Improving productivity of physicians in outpatient clinics for Inflammatory Bowel Disease by developing clinical pathways

(1)

1

Improving productivity of physicians in

outpatient clinics for Inflammatory Bowel

Disease by developing clinical pathways

A case study in the IBD clinic of the University’s Medical

Center of Groningen

Master thesis

MSc Technology & Operations Management

University of Groningen, Faculty of Economics and Business Author: Martijn Dingenouts

Student number: 1906461

E-mail: martijn-dingenouts@hotmail.com Supervisor: University of Groningen:

dr. ir. D.J. van der Zee

Co-supervisor: University of Groningen: dr. J.A.C. Bokhorst

Supervisor at the University Medical Center Groningen: R.P. Borgers

Abbreviations:

Inflammatory Bowel Disease (IBD),

(2)

2

Abstract

Purpose:

The purpose of this paper is to research a possible solution for the capacity problems that outpatient clinics for Inflammatory Bowel Disease (IBD) face. This will be done by developing clinical pathways for consult timing and consult type for outpatient clinics in order to increase the productivity of the bottleneck resource of the outpatient clinics: the physicians.

Method:

In order to achieve the research objective a design research has been performed at the outpatient clinic for Inflammatory Bowel Disease (IBD) of the University Medical Center of Groningen (UMCG). Interviews, observations, questionnaires have been performed at the outpatient clinic to execute the necessary steps of developing a clinical pathways.

Findings

Three alternative clinical pathways have been developed for a target group of patients: patients in remission. The three alternative clinical pathways corresponding to

stakeholder interests have been developed. The productivity increases that can be achieved will be between 6.33% and 32.85%, depending on which barriers created by stakeholders can be removed.

Conclusions

(3)

3

Preface

This Master Thesis will be my final project for my Master of Science in Technology and Operations Management at the Rijks Universiteit of Groningen (RUG).

Doing research in cooperation with the University Medical Center of Groningen

(UMCG) has been a great experience for me. In particular, I would like to thank the Mr Borgers for bringing me in contact with the medical personnel of the UMCG, and providing valuable insights and information required for my project. Furthermore, I would like to thank the physicians, nurses, and other personnel for their valuable time and input in my project.

I would also like to thank dr. ir. Durk-Jouke van der Zee. Being my supervisor, he has provided me with valuable insights on the structure of my paper, the approach for my research, and other constructive feedback.

Finally I also would like to thank my family and friends for their support in this difficult, but pleasant project.

(6)

6

1. Introduction

Vissers et al. (2001) states that hospitals are faced with a growing demand for care and higher expectations for improved service delivery, but equally with tighter budgets and constraints on the availability of resources. The very rapidly growing number of chronically ill patients is one cause for the increasing demand of care (Bodenheimer et al., 2009). Therefore this paper will focus its research on outpatient clinics for chronically ill patients with Inflammatory Bowel Disease (IBD). The outpatient clinics provide regular care to patients with IBD.

The growing number of patients with IBD and the constraints on resources has resulted in capacity problems for outpatient clinics. A more efficient use of resources could enhance the productivity of outpatient clinics. The number of consults and the length of consults provided to patients determine the use of the most expensive resource of outpatient clinics: the physicians. Hu (2013) has found substantial differences in consult frequency and consult type that physicians provide to patients, which indicates an inefficient use of resources. Therefore this paper investigates the possibility to describe in detail the timing and type of consults provided to patients using clinical pathways, thereby aiming to improve the productivity of physicians.

Some research has been done on the goals and effectiveness of clinical pathways. The aims of clinical pathways can vary between: improving quality of care, reduce risk, increase patient satisfaction, and increasing the efficiency in use of resources (De Bleser et al., 2006). This paper will limit its aim to increasing the efficiency of resource use, more specifically; consult frequency and consult type. When clinical pathways aim to increase efficiency of resource use, they should use clinical guidelines in their

development in order to maintain or improve quality of treatment (Every et al., 2000).

(7)

7 use in outpatient clinics for IBD yet, this suggests a gap in literature. This paper can contribute to literature by researching whether clinical pathways can reduce resource use; more specifically consult frequency and type, in outpatient clinics for IBD. The

outpatient clinic for IBD in the University Medical Center of Groningen (UMCG) also faces capacity problems and will be used as a case example to achieve the research objective:

(8)

8

2. Problem background and research design

This chapter will clarify the problem and structure of this research. Section 2.1 will describe the problem background, then section 2.2 will introduce the objective and research questions of this paper, and finally section 2.3 will describe the research design, including the conceptual model and the research steps.

