Development of a novel metric of timely care access to primary care services

Abstract

Objective: To develop a model for identifying clinic performance at fulfilling next-day and walk-in requests after adjusting for patient demographics and risk.

Data source: Using Department of Veterans Affairs (VA) administrative data from 160 VA primary care clinics from 2014 to 2017.

Study design: Using a retrospective cohort design, we applied Bayesian hierarchical regression models to predict provision of timely care, with clinic-level random intercept and slope while adjusting for patient demographics and risk status. Timely care was defined as the provision of an appointment within 48 hours of any patient requesting the clinic's next available appointment or walking in to receive care.

Data collection/extraction methods: We extracted 1 841 210 timely care requests from 613 263 patients.

Principal findings: Across 160 primary care clinics, requests for timely care were fulfilled 86 percent of the time (range 83 percent-88 percent). Our model of timely care fit the data well, with a Bayesian R² of .8. Over the four years of observation, we identified 25 clinics (16 percent) that were either struggling or excelling at providing timely care.

Conclusion: Statistical models of timely care allow for identification of clinics in need of improvement after adjusting for patient demographics and risk status. VA primary care clinics fulfilled 86 percent of timely care requests.

Keywords: access/demand/utilization of services; administrative data uses; primary care.

Figure 1

Timely care requests within VA primary care clinics and location of fulfillment. Starting on the left‐hand side of the diagram, all 1 467 566 appointment requests over the study period are mapped by request type to the place where the appointment was fulfilled. Most timely care requests are fulfilled within VA in primary care, followed by other outpatient (eg, Emergency Department, Urgent Care, Medical Specialty Clinics) [Color figure can be viewed at http://www.wileyonlinelibrary.com]

Figure 2

Caterpillar plots of the estimates and 95% credible interval for clinic‐level baseline effects (top) and time effects (bottom). Baseline effects were significantly different from zero in 25 clinics (top panel). Thirteen clinics had a time effect significantly different from zero (bottom panel). Clinics with random effects not significantly different from zero are included and grayed out in both panels

Figure 3

Trends of timely care success in the 33 clinics with significant group‐level effects. These clinics could be targeted by clinical management to determine why they are significantly different from the average, those that may be struggling or excelling at providing timely care. The shaded area represents the mean and 95% credible interval for the predicted rate of timely care success across all 160 clinics. The top panel is a plot of the timely care success rate over time for the 25 clinics with significant baseline variability. The bottom panel is the timely care success rates over time for the 13 clinics with significant random effects for time [Color figure can be viewed at http://www.wileyonlinelibrary.com]