JULY 2008


Advanced Access flaws uncovered

New study questions ballyhooed system, urges caution

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 times.

"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."

"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 plan yet.

"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."



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