Access to Urologic Care Through Clinical Integration in a Large, Underserved Population

Abstract

This study explores the near-term results of an effort to improve the access of a large, underserved urban population to appropriate urologic specialty care through clinical integration.

Access to surgical care differs from access to nonsurgical care. Frameworks that account for the efficiency of an initial diagnosis, an appropriate workup, and a subsequent intervention may more accurately reflect meaningful access from the patient’s perspective than does the interval between specialty referral and specialty clinic visit. In an effort to optimize the use of physician specialists in the setting of limited resources¹ and to maximize efficiency, the Los Angeles County Department of Health Services (LAC DHS) has pursued clinical integration by concurrently instituting empanelment, an electronic specialty referral system (eConsult; Safety Net Connect), and jointly defined clinical algorithms (expected practices) for managing common diagnoses. We assessed the association of these 3 aspects of clinical integration with access to urologic care.

Methods

Based on patients’ oral consent to our use of deidentified data from their electronic health records, the Olive View–UCLA Education and Research Institute institutional review board exempted our study from review.

To obtain a granular view of how clinical integration affected patient care, we used a pre-post cohort design and performed a manual review of the electronic health records of patients for whom a referral request was sent to the urology department at 1 of our LAC DHS hospitals with a wide catchment area involving many primary care medical homes and community clinics. We reviewed patient records containing eConsult referral requests dating from July 18, 2012, to November 1, 2016. Each of the 3669 eConsult requests placed during this time frame was reviewed by an attending physician. To maximize accuracy, we cross-referenced data from 3 sources: the eConsult portal, the electronic health record, and the eConsult registry.

Eight percent of patients newly referred to urology in each calendar year after eConsult deployment were randomly selected for in-depth analysis (n = 293). For comparison, data from 80 randomly selected patients referred to the urology department between January 1, 2011, and July 17, 2012 (prior to eConsult implementation) were also abstracted, for a total of 373 study participants. Clinical outcomes for patients whose health care needs were met with specialist input but without a specialty clinic visit were grouped into a “non–face-to-face specialty-care touch” category. We then calculated the number of patients who received “inefficient care” (ie, patients who did not need specialty care or who received insufficient workup prior to the specialty clinic visit), as determined by agreement between 2 of the 3 abstractors (S.C.P., A.S., or J.B.); when there was disagreement, a determination was made by the third abstractor. We calculated the time interval to specialty clinic consultation or appointment both as total wait time, from the date of eConsult request submission; and as final wait time, from the eConsult close date (ie, the date on which the request was fulfilled by scheduling of a consultation or appointment).

Software (SAS, version 9.4; SAS Institute) was used to perform statistical analyses. Spearman rank correlation was used to compare total wait times before and after eConsult implementation. Pearson χ² test was used to compare clinical outcomes. All tests were 2-sided with an α of .05 for statistical significance.

Results

Thirty-nine percent of patients for whom an eConsult request was placed and whose records were included in the in-depth analysis (114 of 293) were cared for with remote input from a urology specialist. Of the 80 patients who were seen in the urology clinic on referrals submitted before eConsult implementation, 58 (73%) received inefficient care, compared with 39 of 179 patients (22%) who were seen in the clinic on referrals placed after eConsult was implemented (P = .001). Time intervals from the date of submission of an eConsult request to the appointment date decreased steadily over the study period, with a difference of 5 calendar days between total and final mean wait times indicating timely completion of iterative communications through eConsult (Figure). The improvement in wait times was especially important because approximately 35% of eConsult requests (101/293) were related to malignant disease.

Figure. Wait Times for Urology Specialty Clinic Appointments Before and After eConsult Implementation.

Wait times shown are the mean number of weeks for patients referred before (n = 80) and after (n = 179) eConsult implementation. Total wait time is the interval between the date of request submission and the appointment date; final wait time is the interval between the date of request fulfillment by appointment scheduling (ie, close date) and the appointment date. The “intended” time frame was established on the basis of clinical urgency by the specialist accepting the referral.

Discussion

Access to surgical specialty care is a challenge in all health systems. Our study, from the second-largest public health care system in the United States and in an underserved population, shows the outcome of an innovative, system-wide effort to integrate clinical care and align practice patterns. Delays in surgical treatment result in worse clinical outcomes.^2,3 Thus, current definitions of access, which are based on wait times to evaluation in a surgical clinic, fail to capture the effect of access on outcomes.^4,5 Defining access to care as the time from which a problem began until it was definitively addressed is a better method for determining how access affects quality of care.⁶ The clinically integrated system within LAC DHS, which allows specialist involvement in patient care not only outside the operating room but also beyond the surgical clinic, requires buy-in from both the health system and eConsult physician-reviewers. Although our study was limited by a pre-post, unblinded design, our findings suggest the need for future expansion and investigation of clinical integration as an innovative approach to respond to urgent health care needs in the surgical setting.