2.1 Problem background

The growing number of patients with IBD creates difficulties for the outpatient clinics to serve all their patients. The clinics reach their maximum capacity in which the physicians are the bottleneck resources. With the current decision making for consult frequency and type, the outpatient clinics need more physicians to serve all their patients. However, financial pressures require the clinics to first search for possibilities to consult all their patients with current capacity.

Development of clinical pathways will be proposed as a possible solution to the capacity problems of the outpatient clinics. If clinical pathways can reduce the average frequency of consults and length of consults per patient, this would reduce the physician’s average workload per patient and thereby increasing their productivity. Since physicians are the bottleneck resource in the outpatient clinics this will cause the productivity of the outpatient clinics to increase as well.

2.2 Research objective and research questions

The following research objective, as has been mentioned in the introduction is:

Developing clinical pathways for consult timing and consult type for outpatient clinics in order to increase the productivity of physicians.

In order to reach the objective of this research, the following questions should be answered:

(9)

9 2. What consult frequency and consult type has been used by physicians in the

outpatient clinic?

3. Which patients with Inflammatory Bowel Disease are most suitable to be targeted by clinical pathways?

4. How can clinical pathways plan consult timing and consult type most efficiently in order to enhance productivity of physicians?

5. How much could implementing the clinical pathways increase the productivity for physicians?

2.3 Research design

The development of clinical pathways will take place at the outpatient clinic for Inflammatory Bowel Disease (IBD) of the University Medical Center of Groningen (UMCG). The outpatient clinic will function as a case example. The advantage of a case based study is that the research will be conducted in a natural setting (Karlsson, 2009). This leads to a deeper understanding of the disease, organization, consults and variety of patients in outpatient clinics. The research aim is to develop clinical pathways in order to increase the productivity of physicians in outpatient clinics. Therefore this paper can be classified as a design wise research for a practical problem (Wieringa, 2007).

Before the research steps will be described, the definitions and relations between concepts will be briefly introduced and depicted in a conceptual model (Figure 1).

2.3.1 Conceptual model

The clinical pathways in this research aim to plan decisions concerning timing of consults and consult type for patients. So far, decisions for the timing of consults and the consult type have been made by the physician with support of clinical guidelines.

(10)

10 term for all existing guidelines either internationally or nationally that aim to assist

physicians of outpatient clinics in their decision making.

Clinical guidelines do however not explicitly plan the resource use for patients; more specifically consult timing and consult type, thereby leaving the decision to the

physicians themselves. Planning these resources efficiently with clinical pathways could reduce the average frequency and length of the consults per patient, thereby reducing the average workload of the physicians. A reduction in the average workload per patient for physicians will enable them to serve more patients, thereby increasing their productivity and consequently the productivity of the outpatient clinic.

In the development of clinical pathways, the existing clinical guidelines and physician’s expertise should be considered. This will ensure that the quality of care does not suffer (Campbell et al., 1998; Every et al., 2000). Furthermore, the development of clinical pathways will be limited to a targeted patient group, as suggested by (De Bleser et al., 2006; Campbell et al., 1998), which is homogeneous and has the potential to increase the productivity of physicians.

(11)

11

2.3.2 Research steps

Step 1: Literature review: Clinical pathways

The literature search will be conducted in databases such as Google Scholar,

EBCOHOST and PubMed. The literature search will aim to identify relevant theories the content of clinical pathways, the development of clinical pathways, and the

implementation of clinical pathways.

Step 2: System description: Outpatient clinic

In order to give an appropriate system description for the case example, relevant aspects of the outpatient clinic will be identified and described. Information on these aspects will be gathered by means of interviews and observations. The interviews will concern three physicians, a nurse, and the manager of the clinic. The observations will be made during patient consults.

Step 3: Analysis

This chapter will analyze the consults that have been used for patients treated by the different physicians. This will be done by means of a data analysis of the consults that physicians used during 2013. The data has been provided by the outpatient clinic of the UMCG (source: Cognos-Businessview-Contacten). The data analysis will identify the current productivity of physicians and the patients that should be targeted by clinical pathways. Physicians have been used to verify assumptions made during the data analysis.

