GP) of alternative pathways to care for CHB in order to prevent long-term complications of CHB (liver cancer and cirrhosis). Methods This prospective study was conducted between May 2018 and January 2019 at one site of a tertiary referral hospital in western Melbourne. Patients with minimal liver complications who did not attend their first two initial appointments were included in the study, in addition to referring GPs of new CHB patients to the liver clinic who had minimal liver complications (characterised by minimal fibrosis (<7kPa)) and no liver comorbidities (including cirrhosis and/or hepatocellular carcinoma). GPs of patients who failed to attend the liver clinic as a new patient were sent an alternative discharge letter that included information on alternative pathways to care in the community for their patients. A follow-up survey to referring GPs was conducted afterwards for feedback. Demographic data was also collected for included patients. Results Thirty patients with non-complicated CHB were included in the study (median age 32.5 years). Patients were from 11 different countries and six regions. The mean wait time from referral to clinic date was 424 days (SD 218.9). Only four GPs responded to the letter, with non-responding GPs surveyed primarily not participating due to having over 1 year of no contact from the patient or hospital. Conclusion This study showed that there were long waiting lists for CHB referrals and alerting GPs to alternative pathways after patients failed to attend appointments was ineffective. There needs to be improved coordination between tertiary and primary services to provide timely and effective care for patients with CHB. What is known about this topic? There are 239000 Australians living with CHB: most recent estimates indicate that only 62% have been diagnosed, 15% are being monitored and 6% of those requiring treatment are receiving antiviral therapy. The complications of CHB (liver cancer and cirrhosis) can be averted by routine monitoring and timely commencement of highly effective oral antiviral therapy. In Australia, both GPs and specialists in gastroenterology and infectious diseases are involved in the management of CHB patients, but most prescribing occurs in specialist services. The current specialist-centred model of CHB care has been described as neither practical nor sustainable given the limited resources and capacity of specialist services, and the challenges for people with CHB to access public hospitals for routine care. What does this paper add? Non-attending patients were a primarily young population. The median wait time for a clinic appointment in this hospital setting was 424 days, with some patients waiting ≥800 days for an appointment. This extensive wait time for a largely asymptomatic condition may have affected attendance rates. Although this particular intervention to engage GPs in collaborative care had limited results, it is clear that management of CHB by GPs, transparency in wait lists and adequate resourcing of specialist services would help alleviate the referral burden on hospitals. What are the implications for practitioners? GPs should be aware that waiting lists for liver clinic appointments can be extensive in public hospital settings due to the high referral burden and limited resources of these services. Alternative pathways to care, such as GPs trained to prescribe Schedule 100 drugs, are an effective means of alleviating this burden while also ensuring CHB patients are seen in a timely manner and receive routine monitoring.

A Multicenter Randomized Controlled Pilot Trial Testing the Efficacy and Safety of Pterygopalatine Fossa Puncture Using One Acupuncture Needle for Moderate-to-Severe Persistent Allergic Rhinitis.

Objective To compare the efficacy and safety of pterygopalatine fossa puncture using one acupuncture needle inserted through the temporal fossa (intervention) and Chinese verum acupuncture (VA) in patients with moderate-to-severe persistent allergic rhinitis. Methods The patients were randomized to an intervention group receiving pterygopalatine fossa puncture with one acupuncture needle for 4 weeks (once or twice weekly, 4–8 sessions in total, with a second course performed if required) or to a control group receiving individualized VA for 4 weeks (twice weekly, eight sessions in total). Patients were followed up 4 weeks later. Results Ninety-six participants were assigned to intervention (n = 48) or VA (n = 48) or VA (P > 0.05 in all cases). Compared with the VA, the time to onset of effect in the intervention group was shorter and the duration of effectiveness was longer. The mean clinical waiting time was significantly shorter in the intervention group than in the control group (6.640 ± 3.035 min and 31.19 ± 10.216 min, respectively). The total number of sessions in the VA group was 384; 7 episodes of subcutaneous bleeding occurred but did not require treatment. The total number of sessions in the intervention group was 185. Two cases of subcutaneous bleeding (one of local hematoma during the intervention and the other one of bruising in the palpebra inferior on the day after intervention) resolved upon withdrawal from the study. Conclusions Pterygopalatine fossa puncture using one acupuncture needle resulted in a shorter time to onset of effect, a longer duration of effectiveness, and less clinical waiting time when compared with VA. Though the significant differences for TNSS and TNNSS were shown within intervention and VA groups, there were no differences between the two groups. Although the rate of subcutaneous bleeding was low, these adverse events may influence patient compliance. This trial is registered with ISRCTN21980724.

Trends in Wait Time for Colorectal Cancer Screening and Diagnosis 2013-2016.

OBJECTIVES:Colorectal cancer (CRC) screening has increased in the United States during the past 20 years, resulting in an increased demand for colonoscopy. We tested the hypothesis that such increase resulted in longer wait times for colonoscopy and influenced CRC diagnosis.METHODS:A total of 36,623 consecutive colonoscopies performed at the University of Wisconsin from April 8, 2013, until December 31, 2016, were included in the analysis. Wait times for colonoscopy were stratified by consecutive 6-month periods and indications of screening/surveillance vs diagnostic colonoscopy.RESULTS:Despite unchanged number of endoscopists, more colonoscopies were performed in 2015–2016 than in 2013–2014 (20,897 vs 15,726, respectively, P = 0.004). The mean wait time for colonoscopy increased from 68 days in 2013–2014 to 111 days in 2015–2016 (P < 0.0001), with most change affecting screening/surveillance colonoscopy. In 170 patients with a newly diagnosed CRC, the wait time did not significantly change between 2013–2014 and 2015–2016 (21 vs 27 days, respectively, P = 0.2206).DISCUSSION:An increase in screening/surveillance colonoscopies resulted in a substantial rise in the number of procedures between 2013 and 2016. This increase was associated with longer wait times for screening/surveillance but not diagnostic colonoscopy. Longer wait times did not result in later CRC stage at diagnosis.