Implementing Open-Access Scheduling of Visits in Primary Care Practices: A Cautionary Tale

Kudos to Mehrota and colleagues for their effort to implement and evaluate open-access scheduling of visits to six Boston-area primary care practices. (1) Unfortunately, since the authors didn't come close to achieving their goal of same-day access, it difficult to draw meaningful conclusions from their findings. Few patients with an acute problem are likely to consider an eight day wait for a 15 minute appointment meaningful improvement. But evidently, that was the best these practices could do.

When a patient with a physically uncomfortable or worrisome problem cannot secure an appointment within a reasonable amount of time, one should not be surprised if he or she heads to the nearest emergency department. In fact, ER visits by persons whose family income is greater than 400% of poverty, and those whose usual source of care is a physician's office, are growing at a much faster rate than ER visits by the uninsured. (2) Nevertheless, lack of timely access to primary care has not deterred policymakers and 3rd party payers from labeling many of these ER visits "inappropriate" or "preventable".

For far too long, hospital ERs have been used to band-aid major flaws in our health care system. (3) One of the most serious challenges is that tens of millions of Americans lack timely access to primary care. Mehrota's paper (1) shows just how tough the fix will be.

Arthur L. Kellermann, MD, MPH FACEP, Professor and Associate Dean for Health Policy, Emory School of Medicine

1. Mehrota A, Keehl-Markowitz L, Ayanian JZ. Implementing Open-Access Scheduling of Visits in Primary Care Practices: A Cautionary Tale. Ann Intern Med. 2008;148;915-922.

2. Weber EJ, Showstock JA, Hunt KA, Colby DC, Grimes B, Bacchetti P, Callaham M. Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States? Ann Emerg Med. Published online April 14, 2008. Accessed on June 20, 2008 at http://download.journals.elsevierhealth.com/pdfs/journals/0196- 0644/PIIS019606440800365X.pdf

3. Institute of Medicine Committee on the Future of Emergency Care in the U.S. Health System. Hospital Based Emergency Care: At the Breaking Point. Washington D.C. The National Academies Press. 2006.

Conflict of Interest:

None declared

By claiming that their study calls into question the benefits of Advanced Access, Mehrotra et al have misinterpreted and misconstrued their findings. What they have in fact demonstrated is simply that if a practice attempts to implement Advanced Access and fails, it will not realize any of the well documented benefits of this system. While their reduction in third next available appointments for both "short" and "long" appointments does represent an improvement, it is in no way sufficient to claim that "Advanced Access" has been achieved. It is therefore no wonder that neither no show rates, nor staff and patient satisfaction improved substantially.

Anyone who has attempted to secure a medical appointment and been offered a next available weeks or months in the future can immediately appreciate the benefits of Advanced Access. It is not until the answer for any appointment request is "How would you like to come in today?" that true Advanced Access with all of its benefits can be achieved. Rather than cast doubt on Advanced Access, this study should encourage practices interested in transforming their systems to aggressively plan for and manage the challenges that the practices in this study encountered. Only by bringing into balance the supply of and demand for visits will they achieve success.

We have successfully implemented and maintained Advanced Access in our seven community health center practice locations in Connecticut for several years. While we have faced the same challenges, particularly around maternity leaves, open unfilled positions, and unpredictable demand, we have been able to keep supply and demand roughly in balance through aggressive recruiting, use of locum tenens, and shaping demand in every way possible. Patients and providers have come to know that our commitment to them is that all patients in need of an appointment will be offered one at a day and time convenient for them, preferably within twenty-four hours.

Daren R. Anderson, MD Chief Medical Officer Community Health Center, Inc.

Conflict of Interest:

None declared

I had the opportunity to read "Implementing Open-Access Scheduling of Visits in Primary Care Practices: a Cautionary Tale" by Mehrotra et al, published in June 2008. As one of the authors most commonly cited in the references ( 2, 3, 5,9,12,14,32,43) within the Mehrotra article, I felt qualified to comment. While I applaud the efforts of the practices to make fundamental changes in the way they operate, to make a systematic approach to improvements and to explore change over time, this investigation contains serious and fundamental flaws. First, in all of my references, my co-authors and I emphasize that the fundamental dynamic in appointment scheduling is the necessity of balancing or matching patient demand with practice appointment supply or capacity. The first principle in improvement in this field is to fully understand, measure and achieve a balance between demand and supply. If demand exceeds supply, no system will work. We can develop an understanding of the balance of demand and supply by reviewing three critical metrics: a. third next available (TNA) appointment time, b. daily demand, supply and activity (DSA) and c. accurate measure of panel size. If the TNA is stable, this implies a demand/supply balance. If not, it implies a mismatch. If the daily DSA pattern is favorable then this implies a balance and finally, the panel size simply must be manageable. The panel capacity limit can be defined by a formula. 1,2.

