Cluster randomized trial of a guideline-based open access urological investigation service
Thomas RE., Grimshaw JM., Mollison J., McClinton S., McIntosh E., Deans H., Repper J.
Background. Out-patient services are trying to achieve effective and efficient health care in overcrowded, busy clinic settings. 'One stop' and 'open access' clinics have been advocated as a way of improving out-patient services. Objectives. Our aim was to evaluate the effectiveness and efficiency of a guideline-based open access urological investigation service. Methods. General practices were randomized to receive either referral guidelines and access to the investigation service for lower urinary tract symptoms (LUTS) or referral guidelines and access to the investigation service for microscopic haematuria (MH). The study population comprised 66 general practices in the Grampian region of Scotland referring 959 patients. The outcome measures were compliance with guidelines (number of recommended investigations completed), number of general practice consultations, the number and case mix of referrals, waiting time to initial hospital appointment, and the number of patients with a management decision reached at initial appointment and discharged by 12 months after referral. Results. GPs' compliance with referral guidelines increased (difference in means 0.5; 95% confidence interval 0.2-0.8, P < 0.001). Approximately 50% of eligible patients were referred through the new system. The number and case mix of referrals were similar. The intervention reduced the waiting time from referral to initial out-patient appointment (ratio of means 0.7; 0.5-0.9, patients with LUTS only) and increased the number of patients who had a management decision reached at initial appointment (odds ratio 5.8; 2.9-11.5, P < 0.00001, both conditions). Patients were more likely to be discharged within 12 months (odds ratio 1.7; 0.9-3.3, P = 0. 11). There were no significant changes detected in patient outcomes. Overall the new service was probably cost saving to the NHS. Conclusions. The guideline-based open access investigation service streamlined the process of out-patient referral, resulting in a more efficient service with reduced out-patient waiting times, fewer out-patient and investigation appointments and release of specialist and clinic time.