A Qualitative Study on the Role of Single-Entry Models in Managing Surgical Backlogs in Pediatric Otolaryngology Part 2: Investigating Perceptions of Patients and Their Caregivers

Abstract

Importance

Single-entry models (SEMs) may decrease wait times as they place patients in a common queue to see the first available physician. Accordingly, SEMs are a potential strategy for managing wait times in pediatric otolaryngology. No study has assessed SEMs in pediatric otolaryngology or evaluated the perspectives of patients and caregivers.

Objective

To evaluate the views of patients and their caregivers on the role of SEMs in managing surgical backlogs for high-volume procedures and to capture information regarding their suggestions for optimal SEM design and implementation.

Design

A qualitative study using semi-structured interviews (according to COREQ and SRQR guidelines).

Setting

Academic and community pediatric otolaryngology settings across Ontario, Canada.

Participants

Eight patients, along with their caregivers, were recruited through purposive sampling. Eligibility criteria included Ontario residents who are fluent in English and were scheduled for, or already had, a routine pediatric otolaryngology procedure.

Intervention or Exposures

This study investigated the perceptions of pediatric otolaryngology patients and their caregivers on the concept of implementing SEMs for pediatric otolaryngology.

Main Outcome Measures

Pediatric otolaryngology patients and their caregivers’ perceptions of SEMs as a method of managing wait times in pediatric otolaryngology.

Results

Across the patient and caregiver stakeholder group, four thematic domains were established: (1) challenges of long wait times, (2) current perceptions and hesitations of SEM, (3) enablers and patient buy-in, and (4) additional wait time reduction strategies.

Conclusions

Patients and caregivers agreed that implementing an SEM would effectively decrease wait times for routine procedures in pediatric otolaryngology. They felt that it would likely promote patient equity and accessibility and improve patient healthcare experiences.

Relevance

Emphasizing communication, transparency, patient autonomy, and funding will be imperative to patient and caregiver satisfaction and SEM longevity.

Graphical Abstract.

Background

The COVID-19 pandemic caused significant strain on the Canadian healthcare system, and as a result, the number of elective surgeries performed was significantly reduced.^1,2 Consequently, the country’s pre-existing problem of unacceptably long surgical wait times worsened.^{1 -6} The issue of surgical backlog remains, despite numerous attempts made by Canadian provincial governments to decrease wait times through funding models and programs.^3,4 This problem spans numerous disciplines, including pediatric otolaryngology, where lengthened surgical wait times are particularly concerning.^7,8 Permanent consequences may arise from increased wait times in this population, as these procedures may transpire during periods critical for childhood development.^7,9 Nevertheless, many of the solutions offered to decrease surgical backlogs target adult patients, while pediatric patients are often an afterthought. ⁷

Single-entry models (SEMs), also known as central intake models, have been put forward as a strategy to adequately manage current surgical backlogs.^{10 -14} The basis for SEMs is queuing theory, which has had success in diminishing wait times across a variety of applications.^11,12 The model works by placing patients into a single queue and having them see the surgeon who is first available. ¹²

Numerous Canadian organizations have been advocating for the use of SEMs in the healthcare system. For example, SEMs were promoted by the Canadian Medical Association in 2014 as a method of improving referral triage and decreasing wait times. ¹⁵ Furthermore, the Ontario Government assigned $18 million for the implementation of centralized waitlists to decrease surgical backlogs. ¹⁶ In addition, SEMs have been successfully implemented across other fields and disciplines to curtail wait times.^13,17 Previous research has evaluated the use of SEMs in otolaryngology-head and neck surgery^18,19; however, the implementation of SEMs in pediatric otolaryngology has yet to be examined.

Among pediatric otolaryngology patients, extensive wait times contribute to decreased patient satisfaction and perception of patient-centered care. ²⁰ In addition, excessive surgical wait times for pediatric surgeries can cause significant psychological distress for patients and caregivers. ²¹ As a method of decreasing surgical wait times, SEMs may therefore be a suitable strategy to improve the experience overall of patients and their caregivers in the healthcare system. While the perspectives of physicians have been examined, no research currently investigates the perspectives of patients and their families.^18,22 Accordingly, in this 2-part study, we sought to evaluate the views of referring physicians and otolaryngologists (Part I) and pediatric otolaryngology patients and their caregivers (Part II) across Ontario on the utilization of SEMs to reduce surgical backlog. The present paper (Part II in the manuscript series) reports on the perceptions of patients and their caregivers.

