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Advanced Access—Fad or Important?: Comment on “Advanced Access Scheduling Outcomes”

Advanced Access—Fad or Important?: Comment on “Advanced Access Scheduling Outcomes” Advanced access (AA) burst onto the primary care redesign scene over 10 years ago, led by Murray and Berwick1 and Murray and Tantau,2,3 who helped several medical groups implement it and became key advocates and facilitators for its spread. This disruptive innovation in scheduling was widely accepted for multiple reasons: (1) health care was ready for any change that might improve patient satisfaction; (2) AA provided advantages for clinicians and clinic staff as well as patients; and (3) Murray, Berwick, and Tantau provided very specific tools and actions needed to implement it. This readiness for the AA change was reinforced in 2001, when the now famous report from the Institute of Medicine,4 “Crossing the Quality Chasm,” called for attention to 6 domains of quality, including timeliness. Now, 10 years later, it is appropriate to wonder whether AA was just a passing fad and whether it has had any impact on the other 5 domains of quality—safety, effectiveness, efficiency, equity, and patient-centeredness. Thus it is timely that Rose et al report a systematic review of published studies on this topic. As with virtually every other systematic review, that of Rose et al found many deficiencies in both the design and reporting of most published studies, although that finding partly reflects the prevailing bias that only rigorously controlled trials have value. We are living through a time of enormous tumult in the way medical care is provided and paid for, so it is essential that we learn what we can from before-after, observational, and case study efforts to understand the many natural experiments that are going on everywhere. Other industries have undergone greater changes by relying on anecdotes, hunches, expert opinion (consultants), and business case estimates. No business leaders would expect randomized trials to help them make important redesign or strategy decisions. Judging by the published studies described in this review, there appears to be continuing interest in studying AA, but I have been unable to find any estimate of either prevalence or incidence for its use. However, patients' access to their physicians when and how they desire it is an expected part of the current medical home enthusiasm, and it constitutes one of the least controversial components of the National Committee for Quality Assurance medical home recognition process.5 It is hard to imagine that medical care can increase the patient-centeredness that is being demanded without improving patient access to information, advice, and visits. The harder question is whether there is evidence that improving access also improves safety, effectiveness, efficiency, or equity and whether any such improvements are due specifically to the access change or to other causes. The review by Rose et al found that most studies did not even report on change in access measures, and some of those that did reported such small access changes that we should not expect an effect on anything else. Frankly, I would have separated such studies in an analysis, limiting what we can learn from them to qualitative assessments. By including them, Rose et al suggest that effects on no-show rates and patient satisfaction are variable but that there are still insufficient data about impact. Much can be learned from observational studies with careful measurements. For example, my study group6 found that an apparent association between dramatic improvements in access in a large medical group and improved diabetes performance measures was entirely due to the improved continuity that resulted from emphasizing continuity in the design for AA implementation.6 My group7 also showed that access improvement was associated with decreased operating costs (improved efficiency). Given the difficulty of randomizing such organizational practice changes, there is a need for more willingness to propose and fund rigorous observational studies. Back to top Article Information Correspondence: Dr Solberg, HealthPartners Research Foundation, PO Box 1524, MS#21111R, Minneapolis, MN 55440-1524 (leif.i.solberg@healthpartners.com). Published Online: April 25, 2011. doi:10.1001/archinternmed .2011.169 Financial Disclosure: None reported. References 1. Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA. 2003;289(8):1035-104012597760PubMedGoogle ScholarCrossref 2. Murray M, Tantau C. Must patients wait? Jt Comm J Qual Improv. 1998;24(8):423-4259739509PubMedGoogle Scholar 3. Murray M, Tantau C. Redefining open access to primary care. Manag Care Q. 1999;7(3):45-5510620958PubMedGoogle Scholar 4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001 5. American Academy of Family Physicians. Road to Recognition: Your Guide to the National Committee for Quality Assurance Medical Home. Leawood, KS: American Academy of Family Physicians; 2009 6. Sperl-Hillen JM, Solberg LI, Hroscikoski MC, Crain AL, Engebretson KI, O’Connor PJ. The effect of advanced access implementation on quality of diabetes care. Prev Chronic Dis. 2008;5(1):A1618082005PubMedGoogle Scholar 7. Lewandowski S, O’Connor PJ, Solberg LI, Lais T, Hroscikoski M, Sperl-Hillen JM. Increasing primary care physician productivity: a case study. Am J Manag Care. 2006;12(10):573-57617026411PubMedGoogle Scholar http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

Advanced Access—Fad or Important?: Comment on “Advanced Access Scheduling Outcomes”