In this study, while the TNA was defined, measured and monitored over time, the other two key metrics (DSA and panel size) are missing. Without an understanding of the basic demand and supply dynamic and without any accurate measures, it is not surprising that the practices struggled. In addition, most of the studied practices exhibited some early gains which were derailed by supply loss. If demand continues unabated and supply disappears then a delay will ensue. The supply loss (illness in 3 of 6 practices, departure in 1 of 6 and maternity leave in 5 of 6) was significant, often representing a large proportion of the practice FTE. An aggregate provider "loss" of 9 out of 35.3 total providers = 25%. Second, despite ignoring the most critical of the change strategies that lead to delay reduction, a set of nine "Elements of Open Access Implementation" were introduced within a sidebar. I recognize that word limitations restrict an adequate description of how these strategies were utilized. At the same time, there is little evidence to suggest that backlog ( Element 1) was ever completely addressed except perhaps temporarily in one of the six practices, and it is difficult to visualize how "carved out" capacity for same day appointments (Element 4) was avoided when the delays never reached the goal. In addition, my co-authors and I have never advocated the elimination of follow-up appointments (Element 5).3 In fact, we specifically recommend against this strategy. In summary, there is no evidence that even the incomplete set of elements described in the article was implemented. The real challenge in this work is how to build systems that resonate with what patients want and that reflect the goals and attributes, as outlined in the Institute of Medicine's report. 4 This will require that all of us, I believe, understand the basic flow dynamic at work here. Every day, all day long, one patient at a time, we are matching customer demand to our capacity. We have no choice about this. We do have choice about whether to do that well or to do it poorly. Doing it well means building systems that function without delay. To accomplish that we simply must understand the underlying demand and supply. While this study was admirable in addressing vexing problems that we all face, it is inadequate in its understanding of that underlying dynamic. 1. Murray M, Davies M, Boushon B. Panel Size: How many patients can One Doctor Manage? Fam Pract Manag. April 2007:44-51 2. Murray M, Davies M, Boushon B. Panel Size: Answers to Physician's Frequently Asked Questions. Fam Pract Manag. Nov-Dec 2007:29-32 3. Murray, M. Answers to Your Questions About Same-Day Scheduling. Fam Pract Manag. March 2005;12(3):59-64. 4. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Pr; 2001

Conflict of Interest:

Mark Murray and Associates Healthcare consulting group

Mehrotra et al describe the difficulties experienced by 6 primary care practices in Boston as they sought to implement open-access scheduling. In England, practices have been strongly encouraged to implement Advanced Access (based on open-access scheduling) following the positive experiences reported by Murray and others in the United States.[1] Practices were given financial incentives to offer people an appointment within 48 hours. A Primary Care Collaborative was established and "˜access facilitators' were employed in each local area to help practices work together to introduce Advanced Access.

We undertook a comprehensive evaluation of this initiative, in a before-and-after comparison of 48 practices which did or did not implement Advanced Access.[2;3] By including a control group, a larger sample of practices, and assessing a wide range of outcomes using both quantitative and qualitative methods, our evaluation addresses most of the limitations of previous research highlighted by Mehrotra et al.

Advanced Access practices provided faster access to care than control practices, with 75% of patients in Advanced Access practices being seen within the target of 48 hours, compared with 57% of patients in control practices (adjusted odds ratio 2.32 (95% confidence interval 1.51 to 3.57; p<0.001)). However patients in Advanced Access practices were more likely to complain of difficulties booking in advance, and were no more satisfied overall with the appointment system than those in control practices.[3] There were no differences between the two types of practice in terms of workload, failed appointment rates, or continuity of care.[2] Interestingly, speed of access was not as important to people as being able to book an appointment at a convenient time. For some patient groups, particularly the elderly and those with chronic illness, speed was less important than being able to see a particular preferred doctor.[3]

Early case study reports made dramatic claims for the benefits of Advanced Access and open-access scheduling, but these have not been supported by independent rigorous research once the approach has been rolled out more widely. Several authors (including Murray himself) have described the difficulties and mixed results that practices have experienced in implementing the model.[4;5] This is typical of organisational innovation, as ideas become adapted, diluted and often less effective once they spread beyond the early pioneers. If practices in England had limited success in improving access using open-access scheduling, with all the support and incentives available to them, this should raise questions about the effectiveness of the approach.

(1)Murray M, Berwick DM. Advanced Access. Reducing Waiting and Delays in Primary Care. JAMA 2003; 289(8):1035-1040.

(2)Salisbury C, Montgomery AA, Simons L, Sampson F, Edwards S, Baxter H et al. Impact of Advanced Access on access, workload, and continuity: controlled before-and-after and simulated-patient study. Br J Gen Pract 2007; 57(541):608-614.

(3)Salisbury C, Goodall S, Montgomery AA, Pickin DM, Edwards S, Sampson F et al. Does Advanced Access improve access to primary health care? Questionnaire survey of patients. Br J Gen Pract 2007; 57(541):615- 621.

(4)Murray M, Bodenheimer T, Rittenhouse D, Grumbach K. Improving Timely Access to Primary Care. Case Studies of the Advanced Access Model. JAMA 2003; 289(8):1042-1046.

(5)Pope C, Banks J, Salisbury C, Lattimer V. Improving access to primary care: eight case studies of introducing Advanced Access in England. J Health Serv Res Policy 2008; 13(1):33-39.

Conflict of Interest:

None declared