Methods

This research project received ethics approval from Western University’s Research Ethics Board (REB # 124261).

Study Design

Interpretative description, a method of qualitative research, was used to conduct this study. This approach allowed the ability to draw practical lessons informed by patients and their caregivers to generate actionable takeaways for policymakers, administrators, and clinical leaders as they develop or strengthen SEMs. ²³ Interviews took place on and were transcribed using Microsoft Teams (Microsoft Corp; Version 1.6.00.27547). Transcripts were deidentified and reviewed by a study team member (A.L.).

Data Collection

Study participants were recruited through purposive sampling. Patients and their caregivers were contacted from the senior author’s (J.E.S.) pediatric otolaryngology clinic or from the senior author’s contacts. Eligible participants included those who were Ontario residents, were fluent in English, and were scheduled for, or already had, a routine pediatric otolaryngology procedure, such as ear tube insertion or adenotonsillectomy. Exclusion criteria were those who did not meet the eligibility criteria. Upon patient and caregiver consent, J.S. contacted participants via email in English to schedule an interview.

Interview questions were created by the research team utilizing resources from the literature, including an existing interview guide used by Shapiro et al, ¹⁸ and the expertise of content specialists. Semi-structured interviews were then conducted in English by C.P., L.K., and M.Z. between April 2024 and May 2024. Each participant was asked a series of 10 open-ended questions, some of which had follow-up questions associated (Supplemental Appendix A). The research team reviewed interview transcripts on an ongoing basis. Recruitment concluded when researchers agreed that no new insights were being elicited. For their voluntary participation in the study, participants received a $50 e-gift card.

Data Analysis

To analyze interview transcripts, thematic analysis was implemented as it allowed for flexibility and the ability to identify, describe, and organize themes across a large dataset.24 An inductive coding approach was then employed. Trustworthiness was attained through various methods. Research triangulation, where two researchers (V.G. and L.K) independently coded each de-identified data set using NVivo 14 software, promoted credibility (QSR International Pty Ltd.; Version 14). ²⁴ Researchers independently documented their respective coding frameworks to ensure dependability. To provide an external check and support the authenticity of interpretations, peer debriefing was completed by V.G., L.K., J.S., and O.S. Themes and subthemes were then identified by reviewing similar codes and grouping them as appropriate. Confirmability was established by having researchers reflect on their biases throughout the analysis, when appropriate. ²⁴ Direct quotes and contextual descriptions were incorporated in the results section below to ensure transferability. ²⁴

Researcher Reflexivity

The research team included medical trainees, surgeons, and senior administrative leaders, with varying degrees of experience in pediatric otolaryngology and qualitative methods. Each of the authors brought a unique perspective to the issues of wait times and novel models of care, which allowed for meaningful discussion during the development of themes and subthemes. Throughout the process, team members reflected on their assumptions and professional perspectives via peer debriefing, helping to ensure that data interpretation remained grounded in participants’ perspectives.

Results

Eight caregivers of pediatric otolaryngology patients consented to being interviewed prior to thematic saturation being reached. The caregivers of patients were interviewed without the child present in all interviews. Additional demographic information can be found in Table 1.

Table 1.

Demographic Profile of Patients for Otolaryngology Procedures.

ID	Procedure	Wait time
P1	Bilateral myringotomy and ear tube insertion	8-10 months
P2	Adenoidectomy, bilateral myringotomy, and ear tube insertion	1 month from appointment to surgery (however, issues began in 2020, went between ophthalmology and ENT)
P3	Tonsillectomy, adenoidectomy, ear tube removal	2 months wait between appointment and surgery
P4	Child 1: Bilateral myringotomy and ear tube insertion	2 months
	Child 2: Bilateral myringotomy and ear tube insertion
P5	Child 1: Bilateral myringotomy and ear tube insertion	Child 1: 10 months
	Child 2: Awaiting tonsillectomy	Child 2: 1 year (from time to initial appointment)
P6	Adenoidectomy, inferior turbinate reduction	2-3 months
P7	Tonsillectomy, adenoidectomy	1 week (initially told 1 year, then had appointment moved)
P8	Adenoidectomy, bilateral myringotomy, and ear tube insertion	6-7 months

The qualitative analysis of the interview transcripts revealed four thematic domains, with 13 subdomains (Figure 1). The primary domains included: (1) challenges of long wait times, (2) current perceptions and hesitations of SEM, (3) enablers and patient buy-in, and (4) additional wait time reduction strategies (Figure 2).

