SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
April, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
Long waiting times for non-urgent procedures can cause distress among patients as well as adverse health consequences, and may be perceived as inappropriate healthcare planning. Interventions to reduce waiting times can ration or prioritise demand, expand capacity, or restructure referral or intake assessments of patients.
Key messages
− The effects of direct/open access and direct booking systems on mean waiting times in outpatient settings, and on the proportion of patients waiting less than a recommended time are uncertain.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Elective health procedures are diagnostic or therapeutic procedures that are not delivered in emergency or urgent situations. Even when long waiting times do not have adverse health effects, they can cause distress for patients. They can also be perceived as inappropriate when patients’ expectations are not met. It is important to keep waiting times at a safe and acceptable level, while ensuring quality, equity and efficient use of resources.
This review assessed the effects of any type of intervention targeted at reducing waiting times. The review authors did not cover all possible interventions (for example resource sharing strategies or remuneration schemes). Also, they considered three categories of interventions: ones that increase supply (expanding capacity of a healthcare provider), ones that reduce demand (rationing or prioritising patients), and ones that improve efficiency by eliminating redundancies or obstacles in the process of care (restructuring the intake assessment/referral process).
| Review objectives: To assess the effectiveness of interventions aimed at reducing waiting times for elective care, both diagnostic and therapeutic. | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, controlled before-after studies, and interrupted time series studies of any type of regulatory/administrative, economic, clinical or organisational intervention aimed at reducing waiting times for access to elective diagnostic or therapeutic procedures |
2 cluster-randomised trials, 1 randomised trial, and 5 reanalysed interrupted time series studies of interventions rationing or prioritising demand (1), expanding capacity (1 with a co-intervention), and restructuring the intake assessment/referral process (7) |
| Participants | Healthcare providers of any discipline/area, and patients referred to any type of elective procedure |
7 hospitals, 1 outpatient clinic and 135 general practices/primary care, performing elective procedures for ear-nose-throat referrals (1), uncomplicated spinal surgery (1), dermatology (1), elective surgery (1), colposcopy for abnormal cervical cytology (1), any paediatric clinic conditions treated in an outpatient clinic (1), laparoscopic sterilisation (1), and urological interventions (1) |
| Settings | Any setting |
Studies in UK (5), US (2), and Australia (1) |
| Outcomes | Number or proportion of participants whose waiting times were above or below a time threshold, mean or median waiting times, safety outcomes (mortality, morbidity, complication rates), and costs |
Number and proportion of participants waiting longer (2) or less (2) than a recommended time to be attended or get an appointment, effects on waiting time (5), direct and indirect costs (2) |
| Date of most recent search: November 2013 | ||
| Limitations: This is a well-conducted systematic review with only minor limitations. | ||
Ballini L, Negro A, Malton, S, et al. Interventions to reduce waiting times for elective procedures. The Cochrane Database Syst Rev 2015; (2):CD005610.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
The eight included studies assessed the effect of two types of interventions: interventions to reduce demand by rationing or prioritising patients; and interventions to restructure referral processes (which includes direct/open access and direct booking systems, distant consultancy and single generic waiting list). The review did not find studies assessing the effect of increasing capacity.
One study measuring the effect of distant consultancy was not reported in this summary, since control group results were not reported.
The review included one interrupted time series study with high risk of bias in patients scheduled for any type of elective surgery in one hospital in Australia.
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Interventions to reduce demand by rationing or prioritising patients |
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People Patients scheduled for elective surgery Settings A public hospital in Australia Intervention Prioritising demand Comparison No intervention |
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Outcomes |
Effect of Intervention |
Certainty of the evidence (GRADE) |
Comments |
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Number of patients waiting less than a specific time threshold |
- |
Very low |
The authors reported changes in slope, although direction and magnitude of effect is not clear. |
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GRADE: GRADE Working Group grades of evidence (see above and last page) |
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Two randomised trials and two interrupted time series studies evaluated the effects of direct/open access and direct booking systems. They were conducted in hospitals (3) and ambulatory settings (1) in the UK (3) and US (1).
- probably slightly decrease median waiting times. The certainty of this evidence is moderate.
- may decrease mean waiting times in hospital settings. The certainty of this evidence is low.
- have uncertain effects on mean waiting times in outpatient settings. The certainty of this evidence is very low.
- have uncertain effects on the proportion of patients waiting less than a recommended time. The certainty of this evidence is very low.
