More Rigorous Studies Needed to Assess Use of Advanced Access Scheduling in Primary Care

An analysis of published English-language studies on advanced access (AA) scheduling in the primary care setting revealed mixed results [Arch Intern Med. 2011;171(13):1150-1159]. Although wait times for an appointment typically decreased, as did the proportion of patients failing to show for a scheduled visit, many patients expressed dissatisfaction with the AA system. Improvements in continuity of care and loss of follow-up were inconsistent. In conducting the analysis, investigators searched several medical literature databases using various terms to identify studies of AA in primary care settings. Research letters and brief reports were considered for inclusion, provided they met additional eligibility criteria, such as comparing intervention and nonintervention data. Ultimately, 28 articles were selected for the analysis, which encompassed 24 different studies on AA. Only 1 study was a randomized trial, and all but 2 took place in the United States. Significant variation between the studies in protocol and outcomes reporting precluded conducting a meta-analysis, and the authors instead performed a qualitative assessment. According to the authors, a key measurement of success for an AA scheduling system is decline in the time to third-next available (3NA) appointment. This end point was assessed in 8 studies; the mean time to 3NA appointment with AA scheduling was <5 days in 5 studies and <2 days in 2 studies. In the 5 studies offering a statistical analysis, the decrease in time to 3NA appointment reached statistical significance. In the 4 studies that instead measured improvement in wait times based on time to next appointment, 2 lowered waiting time to <2 days. A report on implementation of AA scheduling at the Veterans Administration (VA) showed that next-appointment availability declined from 42.9 days to 15.7 days. One objective of AA scheduling is to reduce no-shows, and of the 11 studies reporting on this end point, 10 demonstrated improvement. According to the authors, “The change in no-show rate ranged from –24% to 0% and was significantly decreased in 5 studies.” Providers operating in low socioeconomic communities, one of which had a no-show rate of 43% with traditional scheduling, were more likely to see reductions in no-show rates with AA. Only 4 studies examined patient satisfaction with an AA system, none of which included a control group, and just 1 reported statistically significant improvement in satisfaction. One study realized an 8% decline in patient satisfaction for each 10% increase in proportion of same-day appointments. Of the 9 studies to discuss continuity of care, 7 reported improvement, which reached statistical significance in 3 cases. Continuity of care deteriorated in 2 studies. In the few reports on patients lost to follow-up, 2 observed almost no difference between AA and traditional scheduling. One VA practice that adopted AA scheduling found 19% of geriatric patients failed to arrange follow-up appointments, but offered no pre-AA comparison. Overall, the authors found inconsistent results regarding this end point and regarding the effectiveness of AA scheduling on emergency department and urgent care visits, hospitalization, and clinical outcomes for patients with diabetes. “Overall, advanced access yielded neutral to small positive improvements in no-show rates, continuity, and patient satisfaction, while effects on clinical outcomes were mixed,” the authors said. Although the quantitative analysis had several limitations—the primary ones being the lack of rigorousness of the underlying studies and failure to perform statistical analyses—the authors considered these data useful because the investigations took place in real-world settings. “Our results suggest that successful implementation of this scheduling system is challenging,” concluded the authors. They theorized that a large, randomized trial of AA scheduling could shed more light on its utility.