Figure 1.

Thematic analysis of patients’ perceptions of SEMs derived from interview transcripts.

Figure 2.

Proposed mechanisms for SEM implementation.

Figure created with biorender.com.

Theme 1: Challenges of Long Wait Times

The first thematic domain explored the challenges of long wait times, including child suffering and developmental impacts, and the caregiver as a bystander.

Child Suffering and Developmental Impacts

Caregivers commonly reported that one of the hardest parts of waiting for surgery was the “recurring infections” (P1). In turn, their child would experience pain and/or discomfort, often require additional courses of treatment, and would sometimes need to miss school due to illness or medical appointments. Caregivers also struggled to manage the symptoms of their child, as they would occur frequently and lead to significant distress. “That would be the most difficult part. . . just trying to manage your child’s comfort levels while you’re waiting” (P4). Furthermore, caregivers worried that in some cases, their child could experience delays in language and speech development, as well as in daily functioning, as vital functions, such as their child’s hearing, may have been impaired. One parent described their child as having “significant hearing loss because of how much fluid was in her ears” (P2).

Caregiver as a Bystander

In seeking treatment for their children, caregivers reported feelings of uncertainty due to the lack of information they received from their otolaryngologist’s office, as well as their referring clinician. “The hardest part [was] just not knowing how long it would take” and “trying to. . . prep for it” (P3). Participants further explained that they often did not know where their child was on the waitlist to be seen or for surgery, and they did not know who to contact to receive information. Caregivers also reported feeling “frustration and anger” (P5) due to the wait times as they lacked control and were unable to obtain information, nor were they able to intervene or provide lasting relief to their child when they were in pain or in distress.

Theme 2: Current Perceptions and Hesitancies of SEM

The second thematic domain investigated current perceptions and hesitancies of a SEM, including: current model misconceptions, patient receptiveness of SEMs, perception of decreased wait times, and hesitancies.

Current Model Misconceptions

Through interviews, it was revealed that “most people think that [SEMs] are the way it happens. . . that you are on a general wait list and then you get divided up” (P2). They did not recognize that currently, patients are referred to a specific surgeon’s waitlist, and that wait times are not always taken into account when being referred.

Patient Receptiveness of SEMs

Many participants expressed that to them, it did not matter who the surgeon was, so long as their child received the care they required promptly. As one participant described, “I think for most parents, the sooner you can get them in, the better. So, I was never really picky about who it was. It was just can we get it done?” (P3). With that, some participants did emphasize that they could see how some people may be hesitant or bothered by the model if they do not have control over the physician they are seeing.

Perception of Decreased Wait Times

When the SEM was explained to participants, many perceived that this model would provide a streamlined approach to accessing care. Participants extrapolated that, “a more equal distribution of patients among every physician would then result in shorter wait times” (P5).

Hesitancies

Some participants expressed that the nature of the model could lead to a decrease in continuity of care between the otolaryngologist and the patient. Since the surgeon doing the consult appointment may be different than the surgeon performing the surgery, some participants felt this would impede their ability to develop rapport and trust with their surgeon, especially if they “built up a relationship of trust with the first [surgeon] and now it’s somebody else [operating]” (P4).

In addition, some participants felt that this could also lead to breakdowns in communication: “there’s a chance of information getting skewed” if what was discussed in the consult appointment was not relayed to the surgeon (P3). Furthermore, there were also concerns that with numerous surgeons involved, it would be challenging to know who to contact if an issue arises.

Theme 3: Enablers and Buy-in

The third thematic domain examined the enablers and buy-in, including: education and reassurance, communication throughout their entire healthcare interaction, increasing resources, and room for autonomy.

