Feedback on open-access scheduling "by no means glowing"

During the past decade, open-access scheduling has been pushed to make physicians more accessible to patients, improve quality and reduce emergency department use. Patients would get appointments within days -- preferably in less than 48 hours.

Donald M. Berwick, MD, administrator for the Centers for Medicare & Medicaid Services, helped more than 3,000 private practices implement open-access scheduling, also known as advanced access, when he was president and CEO of the Institute for Healthcare Improvement.

Whether open-access scheduling is delivering as promised is unclear, according to a review published April 25 in Archives of Internal Medicine.

"There are lots of anecdotal stories about open access being terrific," said Leora Horwitz, MD, one of the review's authors and an assistant professor of medicine at Yale School of Medicine in Connecticut. "There's relatively little actual research, but the studies that are out there are by no means as glowing."

Researchers reviewed 28 papers analyzing 24 open-access projects. The open-access practices reduced the time patients waited for an appointment, but few cut it down to less than 48 hours. No-show numbers declined, but only if practices started with a rate of at least 15%. Some studies found that patient satisfaction improved, while others found that it worsened. There were no data on patient outcomes or how many were lost to follow up.

Emphasis on medical homes

Open-access scheduling, which is different from a drop-in system in which a patient comes to a clinic and sees the next available physician, has been one of many options proposed in the past decade as part of a movement to redesign primary care and create medical homes. Practices still have a proportion of appointments that are scheduled in advance, but far more are available for both urgent and nonurgent care when the practice opens for the day.

"The key principle is that patients should be able to see their doctor when they choose," Dr. Horwitz said. "But it's not a walk-in clinic."

Patients hope that such access would reduce wait times and improve continuity of care. Physicians hope that they would be able to do more in less time. With less financial loss from fewer patient no-shows, this would lead to higher reimbursement.

"If you think about health care from the patient point of view, it's pretty strange," said David Bundy, MD, MPH, an assistant professor of pediatrics at Johns Hopkins School of Medicine in Baltimore who has researched open-access scheduling.

"Patients say they need to be seen, and we say, 'We understand. Please come back in a month.' There are not many other parts of life that work that way. If you want reservations at a restaurant, if you need your hair cut, if you need an oil change, you can usually get in pretty quickly."

The authors of the paper are calling for randomized controlled trials to determine the impact of open-access scheduling. However, some physicians are skeptical that such trials are feasible, or even necessary, because the need for health system change is so great.

"Other industries have undergone greater changes by relying on anecdotes, hunches, expert opinion [consultants] and business case estimates," Leif I. Solberg, MD, associate medical director at the HealthPartners Research Foundation in Minneapolis wrote in a commentary accompanying the Archives of Internal Medicine research.

"No business leaders would expect randomized trials to help them make important redesign or strategy decisions," he continued.

Even without such trials, researchers have several suspicions as to why open-access scheduling may not always produce desired results. Switching a practice from traditional scheduling to open access can be difficult. Physicians must work harder for months to get through the backlog of patients before same-day or next-day scheduling can start in earnest.

"It's a lot of investment up front of energy and time," Dr. Bundy said. "The benefits are downstream."

Practices must staff according to patient demand. This requires a practice to predict how many patients will call on a given day, taking into account seasonal variations.

Staffing needs to meet this demand. Open-access scheduling can be thrown off course when employees call in sick, go on maternity leave or resign.

"We have had our successes, but it does require constant care and feeding," said Dennis Dimitri, MD, associate professor and vice chair of the Dept. of Family Medicine and Community Health at the University of Massachusetts Medical School in Worcester.

He spent more than two years setting up open-access scheduling at his private practice. "This is not a system that you can just turn the switch and forget about it," he said. "You have to keep tweaking it."