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Interventions to restructuring referral processes |
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People Patients needing elective specialist ambulatory visits, surgery, or procedures Settings Hospital and ambulatory care in UK and USA Intervention Direct/open access and direct booking systems, single generic waiting list and distant consultancy Comparison No intervention |
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Outcomes |
Impact or Absolute effect of intervention |
Certainty of the evidence (GRADE) |
Comments |
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Without Intervention |
With Intervention |
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Direct/open access and direct booking systems |
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Mean waiting time |
127 days |
108 days |
Low |
1 randomised trial with high risk of bias and important indirectness in laparoscopic sterilisation |
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Difference: 19 days |
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- |
Very low |
1 reanalysed interrupted time series study with high risk of bias in a paediatric outpatient clinic. Authors reported an effect favouring the intervention |
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Median waiting time reduction |
70 days |
55 days |
Moderate |
1 randomised trial in patients with urinary tract symptoms |
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Difference: 15 days |
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24 days |
18 days |
Moderate |
1 randomised trial in patients with microscopic haematuria |
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Difference: 6 days |
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Proportion of patients waiting less than specific time threshold |
- |
Very low |
1 reanalysed interrupted time series study with high risk of bias of colposcopy for abnormal cervical cytology |
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Distant consultancy |
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Mean waiting time |
- |
Very low |
1 reanalysed interrupted time series study with high risk of bias and serious imprecision, in ear, nose, and throat patients |
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Single generic waiting list |
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Number of patients waiting less than a specific time threshold |
- |
Very low |
1 reanalysed interrupted time series study with high risk of bias in patients with spinal cord injury |
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GRADE: GRADE Working Group grades of evidence (see above and last page) |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| The studies included in the review were from high-income countries (UK, US and Australia) for selected conditions or type of patients. |
The effect of the interventions included in the review would likely depend on several factors, including: - Waiting list length - Resource availability - Healthcare workers availability - IT development - Health system structure |
| EQUITY | |
| The studies included did not report any differential effect of the interventions on disadvantaged populations. |
Interventions might increase inequity if they are not focused on resources-disadvantaged people or underserved areas. Interventions might be more difficult to design and implement for disadvantaged populations due to a lack of available resources. |
| ECONOMIC CONSIDERATIONS | |
|
The review did not report the cost-effectiveness of interventions. Two studies incorporated direct and indirect costs as outcomes, but no data were reported in the review. |
Both the effects and the costs of the interventions are uncertain. Costing studies should be considered before implementing interventions. |
| MONITORING & EVALUATION | |
| There were no studies or the certainty of the evidence was very low for most interventions and outcomes. |
There is a need for more research in the evaluation of effectiveness of different antibiotic regimens in the treatment of late onset neonatal sepsis taken in count local characteristics of the population and microbiological surveillance. Monitoring of microorganisms responsible for sepsis in different countries and settings is vital for the election of the right antibiotic therapy in specific neonatal populations. Security of different antibiotic regimens most be carefully evaluated given that the therapy is often empiric and many neonates are nor actually infected. |
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
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Olisemeke B, Chen YF, Hemming K, Girling A. The effectiveness of service delivery initiatives at improving patients' waiting times in clinical radiology departments: a systematic review. J Digit Imaging 2014; 27:751-78.
Siciliani L, Borowitz M, Moran V. Waiting Time Policies in the Health Sector: What Works? OECD Health Policy Studies, OECD Publishing, 2013.
Kreindler SA. Policy strategies to reduce waits for elective care: a synthesis of international evidence. Br Med Bull 2010; 95:7–32.
Appleby S, Boyle N, Devlin M, et al. Sustaining reductions in waiting times: identifying successful strategies. Final report to the Department of Health. London: The King’s Fund, 2005.
Cristian Mansilla, EVIPNet Chile, Ministry of Health, Santiago, Chile
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Luciana Ballini, Cristian Herrera, Lama Bou Karroum, and Racha Fadlallah.
Ballini L, Negro A, Malton, S, et al. Interventions to reduce waiting times for elective procedures. The Cochrane Database Syst Rev 2015; (2):CD005610.
Mansilla C. What are the effects of interventions to reduce waiting times for elective procedures? A SUPPORT Summary of a systematic review. April 2017. www.supportsummaries.org
Keywords
evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low and middle-income countries, developing countries, primary health care, elective surgical procedures, time to treatment, waiting lists, queues, waiting times