Education and Reassurance

Educating patients and caregivers was highlighted by many study participants. They noted that education from their primary care providers and otolaryngologists could provide clarity and “reassurance” (P6). “Preparing individuals that they may not be seeing the same otolaryngologist for the surgery that they do for the consult would help lessen the shock” (P4). Some participants suggested utilizing “social media” (P6), websites, or “fact sheets” (P6) to read up on the particular otolaryngologist who would be performing their surgery (P6). Furthermore, having quality explanations of the model, including its benefits such as decreasing wait times and accessing care more rapidly, would provide reassurance.

Communication Throughout Their Entire Healthcare Interaction

Study participants stressed “having better communication” (P2) is an essential component of this model. A downfall many caregivers experienced was a lack of transparency or accessibility to communicate while waiting for their surgery, with one noting, “am I waiting for a phone call? An email?” (P2). Participants felt that uncertainty would be reduced, and families could be more at ease if the SEM regularly communicated with families, “kept patients informed” (P1), and provided them with “approximate wait times” (P1). Multiple participants identified that providing patients/caregivers with numerous ways to access their otolaryngologist and communicate with administrative staff would be helpful. More specifically, providing patients/caregivers with a website link or “portal” to log into, and a central email address and phone number (P1). Participants suggested that “having a constant touch person like a secretary or a nurse. . . would be a good approach” for improving communication as “frequent contact is key” (P6).

Increasing Resources

Caregivers identified that an increase in resources would also improve the SEM, indicating a “need to have an increased number of physicians, nurses, and beds available at the hospital for the SEM to be functional” (P1).

Room for Autonomy

Participants recognized that certain caregivers “might have a preference” for a particular otolaryngologist (P8). As such, some participants recommended a model accommodating patient autonomy. For example, allowing patients to opt out of the SEM and request a particular otolaryngologist on a separate list, with an understanding that there will be extended wait times as a result of being on a separate list.

Theme 4: Additional Wait Time Reduction Strategies

The fourth thematic domain reviewed additional wait time reduction strategies, including: rapid assessment, primary care provider education, and referrals to rural sites.

Rapid Assessment

Rapid assessment clinics were proposed by multiple participants to address the long wait times. One caregiver described a walk-in clinic just for general ear concerns, noting that “if you can get a referral from there it could speed up that process” (P7).

Primary Care Provider Education

To help spread awareness of the SEM models, participants suggested “education in terms of how the model is” (P1) and information-sharing sessions for referring providers. This could include sessions on SEM rollout and the referral process. “It would be helpful if referring physicians were made aware of specifics” of who and how they “can refer to” (P4).

Referrals to Rural Sites

Expanding referrals to more rural locations was also suggested. It was noted that many London and urban centers are at high capacities. One participant explained, “encouraging family doctors to set referrals to the smaller rural areas, which have the shorter wait times, which could then decrease wait times in turn” (P5). Generally, it was thought that expanding referrals to broader areas could be beneficial.

Discussion

This study investigated the perspectives of patients and caregivers on the implementation of a SEM model in Ontario for managing wait times within the field of pediatric otolaryngology. Eight study participants who accessed otolaryngological care were interviewed about their experiences, and the common themes that arose included: (1) the challenges of long wait times, (2) current perceptions and hesitancies of SEM, (3) enablers and patient buy-in, and (4) additional wait time reduction strategies.

All participants discussed the challenges of long wait times, including prolonged patient suffering, and absences from school. In addition, the possibility of language and speech developmental delay was very concerning for caregivers, as their children face impairments in important functions, such as hearing, while awaiting their surgeries. These fears align with current literature, which describes that permanent consequences may arise from increased wait times in pediatric populations, as these procedures may transpire during periods critical for childhood development.^7,9 Moreover, participants noted that prolonged wait times can increase caregiver burden, as they receive minimal information and communication, and are required to watch as their child suffers. Similarly, research has shown that excessive surgical wait times for pediatric surgeries can cause significant psychological distress for caregivers. ²¹ Participants reported that, in contrast to our current system of referrals to specific surgeon’s waitlists, shorter wait times were more important to them than preferences for specific surgeons. Hesitations to implementing a SEM included disruptions in continuity of care and possible breakdowns in communication between providers and patients. Strategies to improve acceptance of a SEM included education of patients about the model, opportunities for patient feedback, consistent communication between patients and healthcare teams, increased healthcare resources, and maintenance of patient autonomy.

