Panel Size, Clinician Time in Clinic, and Access to Appointments

We thank Margolius et al for their recent article, "Panel Size, Clinician Time in Clinic and Access to Appointments"[1]. Their analysis was very much in line with what our instincts would tell us: less time in clinic, or a higher panel relative to time in clinic, would result in longer wait times for patients to book appointments. These findings highlight the importance of adopting strategies specifically for part-time providers, such as sharing the care with other team members to improve access[2].

We hypothesized something similar. For the last few years, our primary care organization has made concerted efforts to measure and improve timely access to booked physician appointments[3]. We are an academic, interprofessional practice with six clinics spread in the downtown core of Toronto, Canada. Many of our physicians are in clinic part-time due because of academic responsibilities including teaching, administration, and research. We measure third next available appointment (TNAA) biweekly for our 77 physicians and feed the data back to physicians in real-time. In an effort to understand drivers of variation in physician TNAA, we analyzed the correlation between TNAA and three factors: i) panel size, ii) a clinician's full-time equivalent (FTE) and iii) the panel size to FTE ratio. We included data for 67 physicians who had complete data for 2017, an established roster, and who were not on extended leave during that period. We determined panel size by the number of patients formally rostered to the physician. Clinician's FTE was the number of weekly half-day sessions, the same definition used as Margolius and colleagues. We performed bivariate analysis using Spearman correlation. We did not look at number of physicians in clinic as we did not hypothesize that factor would correlate to TNAA.

Our results surprised us and were different than those found by Margolius and colleagues.

We found there was no significant correlation between TNAA and any of i) panel size (Spearman correlation coefficient=0.04, 95% CI -0.20 to 0.28), ii) FTE (Spearman correlation coefficient=-0.03, 95% CI -0.27 to 0.22), and iii) panel size to FTE ratio (Spearman correlation coefficient=0.10, 95% CI -0.14 to 0.34)

Our findings suggest reducing panel size or increasing time in clinic will not necessarily improve access. There are likely many other factors at play including elements of practice style that are difficult to measure. Our findings together with those of Margolius and colleagues illuminate the complexity of improving access to booked appointments in primary care.

Mary Beth Derocher, Mo Alhaj, Tara Kiran

References:
1. Margolius D, Gunzler D, et al. Panel size, Clinician Time in Clinic, and Access to Appointments. Ann Fam Med. 2018; 16(6):546-548
2. Bodenheimer T, Haq C, Lehmann W. Continuity and Access in the Era of Part-Time Practice. Ann Fam Med. 2018; 16(4):359-360
3. Kiran T, Ramji N, DeRocher MB, et al. Ten Tip for advancing a culture of improvement in primary care. BMJ Qual Saf. Published Online First: 31 October 2018. Doi:10.1136/bmjqs-2018-008451

Competing interests: None declared