Step 4: Design: Developing clinical pathways

(12)

12 Step 5: Results: Computing productivity gain

(13)

13

3. Literature review: Clinical pathways

In order to find literature on clinical pathways, the following databases have been used: EBCOHOST, Google Scholar, and PubMed. Search keywords that have been used in these databases include: guidelines, protocol, pathways, clinical pathways, pathways, productivity, resource use, healthcare, and Inflammatory Bowel Disease (IBD). The following questions guided the collection of relevant literature:

- Which contents and aims do clinical pathways have?

- What steps should be taken in order to develop clinical pathways? - Will implemented clinical pathways be followed by physicians?

In order to answer these questions section 3.1 will give a description of clinical pathways and its aims, then section 3.2 will describe steps that can be used in the development of a clinical pathway, finally section 3.3 will discuss the adherence to clinical pathways.

3.1 Clinical pathways

Many alternative terms have been used for clinical pathways, most common terms were care pathway, critical pathway, integrated care pathway and care map (De Bleser et al., 2006; Kinsman et al., 2010). Besides the variety of terms that can be used for this intervention, a uniform definition has not been agreed on in literature either (Kinsman et al., 2010).

Kinsman et al. (2010) has therefore identified 5 criteria, by reviewing (De Bleser et al., 2006., Campbell et al., 1998; Vanhaecht et al., 2006), which have been used to define clinical pathways.

o The intervention is a structured multidisciplinary plan of care. o The intervention is used to translate guidelines or evidence into local

(14)

14 o The intervention details the steps in a course of treatment or care in a plan,

pathway, algorithm, guideline, protocol or other ‘inventory of actions’. o The intervention has timeframe or criteria-based progression.

o The intervention aims to standardize care for a specific clinical problem, procedure or episode of healthcare in a specific population.

Kinsman et al. (2010)

These criteria will all be considered in the development of clinical pathways. Although the aim is to increase the productivity of the physicians, the plan should be

multidisciplinary, and therefore the role of nurses will also be described shortly.

Similarly to the lack of agreement on terms and definitions for clinical pathways, the aims of the clinical pathways in literature vary as well. De Bleser et al. (2006) have found that the possible aims for clinical pathways can be the increase quality of care, reducing risk, increasing patient satisfaction, and a more efficient resource use.

This paper will focus its aim on improving the resource use, i.e. the consult frequency and consult type, which determine the productivity of physicians. The quality of care, risk for patients, and patient’s satisfaction may however not suffer. Pearson et al. (1995), which state that clinical pathways should maintain or improve quality of care. The use of clinical guidelines is essential in the development of clinical pathways to ensure that the quality of care does not suffer (Campbell et al., 1998; Every et al., 2000). Therefore the clinical guidelines created by the Nederlandse Vereniging van Maag-Darm-Leverartsen (2008) assisted by the knowledge of the physicians in the IBD clinic will be used in the development of the clinical pathways.

3.2 Development of clinical pathways

(15)

15 pathway can exclusively be developed for a more homogeneous group of patients (De Bleser et al., 2006). Besides the homogeneity of patients, the potential profit of a clinical pathway should be considered in the selection of a target group (Campbell et al., 1998). Appropriate patients to target with clinical pathways will be selected during the analysis.

Panella et al. (2003) and Campbell et al. (1998) developed the following steps to build clinical pathways (Figure 2). Most of these steps can be useful to develop clinical

pathways in this research. This paper however has a specific aim and area of practice, and therefore the steps of Panella et al. (2003) and Campbell et al. (1998) will be combined to fit our research.

Panella et al. (2003) Campbell et al. (1998)

1. Select the area of practice 1. Select an important area of practice 2. Build the multidisciplinary

work-team

2. Gather support for the project 3. Define the diagnosis 3. Form a multidisciplinary group 4. Define the patients 4. Identify established guidelines 5. Review practice and literature 5. Review practice

6. Develop the clinical path 6. Involve local staff 7. Pilot and implement the clinical

pathway

7. Identify key areas for service development

8. Ongoing evaluation 8. Develop an integrated care pathway

9. Implementation 9. Prepare documentation

10. Educate staff 11. Pilot

12. Regularly analyze variances Figure 2 Source: Panella et al. (2003) and Campbell et al. (1998)

3.3 Adherence to clinical pathways

(16)

16 physicians, which reduces their usefulness. Cabana et al., (1999) developed a model of the causes for lack in adherence to clinical guidelines that have been found in many different healthcare settings (Figure 3).