SEMs have been implemented across Organization for Economic Co-operation and Development countries, Canadian provinces, and within various subspecialties.^{11,13,14,25,26} Studies that have investigated the impact on SEMs have reported decreases in wait times, with the highest wait time reductions seen in surgical specialties, including general surgery and orthopedic surgery.^11,13 Studies have also shown positive patient satisfaction after the implementation of an SEM.^11,13 These findings are aligned with the general attitude of our participants that implementation of a SEM in pediatric otolaryngology will have a positive impact on wait times and patient care. Similar to our cohort, some patients in other studies expressed a desire to remain with their specific surgeon. However, these same studies found that when the consulting and operating surgeons were not the same, patients no longer considered seeing one surgeon as crucial. Regardless of whether patients had the same surgeon for both assessment and surgery, patients’ confidence in their surgeon was high.^11,13 These findings demonstrate that there are different interpretations of how an SEM would be formatted. An SEM could be implemented such that patients are placed with the first available surgeon for consult, and then the patient remains with the same surgeon for their surgery and the rest of their care. Alternatively, patients could be placed with the first available surgeon for their consult, and then again with the first available surgeon for their surgery. In this scenario, the patient may not be seen by the same surgeon for their consultation and their surgery. Prior to the implementation of an SEM, clarification is required for the model specifics. One study looking at an SEM for pediatric physiotherapy reported that caregivers found the new system provided more accurate information on wait times and improved communication with the healthcare team. ²⁷ These findings could reassure caregivers with concerns regarding fractured communication and a desire for more accessibility to approximate wait times. Overall, the existing literature largely affirms the positive perceptions our participants have of SEMs while also addressing many patient concerns.

This study had several limitations. First, this study was restricted to the Ontario healthcare system. As Ontario is the largest province, we are optimistic that this could translate into a diverse group of participants. However, the perspectives of patients in other provinces and countries may vary as they access different healthcare systems. Furthermore, this study had a small sample size, which, although common in qualitative studies, may limit the generalizability of our findings. This sample size was, however, adequate to achieve thematic saturation. The majority of patients and their caregivers were recruited from the senior author’s pediatric otolaryngology clinic in London, ON, Canada. The four pediatric otolaryngologists at that center already have a centralized referral system for outpatient consultations in place. In addition, only patients undergoing routine pediatric otolaryngologic procedures were approached. Finally, given that this study sampled pediatric patients, the majority of patients were too young to be interviewed, and caregivers were used as a conduit to understand the patient experience.

Both shared and differing perspectives among patients and caregivers (Part II), and referring physicians and otolaryngologists (Part I) were revealed in this 2-part study. Unlike the otolaryngologist and referring physician participants, patients and caregivers were not concerned with the logistics of SEM implementation as long as patient care was improved. In addition, in both Parts I and II, participants expressed the importance of education and awareness surrounding SEMs for successful SEM implementation. Furthermore, patients and caregivers suggested a patient-centered opt-in system for SEMs, whereas clinicians suggested an “all-or-nothing” approach of SEM rollout.

Similar studies can be conducted for other subspecialties or patient populations to develop a broader understanding of the perspectives of Canadians on implementing a SEM. Finally, a quantitative study comparing wait times before and after SEM implementation in pediatric otolaryngology care is imperative to provide evidence for or against the effectiveness of an SEM in the field.

Conclusion

Wait times and surgical backlogs continue to be a problem facing the Ontario healthcare system across a broad range of specialties. This problem extends into the field of pediatric otolaryngology, having implications not only on patient and caregiver satisfaction, but on child suffering and development. SEMs are seen as a realistic option to help manage this ongoing issue and have practical implications in pediatric otolaryngology. Participants perceive that SEMs may reduce wait times, promote patient equity and accessibility, and improve the healthcare experience of many. It is important that clinical leaders and institutions take into consideration a broad range of factors to ensure the longevity of these models. If designed to address local needs, SEM implementation may decrease wait times, improve care delivery of care, and raise patient satisfaction and outcomes.

Key Points

1. Patients and their caregivers often experienced prolonged suffering, developmental concerns, and psychological stress as a result of long wait times, making reducing wait times a priority.

2. Hesitations about SEMs can be mitigated through education, consistent updates, patient feedback mechanisms, and preserving patient autonomy.