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Increasing Access to Specialty Care: Patient Discharges From a Gastroenterology Clinic
Delphine S. Tuot, MDCM, MAS; Justin L. Sewell, MD, MPH; Lukejohn Day, MD; Kiren Leeds, BA; and Alice Hm Chen, MD, MPH
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Increasing Access to Specialty Care: Patient Discharges From a Gastroenterology Clinic

Delphine S. Tuot, MDCM, MAS; Justin L. Sewell, MD, MPH; Lukejohn Day, MD; Kiren Leeds, BA; and Alice Hm Chen, MD, MPH
The authors used a modified Delphi process involving primary care providers and gastroenterologists to identify safe patient discharges from gastroenterology clinics to primary care.
ABSTRACT
Objectives

Access to specialty care among safety net patients in the United States is inadequate. Discharging appropriate patients to routine primary care follow-up may improve specialty care access. We sought to identify, by consensus, patients who could safely be discharged from a gastroenterology (GI) clinic, and to evaluate the impact of the discharges on GI clinic work flow.

Study Design
Pre- and post intervention.

Methods
We developed and implemented a modified Delphi process. Gastroenterologists and primary care providers (PCPs) rated their comfort (using 5-point Likert scales) with discharging patients immediately post endoscopy for 24 clinical scenarios, assuming formal recommendations were communicated to the PCP. We examined the impact of implementing these criteria on clinic wait times and on the ratio of new to follow-up visits.

Results
All gastroenterologists (100%; 7 of 7) and 71.0% of PCPs (130 of 183) participated. Consensus was achieved for 13 of the 24 clinical scenarios for which discharge criteria were developed. Post intervention, 403 patients were discharged from the GI clinic, compared with 0 patients in the same 4 calendar months pre-intervention. The ratio of new to follow-up appointments increased from 0.9:1 to 1:1 (P = .05). Median wait time for the third next available appointment at GI clinics decreased from 158 days to 74 days (P = .0001).

Conclusions
Discharging patients from specialty care back to primary care with consensus standards is one method to improve access to specialty care. Understanding the concerns of all stakeholders is necessary to refine and disseminate this process to other specialties and healthcare systems to ensure timely access to specialty services for all patients.

Am J Manag Care. 2014;20(10):812-819
Discharging patients from specialty care back to primary care via consensus standards is one method to improve access to specialty care.
  • A modified Delphi process involving primary care providers (PCPs) and gastroenterologists was used to identify safe patient discharges to primary care, resulting in a health system policy change.
     
  • Providers were engaged with the process; 100% of gastroenterologists and 71.5% of PCPs participated.
     
  • Out of 540 patients, 403 were discharged from our outpatient GI clinic within 4 months of the start of the intervention.
     
  • We enhanced access to our outpatient GI clinic; median clinic wait times decreased from 158 days pre-intervention to 74 days post intervention.
Utilization of specialty care in the United States continues to rise. Over the past decade, ambulatory referrals for specialty care increased more than 150%, such that 1 out of every 5 visits to a primary care provider (PCP) now results in a referral to a specialist. 1 Simultaneously, inadequate access to specialty care remains among the most pressing healthcare issues for safety net patients across the United States.2 A 2002 study of 5 medium-sized US cities found that without exception, specialty access in the safety net was strained, with wait times for nonurgent appointments as long as 6 to 12 months.3 Contributing to this issue is the high percentage of specialty care visits that are for routine follow-up care.4 The imminent expansion of Medicaid demands a redesign of the primary care/specialty care interface to ensure timely access to high-quality specialty care.