Figure 3 Source: Cabana et al. (1999)

Seven main causes were identified: - Lack of familiarity, - Lack of awareness, - Lack of agreement with guidelines, - Lack of outcome expectancy, - Lack of self-efficacy, - Lack of motivation/inertia of previous practice and - External barriers. If physicians deviate from clinical guidelines, this might also decrease the usefulness of clinical pathways.

There is however evidence that suggests that an increase in specificity can increases adherence to the clinical guidelines (Richens et al., 2004). Michie and Johnson (2004) found that clinical guidelines often lack the specificity. Clinical pathways can provide the need for specificity by clarifying the implications for resource use, i.e. consult timing and consult type.

(17)

17 should be considered in order for a research design to be effective. The interests of

stakeholders will therefore be considered in the development of clinical pathways for consult timing and consult type.

(18)

18

4. System description: Outpatient clinic

This chapter will describe the current situation of the outpatient clinic, including relevant actors in the care for their patients. Section 4.1 will describe the patients that the

outpatient clinic faces, section 4.2 will describe the physicians in the outpatient clinics whom supply the consults, section 4.3 will describe the roles of the nurses in the provision of consults, and section 4.4 will describe the different types of consults that have been used by physicians for their patients. Information about the roles of nurses, physicians, patients, and the possible consults has been obtained during interviews.

Finally, section 4.5 will describe criteria which influence the decision for consult frequency and consult type. These will be based on clinical guidelines and the expertise of physicians.

The system description can be depicted in to following figure.

Figure 4 System description

4.1 Patient characteristics

Inflammatory Bowel Disease (IBD) is a chronic disease, which requires patients to be monitored and treated continuously during their life. The activity of the disease differs among patients and during the lifetime of the disease. In order to monitor and treat

(19)

19 - New patients: patients that visit the clinic for the first time. They can be either

referred to the clinic by another physicians or they can be hospitalized with complains that appear to be related to IBD.

- Trial patients: patients that are on trial medicine to possibly improve their disease. - Regular patients: patients that have been diagnosed with IBD and are monitored

and treated by the outpatient clinic.

The regular patients can be further divided in groups, which specify the activity of their disease:

- Patients in remission state of the disease: patients that are on medicine for their IBD and do not experience many symptoms.

- Patients in active state of the disease: patients of which the disease is not control, and therefore suffer from several symptoms of the disease.

- Patients in urgent state of the disease: patients that experience symptoms that require immediate attention.

The state of the disease will vary during the lifetime of a patient. So the classification of a patient to a state of the disease is only temporary. Four different curves in Figure 5 show how the

activeness of the disease can vary during the years (Scheffer., 2013).

Figure 5 Source: Scheffer (2013)

4.2 Physicians

(20)

20 consults in the Department of Gastroenterology and Hepatology (DGH). Therefore these two physicians will be excluded. Another physician has been appointed since 2013, and has a disproportionate amount of new patients. The patient mix therefore differs to such an extent that this physician will be excluded as well. The remaining three physicians will be included in this research.

4.3 Nurses

The nurses facilitate the provision of consults by physicians. Both trial and new patients will also visit nurses. Regular patients are exclusively consulted by physicians. Nurses do however perform administrative work for these patients. Furthermore they are available for questions on treatment and medication by patients. Therefore they also assess whether questions by patients require additional consults by physicians.

4.4 Consult types

There are different types of consults that can be used by the outpatient clinic to serve their patients. The different patient characteristic (4.1) determine to a large extent which type of consult is required. The time required for the physicians to consult a patient differs extensively between the types of consults. Therefore the decision for consult type also influences the productivity of the physicians. A description of the three types of consults has been given below.

4.4.1 Physical consults

A physical consult requires a patient to come to the outpatient clinic. There the patient will receive a consult with the planned length of 20 minutes (validated by the physicians). This type of consult is suitable for all patient groups identified in section 4.1.

4.4.2 Telephone consults

(21)

21 When a patient with IBD experiences symptoms which require attention, he or she can call the clinic. A nurse will decide whether his symptoms require attention from a physician. If this is the case, a short term telephone consult with the physician will be planned. These consults will therefore occur when a regular patient’s disease becomes more active or needs urgent attention.

When medical test(s) are performed on the patient a telephone consult can be planned by the physician. The consult will be used to report the results of the medical test(s).

