An evaluation of a guideline based open access urological investigation service
Background: Outpatient clinics are struggling to deal with increasing workload and demand for services and hence to meet performance indicators and waiting time targets. Outpatient services are trying to achieve effective and efficient health care in overcrowded, busy clinic settings. Open access clinics have been advocated as a way of improving outpatient services. Methods: A cluster randomised trial was undertaken of a guideline based open access urological investigation service for two common conditions - prostatism and microscopic haematuria. The trial used a balanced incomplete block design. The study involved sixty-six (73%) of general practices in the Grampian region of Scotland. Data were collected before and after the intervention on general practitioners’ pre-referral and post-referral management, hospital management, patient outcome and costs. Analysis was by intention-to-treat and multilevel modelling was adopted for analyses conducted at the individual patient level. Findings: General practitioners’ compliance with referral guidelines increased (difference in means 0.5; 95% confidence interval 0.21 to 0.81, P>0.001). Approximately 50% of patients were referred though the new system. There were no changes in the number or casemix of referrals. The intervention reduced waiting time from referral to initial outpatient appointment (ration of means 0.7; 0.55 to 0.89, prostatism patients only) and increased the number of patients who had a management decision reached at initial appointment (odds ratio 5.8; 2.9 to 11.5, P<0.00001, both conditions). Patients were more likely to be discharged within 12 months (odds ratio 1.7; 0.9 to 3.8, P=0.11). Overall the new service was probably cost saving to the NHS. Interpretation: The guideline based open access investigation service streamlined the process of outpatient referral and resulted in a more efficient service with reduced outpatient waiting times.