Archives of Internal Medicine , Volume 171 (13) – Jul 11, 2011

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Publisher
American Medical Association
Copyright
Copyright © 2011 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2011.169
Publisher site
See Article on Publisher Site

Abstract

Advanced access (AA) burst onto the primary care redesign scene over 10 years ago, led by Murray and Berwick1 and Murray and Tantau,2,3 who helped several medical groups implement it and became key advocates and facilitators for its spread. This disruptive innovation in scheduling was widely accepted for multiple reasons: (1) health care was ready for any change that might improve patient satisfaction; (2) AA provided advantages for clinicians and clinic staff as well as patients; and (3) Murray, Berwick, and Tantau provided very specific tools and actions needed to implement it. This readiness for the AA change was reinforced in 2001, when the now famous report from the Institute of Medicine,4 “Crossing the Quality Chasm,” called for attention to 6 domains of quality, including timeliness. Now, 10 years later, it is appropriate to wonder whether AA was just a passing fad and whether it has had any impact on the other 5 domains of quality—safety, effectiveness, efficiency, equity, and patient-centeredness. Thus it is timely that Rose et al report a systematic review of published studies on this topic. As with virtually every other systematic review, that of Rose et al found many deficiencies in both the design and reporting of most published studies, although that finding partly reflects the prevailing bias that only rigorously controlled trials have value. We are living through a time of enormous tumult in the way medical care is provided and paid for, so it is essential that we learn what we can from before-after, observational, and case study efforts to understand the many natural experiments that are going on everywhere. Other industries have undergone greater changes by relying on anecdotes, hunches, expert opinion (consultants), and business case estimates. No business leaders would expect randomized trials to help them make important redesign or strategy decisions. Judging by the published studies described in this review, there appears to be continuing interest in studying AA, but I have been unable to find any estimate of either prevalence or incidence for its use. However, patients' access to their physicians when and how they desire it is an expected part of the current medical home enthusiasm, and it constitutes one of the least controversial components of the National Committee for Quality Assurance medical home recognition process.5 It is hard to imagine that medical care can increase the patient-centeredness that is being demanded without improving patient access to information, advice, and visits. The harder question is whether there is evidence that improving access also improves safety, effectiveness, efficiency, or equity and whether any such improvements are due specifically to the access change or to other causes. The review by Rose et al found that most studies did not even report on change in access measures, and some of those that did reported such small access changes that we should not expect an effect on anything else. Frankly, I would have separated such studies in an analysis, limiting what we can learn from them to qualitative assessments. By including them, Rose et al suggest that effects on no-show rates and patient satisfaction are variable but that there are still insufficient data about impact. Much can be learned from observational studies with careful measurements. For example, my study group6 found that an apparent association between dramatic improvements in access in a large medical group and improved diabetes performance measures was entirely due to the improved continuity that resulted from emphasizing continuity in the design for AA implementation.6 My group7 also showed that access improvement was associated with decreased operating costs (improved efficiency). Given the difficulty of randomizing such organizational practice changes, there is a need for more willingness to propose and fund rigorous observational studies. Back to top Article Information Correspondence: Dr Solberg, HealthPartners Research Foundation, PO Box 1524, MS#21111R, Minneapolis, MN 55440-1524 (leif.i.solberg@healthpartners.com). Published Online: April 25, 2011. doi:10.1001/archinternmed .2011.169 Financial Disclosure: None reported. References 1. Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA. 2003;289(8):1035-104012597760PubMedGoogle ScholarCrossref 2. Murray M, Tantau C. Must patients wait? Jt Comm J Qual Improv. 1998;24(8):423-4259739509PubMedGoogle Scholar 3. Murray M, Tantau C. Redefining open access to primary care. Manag Care Q. 1999;7(3):45-5510620958PubMedGoogle Scholar 4. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001 5. American Academy of Family Physicians. Road to Recognition: Your Guide to the National Committee for Quality Assurance Medical Home. Leawood, KS: American Academy of Family Physicians; 2009 6. Sperl-Hillen JM, Solberg LI, Hroscikoski MC, Crain AL, Engebretson KI, O’Connor PJ. The effect of advanced access implementation on quality of diabetes care. Prev Chronic Dis. 2008;5(1):A1618082005PubMedGoogle Scholar 7. Lewandowski S, O’Connor PJ, Solberg LI, Lais T, Hroscikoski M, Sperl-Hillen JM. Increasing primary care physician productivity: a case study. Am J Manag Care. 2006;12(10):573-57617026411PubMedGoogle Scholar

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Jul 11, 2011

Keywords: appointments and schedules

References