4.4.3 Email consults

Email consults are initiated by the physician. The planned time for an email consult is 5 minutes (validated by the physicians). These consults are used to monitor the activeness of the IBD for patients. In an email consult the blood tests and a questionnaire filled in by the patient will be examined by the physician. These consults are meant for patients in remission.

4.5 Medical decision criteria

The decision concerning time until next consult and choice of consult type is the main interest of this research. The criteria that influence this decision have been identified by investigating the clinical guidelines and interviews with physicians, in line with the conceptual model described in 2.3.1. The precise implications for consult frequency and consult type have however not yet been documented in clinical guidelines and can therefore not yet be described.

4.4.1 Medicine

The medication that a patient uses influences the consult frequency and consult type required for a patient. Patients on medicine require a certain amount of blood tests, which should be checked by a physician. The medicines for IBD can be divided among 4

categories:

(22)

22 - Azathioprine

- Mesalazine - Methotrexate

4.4.2 Disease state

A patient with IBD can be in different disease states, which are distinguished by the activeness of the disease. The level of activity changes during the lifetime of patients. When a patient experiences a more active phase of the disease, a more frequent consult is necessary to treat patients. The three possible states are described in 4.1.

4.4.3 Medical test results

In order to monitor the activity of the IBD, patients are required to do regular medical tests. The most common tests for IBD patients are bloods tests. The results of these and other medical tests might be critical for the required treatment of the patient. Therefore these tests can result in a more frequent consult.

4.4.4 New symptoms

(23)

23

5. Analysis

This chapter will analyze the current consult frequency and consult type that physicians have used to serve their patients, which determines the current productivity of the physicians. Then patients will be selected that are suitable to be targeted by a clinical pathway.

5.1 Current consult frequency and consult type

In order to determine the consult frequency and consult type used by physicians, a data analysis has been performed. Data, including all consults of 2013, has been provided by the IBD clinic of the UMCG (source: Cognos-Businessview-Contacten, 2013). Some assumptions have been made in order to analyze the consult frequency and consult type accurately:

o The data includes three physicians, as has been described in 4.2

o The data exclusively includes regular patients. New patients and trial patients have been excluded for their unequal

distribution among physicians and their limited impact (Figure 6)

o The data analysis will include physical, telephone, and email consults. This could result in differences of the results in comparison to Hu (2013), which has merely included the physical consults to determine consult frequency.

Figure 6

source: Cognos-Businessview-Contacten (2013)

(24)

24

Current situation Patients Total consults Average consult frequency

Physician 1 444 1349 3.0

Physician 2 466 1477 3.2

Physician 3 337 848 2.5

Total 1247 3674 2.9

Table 1 source: Cognos-Businessview-Contacten (2013)

Consult

frequency Patients Email consults Telephone consults Physical consults Total consults

Physician 1 444 53 512 784 1349

Physician 2 466 140 489 848 1477

Physician 3 337 16 234 598 848

The physicians differ in both consult frequency (Table 1) and in consult type (Table 2). Assuming the lengths of consults that have been identified in the system description (5, 7, and 20 minutes), the productivity of the physicians can be computed. The physician’s workload will be expressed in average time (minutes) per patient and the productivity of physicians in average patients per time unit (hours) (Table 3).

Current situation Patients Time email consults Time telephone consults Time physical consults Time total consults Average consult length Average workload per patient Productivity (patients per hour) Physician 1 444 265 3584 15680 19529 14.5 44 1.36 Physician 2 466 700 3423 16960 21083 14.3 45 1.33 Physician 3 337 80 1638 11960 13678 16.1 41 1.48 Total 1247 1045 8645 44600 54290 15.0 43 1.39 Table 3 source: Cognos-Businessview-Contacten (2013)

The average workload per patient differs between the physicians (44, 45, and 41 minutes per patient), assuming a similar patient mix. A similar patient mix has been verified by the physicians and the IBD manager, under the condition that trial and new patients have been removed.

(25)

25 Trial patients and new patients have been removed and all types of consults have been included in the computation of the consult frequency.

5.2 Selecting targeted patients

In order to develop a clinical pathway, a target group of patients will be selected; this has also been suggested by Panella et al. (2003) and Campbell et al. (1998). Clinical

pathways for consult timing and consult type will exclusively be developed for this patient group.

