When Dr Jeff Harries' wife became
pregnant with their ninth child, he searched long and
hard for a locum to pitch in at their shared Penticton,
BC, practice. Yet, no one came forward. Dr Harries knew
he'd have to pick up the slack himself.
As her due date rapidly approached,
he decided to do something radical. He travelled south
to Washington for a conference on Advanced Access
a scheduling system designed to cut wait times
and on returning revamped his practice completely. That
was three years ago and today he boasts: "I was able
to take care of my wife's practice and become 10-20%
more efficient using Advanced Access."
Since then, many provinces have
shovelled money into programs to get physicians started
with the strategy. But is Advanced Access really all
it's cracked up to be? Can it save Canada's swamped
medical system? Last month the Annals of Internal
Medicine published a study that cautions there may
be trouble for the scheme down the road, and that physicians
should look hard before they leap.
The concept of Advanced Access is simple: if a patient
calls for an appointment at a clinic they are given
one as soon as possible, ideally the same or next day.
After being seen they are told to call back for a follow
up within two months.
Advanced Access (also called "open
access") is supposed to improve practice efficiency,
increase patient satisfaction, reduce no-shows, and
fulfill the call for timely access. But doctors can
only meet with patients this quickly after working overtime
or hiring a locum to help reduce their backlog. This
takes time and dedication.
University of Pittsburgh internist Dr Ateev Mehrotra
was impressed by the promise of Advanced Access and
decided to do what any good scientist would: a literature
review. But when he started researching he found some
inconsistencies in the small number of studies on the
topic. He wrote up his findings in the controversial
Annals review on Advanced Access.
He identified 29 studies that examined
the effect of open-access scheduling. Nearly all of
them had "important methodological limitations."
"I think that it's an idea that
has a lot of merit," Dr Mehrotra told NRM, "but
what was shown in the literature suggests that there
isn't a good amount of evidence that it does everything
we think it will."
To test Advanced Access, he monitored the strategy in
five New England practices over two years, with mixed
results. In the first four months all five practices
reported large decreases in wait times. But after two
years the wait times had increased again, and two of
the five practices ended up with worse wait times than
they began with.
Most of the problems Dr Mehrotra
encountered were typical: physicians went on holiday
or maternity leave, some practices suffered from disagreements
in implementation or prolonged planning periods, and
others had difficulty assessing appointment demand.
There was another problem too. Most of the practices
started to take on new patients. All compounded wait
"Physicians are busy, and to maintain
and keep access open takes work and constant maintenance,"
says Dr Mehrotra. "That is an issue that's going to
come up again and again."
IN BC PLAN
"If you go away on holidays you're going to have a fair
bit of work coming back," agrees Dr Bill Cavers, a BC
Medical Association (BCMA) administrator who oversees
a provincial program that pays physicians to adopt Advanced
Access. He recognizes the workload may be overwhelming
and some docs could fall back into old habits, but the
key is to always work down your backlog.
The BCMA's training program, he
says, tries to counter this phenomenon, since trainers
check in with physicians every three months to make
sure they're on track. But there isn't a longterm monitoring
"This program has only been going
on for a year or so," says Dr Cavers. "We're getting
surveys and will do an overall review in about a year."
As for Dr Jeff Harries, he's still
delighted with Advanced Access in fact he's been
helping the BCMA educate other BC docs on how to implement
it the right way. "There are some complicated
ways that are confusing," he says. "The basic thing
is to do today's work today."