The Patient-Centered Medical Home-Neighborhood (PCMH-N) framework of healthcare delivery proposed by the American College of Physicians aims to reduce care fragmentation and other inefficiencies prevalent in patient care in the United States.5 Through mutually agreed upon expectations and clearer communication, the PCMH-N proposes new roles for both PCPs and specialty care providers. This could include reallocation of routine follow-up care from specialists to PCPs for appropriate patients, enabling specialists to spend more time providing the type of care for which they are trained: managing rare or complex conditions, directing complex diagnostic evaluations, and/or performing therapeutic interventions requiring their expertise. Reallocation of routine “follow-up” specialty care within the PCMH-N stands to increase availability of, and access to, specialty care. However, the development, implementation, and impact of such efforts have not been examined.

In the San Francisco safety net, the supply-demand mismatch for gastroenterology (GI) care has been particularly vexing. In 2005, the wait time for a routine ambulatory GI clinic appointment was 11 months. This was decreased substantially after the implementation of eReferral, an electronic patient referral system.6 However, in 2012 the wait time remained stagnant at 6 months, still far longer than desirable. To address this pressing issue, we sought to use the PCMH-N framework of shared responsibility and care coordination to develop consensus criteria for patients who could be safety discharged from GI clinic and receive their follow-up care in their medical home. Specifically, our goals were to: 1) use formal consensus methodology to identify a subgroup of patients who could safely be discharged from the San Francisco General Hospital (SFGH) GI clinic to primary care (assuming high-quality communication and provision of anticipatory guidance) and 2) develop, implement, and study the impact of formal discharge criteria on GI clinic work flow, with a focus on wait times for new GI clinic appointments. If successful, this method of developing consensus statements and concordant policy changes could be disseminated to other specialties and strengthen the PCMH-N model of healthcare delivery.

METHODS

Setting

SFGH is the main source of specialty care for the San Francisco safety net, the public healthcare delivery system that serves San Francisco’s uninsured and underinsured residents. This network serves approximately 20% of San Francisco’s population and includes PCPs who work in hospital-based primary care clinics, community clinics managed by the San Francisco Department of Public Health, and independently funded community health centers. The GI clinic at SFGH is the primary source of gastrointestinal specialty care within the system, receiving nearly 5000 patient referrals per year.

Delphi Consensus Process

Using International Classification of Diseases, Ninth Revision, Clinical Modification codes from GI clinic, we identified the top reasons for ambulatory GI visits at SFGH, focusing on high-volume clinical entities. We found that a large number of patients were scheduled for clinic appointments to review biopsy results after undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy for routine, noncomplex indications not requiring long-term GI followup. Such clinical conditions included patients undergoing EGD for dyspepsia or melena, colonoscopy for colorectal cancer screening/surveillance or hematochezia, and EGD plus colonoscopy for iron deficiency anemia.

An advisory panel consisting of PCPs and specialists developed a modified Delphi process7 involving all SFGH gastroenterologists and a random sampling of half of the PCPs who practice in the San Francisco safety net. The consensus process consisted of 2 rounds of online surveys over a period of 6 months. The goal of each survey was to ascertain provider comfort levels discharging post endoscopy patients who fit certain clinical scenarios from the GI clinic immediately after their procedure rather than having them follow up in the GI clinic, which was the previous standard. Such patients would receive their endoscopy results by mail as well as in their primary care medical home rather than in the GI clinic. Key informant specialists and PCPs helped refine the surveys, which were created and distributed using REDCap, an academic software solution that supports clinical and translational research.8

During the first round of surveys, gastroenterologists were asked to rate their comfort discharging patients in 5 different post endoscopy clinical scenarios, with 4 to 8 different possible pathology results, for a total of 24 unique clinical situations, assuming formal recommendations were communicated by the specialist to the PCP via the electronic medical record (EMR). A 5-point Likert scale was used to grade comfort levels. Possible responses were “not comfortable,” “mildly uncomfortable,” “ambivalent,” “somewhat comfortable,” and “very comfortable.” PCPs were asked to rate their comfort receiving patients with identical clinical scenarios directly after endoscopy, assuming formal recommendations were communicated to them by a gastroenterologist via the EMR. Responses were analyzed with simple descriptive statistics.