The most important requirement for the development of a clinical pathway is to target a homogeneous group of patients (De Bleser et al., 2006). More specifically, heterogeneous patients require different clinical pathways. Campbell et al. (1998) also advice to

exclusively select patient groups that could significantly contribute to the aim of the clinical pathways, i.e. could potentially increase the productivity of physicians.

In section 4.1 the possible patient groups have been identified. New patients and trial will not be considered as a target group. These groups have yet been removed in section 5.1 on the basis of their distribution between physicians and limited impact. The regular patients will be further divided by the disease state in order to target a homogeneous group of patients.

Patient type Consults Percentage

Trial 57 2% New 111 4% Regular 2328 93% Remission 1123 45% Urgent/active 1205 48% Total 2496 100%

(26)

26 the impact of patients in a certain disease state. Physicians verified that patients consulted twice or less by a combination of email and physical consults were in remission. All other patients were either in an active or urgent state somewhere in that year; these could not be further divided. The estimates could therefore be derived from the UMCG data base (Cognos-Businessview-Contacten, 2013). Using consult frequencies to divide the patients in groups is questionable, since clinical pathways partially aim to plan consult frequency. These estimates can however give a reasonable approximation of the real impact and will therefore be sufficient to assess the impact of patients.

The impact of both groups is similar (Table 4). However between the patients in an active or urgent disease state, there is still a lot of variation in the care that is required for these patients. Therefore patients in remission are the most suitable candidate for clinical pathways. They are homogeneous, have a large impact on capacity, and there are opportunities to increase productivity of physicians for these patients. This has been identified during observations combined with interviews with physicians.

(27)

27

6. Design: developing clinical pathways

This chapter will develop the clinical pathways which aim to increase the productivity of the physicians by reducing the average consult frequency and length. The development of clinical pathways will be executed according to steps that have been derived from Panella et al. (2003) and Campbell et al. (1998). A step suggested by Wieringa (2007) for

research designs in general has been added (Figure 7).

Figure 7 Development steps of clinical pathways for consult frequency and -type

6.1 Select area of practice

An area of practice has been selected at the start of this report. The focus will be on outpatient clinics for patients with Inflammatory Bowel Disease (IBD).

6.2 Gather support

Support for the development of clinical pathways has been gathered at the IBD clinic in the University Medical Center of Groningen (UMCG). The support that has been gathered includes the IBD manager, nurses, physicians, and access to the data base (Cognos-Businessview-Contacten, 2013).

6.3 Define targeted patients

In order to develop a clinical pathway, a target group of patients has been selected. This has been done accordingly to suggestions by Panella et al. (2003) and Campbell et al. (1998). The patients that have been selected are in remission. This means that the disease is not in active state and that these patients do not require additional care by the

(28)

28

6.4 Identify established guidelines

In order to develop clinical pathways for patients in remission, the established guidelines should be identified. The use of clinical guidelines is essential in the development of clinical pathways that focus on resource use, in order to maintain or increase quality of treatment. (Campbell et al., 1998; Every et al., 2000).

The existing guidelines for patients in remission are related to the medicines (4.4.1) and the required number of blood tests for these medicines. The guidelines have been documented per described medicine. Investigating these guidelines per medicine led to the conclusion that nearly all medicines require two blood tests a year:

o ANTI-TNF o Azathioprine o Methotrexate

o And combinations medicines

And that one medicine requires one blood test a year: o Mesalazine

Starting on a new medicine requires more frequent tests, but those patients will not be classified as patients in remission.

Although these guidelines do not describe consult frequency, blood tests are the sole driver of the consult frequency required for patients in remission. The blood tests will be combined with a questionnaire concerning the patient’s health, including questions about weight and stool frequency. The blood samples can be taken at the general practitioner, at a close by hospital or the UMCG. This does not influence the productivity of the

physicians, since they are exclusively required to examine the blood test results. Nurses will be used to take the blood samples, when the blood samples of patient will be drawn at the UMCG.

(29)

29 have been received by the outpatient clinic. The result is that all patients in remission require either 1 or 2 consults a year, depending on the number of blood tests required by their medication. The existing guidelines do however not specify the type of consult that is required for the examination of blood results. Clinical pathways can complement the clinical guidelines by specifying the consult type for patients in remission, i.e. translating clinical guidelines in local structures (Kinsman et al., 2010). This might reduce the average length of consults, thereby increasing the productivity of physicians.

The next step will be to investigate which types of consults should be provided to patients in remission and which types of consults have been provided to patients in remission during the year 2013.

