What’s the harm in waiting? Patient harms in the referral waiting gap

Abstract

Background Patient safety research seeks to improve the delivery of care, and ensure that patients’ risk of injury from healthcare itself is minimised. Referral between primary healthcare, specialist diagnostic agencies (such as community medical laboratories and radiological centres), and hospital based healthcare is common and important in primary care, yet patients have highly variable waiting times before receiving their care. However, there is almost no research exploring what happens to patients while they wait.

Aims This study aims to investigate patient’s waiting periods between referral from their General Practitioner (GP) and receiving specialist healthcare. Specifically, this study aims to determine if patients come to any harm in this waiting gap, and if so, which patients are harmed and what types of harm happen.

Methods I reviewed 5 years (2003-2007) of healthcare records of 201 general practice patient’s notes. Each consultation record was examined to identify the types of referral that were made and to find evidence of harms while the patient was waiting for referred healthcare. A subset of 101 of these patients also had the records reviewed for investigation types and evidence of harm while waiting for investigation. A broad definition of harm was used to capture a greater number of harms. Harms were categorised as related to referral for investigation, referral to medical specialty or referral to other non-medical specialty. Harms were also graded in severity (mild, moderate and severe) and were described under the following: ‘continued symptoms’, ‘delay in subsequent management’, ‘deterioration of condition’, ‘financial cost to patient’, ‘anxiety/mental harm’ or ‘other’. Comparisons were made between patients whose referrals had evidence of harm in the waiting gap with patients who did not. Comparisons included length of waiting gap, age, gender and specialty referred to and used t-tests or non-parametric tests, as appropriate.

Results 5003 Consultation records were reviewed. A referral rate of 0.21 per person per year for medical and non-medical specialties was found, and a referral rate of 1.00 per person per year for investigations was found. 45 of 183 (25.5%) of referrals to medical or non-medical specialties had evidence of harm in the waiting gap, whereas 9 of 105 (1.8%) of referrals for investigation had harm in the waiting gap. Of the 58 total harms, 43 (74.1%) of harms were minor, 12 (20.5%) were moderate and 3 (5.2%) were severe. The largest broad classification of harm was “continued symptoms” with 38 harms (65.5%), followed by “delay in subsequent management” with 14 harms (24.1%) and “deterioration in condition” with 14 harms (24.1%). There were no statistically significant relationships between the age of patient nor sex of patient nor length of waiting time and the incidence of harm in the waiting gap.

Conclusion This is the first study of harm in the referral waiting gap. The findings indicate that harm does happen while patients wait for referred care, and more research is needed to explore these harms. While the relatively small number of patients in this study limits the ability to draw robust implications for changed clinical practice, it is a strong starting point for larger, future research.