In round 2, the same surveys were distributed to the Delphi participants, this time including aggregated response data from the first round. For each survey question, the most common response and distribution of PCP and specialist responses from round 1 were provided. Participants were again asked to rate their comfort discharging or receiving patients under specific clinical scenarios, taking into account the aggregated group data from the previous round.

Consensus was defined by >95% of participants agreeing on whether a patient should be discharged from the GI service, with <2% of participants responding with the opposite extreme option (“not comfortable” or “very comfortable”) and <5% of participants responding with the less extreme opposing option (“mildly uncomfortable” or “mildly comfortable”). Results were provided to the advisory panel, which subsequently formulated discharge criteria for the clinical entities for which consensus had been achieved. To ensure appropriateness and acceptability, discharge criteria were reviewed and edited by key-informant specialists as well as primary care clinic medical directors.

Outcome Measures—Impact of Discharge Criteria

New discharge criteria representing a change in policy were officially implemented in January 2013. A pre-post study design was used to examine the impact of the discharge criteria on the SFGH GI clinic work flow, using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework of evaluation.9 Outcomes measures included administrative data that are routinely collected in clinic. Post implementation data were collected from January 1, 2013, through April 30, 2013, and were compared with previously collected data (pre-implementation) from January 1, 2012, through April 30, 2012. Impact of the intervention on access to GI care (effectiveness) was the primary outcome, defined by days to third next available new patient appointment, the third most commonly used metric to evaluate acess to care to ambulatory services. A secondary effectiveness outcome was the ratio of new to follow-up ambulatory visits. Reach was determined by the absolute number and percentage of patients discharged from the GI service, among those who had an endoscopy with biopsy performed. Adoption or fidelity of the intervention was defined by the percentage of patients actually discharged who met official criteria. Fidelity data were abstracted from medical charts for 1 week of each month during the study period.

Analysis

Chi-square and t tests were used to examine the statistical significance of differences, pre- versus post intervention, in number of patients discharged from the GI clinic, the ratio of new to follow-up ambulatory visits, and clinic wait times. P values <.05 were considered significant.

Ethical Considerations

This study met criteria for a Quality Improvement Project, as defined by the University of California-San Francisco Committee on Human Research, and therefore did not require formal review by an Institutional Review Board.

RESULTS

Participants


A total of 140 providers participated in the modified Delphi process, including all 7 SFGH gastroenterologists and 130 of 183 (71.0%) PCPs. Gastroenterologists had a 100% (n = 7) response rate during both rounds of the Delphi process. The gastroenterologists were evenly split in patient care experience; 3 had 6 to 10 years’ experience since graduation from medical school, while 4 had 21 or more years’ (Table 1). Among PCPs, the response rate was 71.0% (n = 130) during round 1 and 59.0% (n = 108) during round 2. Of the PCPs who participated, there was an even distribution of patient care experience, ranging from 0 to 21-plus years since graduation from medical or professional school. Approximately 58.4% of participating PCPs were attending physicians, 16.2% were physician trainees, and 25.4% were nurse practitioners or physician assistants (Table 1). Demographic characteristics were similar among PCPs who did not participate in the Delphi process, of whom 44% were attending physicians (data not shown).

Delphi Process Results

Consensus among PCPs and gastroenterologists regarding scenarios in which patients could or could not be safely discharged was achieved for 4 of 24 clinical scenarios after round 1. In round 2, PCP and gastroenterologist responses became more similar, with 13 of 24 clinical scenarios achieving consensus (Table 2). The largest shifts in agreement between the 2 rounds were noted among clinical scenarios for which gastroenterologists felt very strongly in round 1 that a patient should not be discharged, prompting PCPs to shift their responses in round 2 (Figures 1D and 2B and scenarios 3D, 4H, and 5D embedded in Figures S3-S5, eAppendix at www.ajmc.com).

 
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