6.5 Review current practice

The review of current practice has been executed in two steps. First the possible consult types that have and could be used for patients in remission have been identified in interviews with physicians. Then an analysis of the consults for patients in remission during 2013 has been performed to identify which number of consults and which consult types have been used for these patients (Source: Cognos-Businessview-Contacten, 2013).

The possible consult types comprise physical, telephone, and email consults. In line with the system description (4.3), telephone consults have not been used by physicians for patients in remission. This leaves both email and physical consults which have been used for patients in remission. Physicians validated that when a patient is in remission, the quality of treatment would not be reduced by the use of email consults. This has been confirmed by the observation that some patients in remission have exclusively consulted by email in 2013.

Shifting the use of physical consults to email consults in a clinical pathway could reduce the average length of consult, which reduces the workload of physicians, thereby

(30)

30 In order to review the consult types that have been used for patients in remission, the active patients and urgent patients should be extracted from the data. In order to select the patients in remission assumptions validated by the physicians have been made:

o The telephone consults have been removed from the data. These consults have not been used as planned consults for patients in remission.

o Patients with a consult frequency (physical and email) higher than two, have been removed from the data. A frequency above two consisting of physical and email consults have exclusively been used for active or urgent patients.

o In order to exclude active patients with a consult frequency of two, merely patients with a time between consults of less than 100 days have been excluded.

Patients with 1 consult _{Patients with 2 consults} Number of patients (physical) 409 Number of patients (physical ) 209 Number of consults (physical) 409 Number of consults (physical) 418 Number of patients (email) 162 Number of patients (email) 58 Number of consults (email) 162 Number of consults (email) 116 Number of patients (combo) Number of patients (combo) 23 Number of consults (combo) Number of consults (combo) 46

Total number of patients 571 Total number of patients 290 Total number of consults 571 Total number of consults 580

The assumptions have resulted in the patients combined with their consults displayed in Table 5. These patients have been consulted once or twice, either by email, physically, or a combination.

(31)

31

6.6 Considering stakeholder interests

The different interests of stakeholders should be considered in a design research

(Wieringa, 2007). Therefore the interests of different stakeholders will be considered as barriers to a shift from physical consults to email consults. Individual and group

interviews are the most effective tools to identify barriers (Baker et al., 2010). The physicians and the IBD manager have been interviewed to identify stakeholders that could be a barrier to more email consults.

6.6.1 Patient’s/physician’s preference

In the interviews physicians mention that some patients prefer to be consulted physically, and that they often satisfy this preference. To what extent they satisfy this preference differs per physician. All the physicians however agreed that the patient preference could be limited to one physical consult per year, but that this rule had not harmonized this within the clinic yet.

6.6.2 Insurance companies

The insurance companies are important stakeholders for the IBD clinic. They have to reimburse the medical costs for IBD patients. Currently insurance companies do not reimburse costs of patients that have not been seen physically in a year. The lack of reimbursement is a barrier for physicians to stop seeing their patients physically. These patients still require expensive medicine, which makes exclusively seeing them by email unaffordable. The insurance companies are therefore currently a barrier to the

(32)

32

6.6.3 Alternative pathways corresponding to stakeholder interests

The interests of the patients, physicians and insurance companies are currently barriers to see patients exclusively by email consults. Which of these barriers can be removed determines to a large extent how much productivity increase the clinical pathways can establish. The barriers will lead to three alternative clinical pathways:

o Alternative 1 (barrier: insurance companies): in this alternative patients all

patients in remission should be consulted once per year physically in order for the insurance company to be reimbursed for these patients

o Alternative 2 (barrier: physician/patient preference): in this alternative all patients will be reimbursed. The patient preference is will however be satisfied up to 1 physical consult per year. The number of patients that will be consulted physically will therefore vary, depending on patient preference.

o Alternative 3 (no barriers): in this alternative all patients will exclusively be consulted by email, since this will not hurt quality of treatment.

6.7 Development of clinical pathways

The previous steps will be input for the development of clinical pathways for patients in remission. Clinical pathways should have timeframe or criteria-based progression (Kinsman et al., 2010). The consults for patients in remission are separated by time-frames of 6 or 12 months, corresponding to the blood tests required per medicine (6.4). The blood tests have to be drawn (possibly by a nurse of the clinic), one month before the consult. A (possible) change in disease state is a criterion for which the next consult can be accelerated.

