Better Elective Waiting Times For The Surgical Outpatient Clinic

Abstract

Aim This thesis seeks to optimise the delivery of health care of patients referred to the General Surgical Outpatient Clinic with rectal bleeding. Method Patients referred to the General Surgical Outpatient Clinic at Counties Manukau Health with the presenting complaint of rectal bleeding (also regarded as minor anorectal conditions) represented a pressure point for the Department of General Surgery. The work described in this thesis is divided into three distinct sections. The first section takes a whole system approach in determining bottlenecks in the system and assessing some possible solutions. This was done, firstly by examining the trends of the current waiting list and also by performing a literature review of some of the strategies employed in other health care systems to help improve elective waiting times. This was followed by a systematic review into computer modelling systems as a means to analysing its use in the outpatient clinic setting. This provided a basis for the development of a generically constructed simulation model specific to the set-up of the outpatient clinic at CMH. The aim of the constructed simulation model was to test changes to the waiting list of outpatient clinic with hypothetical scenarios of increasing capacity through extra clinics, or through reducing unnecessary follow up appointments and of both strategies combined. The second section of the thesis investigated a patient initiated approach to follow up appointments and using General Practitioners with Specialty Interests (GPwSI). The findings from the modelling system and the systematic reviews were used to help create a clinical pathway for patients with Per Rectal (PR) bleeding. The pathway was evaluated in a quasi-randomised controlled study to look at outcomes of PR bleeding patients referred to the outpatient clinic compared to a historical cohort. The final section of the thesis investigated the validity of the generically constructed model by comparing its predictive value to real-time data. Results A literature review into strategies in health care designed to improve elective waiting times in public secondary care suggested that, while there was no onestop solution, a whole system approach was critical to any implemented strategy. The systematic review into modelling systems showed evidence of modelling system s use in improving access time via queuing theory. The prospectively constructed model analysed three hypothetical scenarios. It predicted that reducing follow up appointments would help improve waiting list at a similar rate to increasing capacity by means of an additional clinic. A systematic review into the strategy of patient initiated follow up, showed that there is merit in such a policy. However, a systematic review looking at the role of GPwSIs showed limited evidence of efficacy and raised question marks regarding their cost-effectiveness. A prospective study, implementing the concept of Patient Initiated Follow Up (PIFU)and streamlining a pathway for PR bleeding patients showed, that follow up rates for patients were much lower in the new clinic (6% vs. 45%, p<0.001). With reduced follow up appointments and the addition of a new clinic, the simulation model was tested against real data. Validity was high, for all the hypothesised scenarios, although the best match with the real data was when the model was simulated for the addition of the new clinic alone, as opposed to the combination of reduced follow up appointments and a new additional clinic. Conclusion Computer simulation modelling of a health system can help identify bottlenecks within a health system and this can be used to implement protocols and pathways that can not only streamline the delivery of care but also help optimise access to that care.