Facing high demand for its services, the dermatology department at a major Boston hospital sought to expand patient access by motivating physicians to increase discharge rates and lengthen intervals between appointments, where medically appropriate. The quality improvement intervention opened up nearly 300 appointment slots during the 3-month study.
Discharge rates and follow-up intervals for medical dermatology patients can be increased through targeted feedback.
Actionable data and modest financial incentives can help motivate clinicians to adjust their behavior around scheduling follow-up appointments.
Strategies used in this study may prove useful for practices trying to increase access and contain per-patient costs through quality improvement measures.
More research is needed to establish evidence-based guidelines for follow-up appointments for many diagnoses in dermatology.
Dermatology services continue to be in great demand, resulting in long waits in many areas of the United States. Timely access to appropriate specialists is important because it can meaningfully improve care, outcomes, and patient satisfaction, and is likely to be cost-effective. Given these advantages, access to specialists is a priority in accountable care organizations and central to population health management strategies.
In the absence of major changes in the dermatologic workforce, a powerful lever affecting access is managing the frequency of follow-up visits, which typically comprise 80 to 85% of office visits. Frequency adjustments can be achieved by increasing discharge rates and lengthening intervals between appointments.
Appropriate follow-up intervals have not been established for most diagnoses in medicine, including dermatology, and are typically a matter of habit, rather than evidence-based practice. However, small adjustments in follow-up times, such as extending them by 10%, can open access in a sustainable way and decrease utilization per capita. For a patient presenting with acne, for example, it is typical to recommend an initial follow-up visit in 3 months (four times a year). Shifting to three times a year instead of four does not, intuitively, seem likely to make a clinical difference for most patients, and this adjustment yields 25% more follow-up visits. Moreover, some therapies do not reach peak effectiveness until 6 months, so extending follow-up appointments in these scenarios makes sense.
We set out to determine if discharge rates and follow-up intervals could be increased using a quality improvement initiative.
We conducted a 3-month intervention that offered modest incentive payments to participating dermatologists who increased their discharge rates by 5% or extended their follow-up intervals by 7.5% over their own baseline.
The intervention was implemented at the Massachusetts General Hospital (MGH) Dermatology Associates in medical dermatology, which employs 32 physicians. It was incorporated into the Massachusetts General Physicians Organization Quality Incentive Program, which provides incremental financial incentives to salaried MGH-affiliated physicians who achieve specific quality and safety improvement targets.
Before the pilot, we convened several work groups to evaluate recommended follow-up intervals for commonly seen diagnoses, such as nonmelanoma skin cancer. In most cases, there was little evidence to establish appropriate follow-up intervals. However, in reviewing the literature for some conditions, such as basal cell carcinoma, we concluded that we were seeing certain patients more frequently than needed in follow-up. We presented the results at a faculty meeting to develop buy-in for the pilot.
Twenty-three physicians were eligible based on sufficient clinical activity in medical dermatology, and the following baseline metrics were calculated per physician from March through May 2013:
- Discharge Rate: Percent of arrived appointments where the patient did not subsequently arrive for a future appointment within 15 months.
- Follow-up Interval: Average number of days between an arrived appointment and the next arrived appointment within 15 months.
Initial appointments were ascribed to each physician, and if a patient arrived for an appointment within 15 months, it counted as a follow-up arrived appointment, even if it was with a different physician. During the intervention, which ran July to September 2013, physicians received their baseline information and then biweekly dashboards tracking their weekly and total (cumulative) progress against their individual goal — which was set in relation to their baseline.
Participants received incentive payments if they increased their scheduled discharge rates by 5% or extended their follow-up intervals by 7.5% over the 12-week period, regardless of patient volume or diagnoses. The department set these targets based on the premise that each physician could realistically make adjustments for at least some patients in their panel. Physicians were given the option to either discharge a patient or extend the follow-up visit, where appropriate. An example of a discharge would be a 23-year-old patient who arrived for an initial evaluation of a normal-looking mole, with few risk factors (young, works inside, few moles, etc.). Many patients like this can be seen again in several years, but habit has been to schedule an annual follow-up.
The payment was roughly $800, following the quality incentive program guidelines. However, consistent with experience and data that physicians respond to incentive programs that provide distinct goals but fairly modest financial rewards, our physicians were also motivated to achieve the performance goal. We were not overly concerned about the dermatologists discharging patients too early to influence their results. Our physicians regularly advise patients, on discharge or extended follow-up, to return if an interim problem arises.
Key team members needed to make this project effective included: a physician leader to design the intervention and engage physicians around the vision of the project; a physician champion to lead discussions within the department on the current evidence base; a data scientist to create the algorithms to extract data from the scheduling platform; and a project manager to help with generating timely and frequent reports to individual physicians.
We fit generalized multivariate linear models to determine statistical significance, holding the physician as a random effect for the discharge rates and follow-up intervals between the intervention and baseline. In addition, we used the change in discharge rates to estimate the number of appointment slots freed up as a direct result of the intervention. We could then calculate the expected number of appointment slots that could be opened annually for the entire department.
At the end of the intervention period, 19 of 23 physicians met the goal, either by increasing their discharge rate or follow-up intervals. The department’s overall discharge rate rose during the pilot to 35.6%, up from 32.6% (P<0.0001). The average follow-up week interval rose to 27.4 weeks, up from to 26.1 weeks (P<0.0001). This increase was likely affected by the conversion of some annual follow-up visits into discharges, which shortened the average follow-up time for the remaining patients and so may underestimate the true effect.
The 3% increase in the discharge rate freed up an estimated 287 appointment slots during the 3-month study. For a department with approximately 35,000 arrived follow-up appointments, a similar change could theoretically open up 1,050 appointment slots annually. (A limitation was that some patients might have booked appointments after the observation period, which would lead to a lower actual discharge rate.)
This improvement also has the potential to reduce per-patient costs through a reduction in the overall number of visits.
This study introduces two actionable metrics that can be used to raise awareness among physicians, improve patient access, and decrease the cost of care per patient. Using actionable data and modest incentives embedded in our ongoing quality improvement program, clinicians were able to reduce the number of follow-up visits (by managing discharges), as well as lengthen intervals between appointments, resulting in increased availability for new patients. Because dermatology is a specialty with unmet demand, this intervention is a winning strategy for patient care, patient satisfaction, and population management.
Our study is limited because it was performed in a single department for a 3-month intervention. However, we believe the results are generalizable to other specialties.
Where to Start
To implement this plan, appropriate follow-up intervals must first be established based on health care outcomes. For diagnoses that already have established guidelines, physicians must make adjustments to adhere to these recommended interval lengths, rather than relying on habit. Where none exist, research efforts must be focused on developing evidence-based guidelines for follow-up visits for common chronic diagnoses.