The report is a product of the VA/HSR Evidence Synthesis Program.

Systematic Review: Access Management Improvement

Timely access to care is one of the fundamental characteristics of a healthcare system. Access to primary care is important since primary care providers both diagnosis and treat most common conditions and also act as the entry point to more specialized care. Primary care access management involves the consideration of various interacting system parts and goals, including continuity, team roles, and management structures. This systematic review sought to determine what evidence is available regarding primary care access management strategies that support improved organizational management of access in an organized and accountable healthcare delivery system such as VA.

The West Los Angeles-based VA's Evidence-based Synthesis Program team searched CINAHL (2005 through 9/19/2006) and PubMed (2005 through 3/3/2016) for relevant literature related to group practice management and access or accessibility. After reviewing 979 potentially relevant citations, investigators included 53 publications. Of these, 29 discussed 19 interventions to improve access in primary care using management strategies, 6 described toolkits or tools, and 5 additional articles provided information that is relevant despite not fitting as evidence for one of the Key Questions (i.e., modeling studies or past reports).

Key Questions and Answers
What definitions and measures of intervention success are used, and what evidence supports use of these definitions and measures?

• In studies of management interventions to improve primary care access, the third next available appointment was the most commonly used measure of success (14/19 studies, 74%). The third next available appointment measure is believed to be a more stable measure of access than the first or second available appointment.
• The next most commonly used measure of success was continuity (7 studies), followed by patient satisfaction (3 studies).
• No formal evidence is currently available that links any access measure with clinical outcomes.

What samples or populations of patients are studied, including eligibility criteria? What are the salient characteristics of local and organizational contexts studied?

• Patient populations and contexts have been described at only a basic level. Many sites were academically-affiliated clinics, part of the British system, or in VA, and the patient populations are likely typical of those attending these types of practices.

What are the key features of successful (and unsuccessful) interventions for organizational management of access?

• The most common intervention components were: 1) reducing the backlog of appointments, 2) using fewer appointment types, and 3) producing regular activity report. However, whether or not these are key features of success cannot be determined from the data, nor whether organizational commitment is as, or more important than any particular features.
• Some studies of longer duration (more than one year after implementation) reported more mixed results, with rising wait times and the need for modifications to the access management strategy reported in two large, long-term studies.

Are relevant, tested tools, toolkits, or other detailed material available from successful organizational interventions?

• Six tools or guides were identified for improving primary care access, four from settings linked to implementation studies, one from a VA setting, two from the Institute for Healthcare Improvement (IHI)/Advanced Access group, and one from the National Health Service (England). Two additional online tools came from Canada.

CONCLUSIONS
A key finding of this review is that evidence about primary care access management is essentially limited to the implementation of Advanced/Open Access, with all but three publications coming in a 10-year period of time (2001-2010). Most studies reported dramatic improvements in access over the short-term, but the more mixed results reported in studies of longer duration suggests that gains in access are difficult to sustain.

FUTURE RESEARCH
The most important research gaps include better reporting of intervention components and contexts, longer period of follow-up time, and a systematic examination for other impacts of the primary care access management strategy on system outcomes – other than the third next available appointment. As VA works to develop and field new measures for patient-reported access, understanding how these relate to system outcomes also will be important. If primary care access management strategies other than Advanced/Open Access exist, then they should be subject to hypothesis-testing studies.

Reference
Miake-Lye IM, Mak S, Shanman R, Beroes JM, Shekelle PG. Access Management Improvement: A Systematic Review. VA ESP Project #05-226; 2017.

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This report is a product of VA/HSR&D's Quality Enhancement Research Initiative's (QUERI) Evidence-Based Synthesis Program (ESP), which was established to provide timely and accurate synthesis of targeted healthcare topics of particular importance to VA managers and policymakers – and to disseminate these reports throughout VA.

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