(33)

33 Three alternatives for patients that require blood tests once a year:

Alternative 1: Patient is in remission and receives medicine which requires bloodtesting once a year Physical consult

1 year 1 year Physical consult 1 year And so forth….

Alternative 2: Patient is in remission and receives medicine which requires bloodtesting once a year Email consult or Physical consult 1 year Email consult or Physical consult

1 year 1 year And so forth….

Alternative 3: Patient is in remission and receives medicine which requires bloodtesting once a year Email consult (examination of blood test) 1 year Email consult (examination of blood test)

1 year 1 year And so forth….

Three alternatives for patients that require blood tests twice a year: Alternative 1: Patient is in remission and receives medicine which requires bloodtesting once

every six months

Email consult (examination of

blood test)

6 months 6 months Physical consult 6 months And so forth….

Alternative 2: Patient is in remission and receives medicine which requires bloodtesting once

every six months

Email consult (examination of blood test) 6 months Email consult or Physical consult

6 months 6 months And so forth….

Alternative 3: Patient is in remission and receives medicine which requires bloodtesting once

every six months

Email consult (examination of blood test) 6 months Email consult (examination of blood test)

(34)

34 Besides the clinical pathways that have been developed for patients that remain in

remission, the clinical pathways should also include scenarios for when a patient’s disease state becomes active or urgent. Two criteria have been identified to detect an increase in activity of the disease:

The blood test that is examined by the physician has negative results. The results need attention and additional treatment. The occurrence of negative results from a blood test has been displayed in the following pathway:

Patient is in remission and receives medicine

which requires bloodtesting once

every six months

blood test)

6/12 months Bloodtest results

are negative Decision concerning time untill next consult and type Patient enters another pathway Telephone consult Patient returns to initial pathway

The patient can experience symptoms either from side effects of the medication or from the disease and call the clinic. A nurse will assess whether the symptoms require attention of a physician, then a telephone consult will be planned. The occurrences of these

symptoms have been displayed in the following pathway:

Patient is in remission and receives medicine

which requires bloodtesting once

every six months

blood test)

6/12 months Patient calls

(35)

35 Both criteria to detect a change in disease state to active or urgent will thus be handled by telephone consults.

6.8 Summarizing the clinical pathways

The implications of the developed clinical pathways for the average consult frequency and length can be summarized by the following rules.

- Patients in remission are consulted every six or twelve months, corresponding to their blood tests required by the medication.

- Consults for patients in remission will comprise email consults or physical consults.

- Patients should exclusively be consulted by email, except when barriers prevent the use of email consults.

- Telephone consults should be used when the IBD becomes active. These can either be initiated by the physician or by the patient.

(36)

36

7. Results: Productivity gains for physicians

The productivity gains of the alternative clinical pathways can be computed by

comparing the dataset for 2013 (Cognos-Businessview-Contacten) with consult timing and consult types used in the clinical pathways. The physical consults that will be replaced by email consults can be derived the table created in section 6.5 (Table 5). The computation will be done for the three alternatives identified in 6.6.

Patients with 1 consult _{Patients with 2 consults} Number of patients (physical) 409 Number of patients (physical ) 209 Number of consults (physical) 409 Number of consults (physical) 418 Number of patients (email) 162 Number of patients (email) 58 Number of consults (email) 162 Number of consults (email) 116 Number of patients (combo) Number of patients (combo) 23 Number of consults (combo) Number of consults (combo) 46

Total number of patients 571 Total number of patients 290 Total number of consults 571 Total number of consults 580

7.1 Computation productivity gain alternative 1 (barrier: insurance companies)

In alternative 1 the patients receive 1 physical consult per year. The productivity gain will be computed by replacing the excess physical consults by email consults, in this

alternative 209 (Table 5). The lengths of a physical consult and an email consult are 20 minutes and 5 minutes, the workload will be reduced by 15 minutes per consult.

(37)

37 Current situation Patients Time email consults Time telephone consults Time physical consults Time total consults Productivity (minutes per patient) Productivity (patients per hour) Physician 1 444 265 3584 15680 19529 44 1.36 Physician 2 466 700 3423 16960 21083 45 1.33 Physician 3 337 80 1638 11960 13678 41 1.48 Total 1247 1045 8645 44600 54290 43 1.39 Table 3 source: Cognos-Businessview-Contacten (2013)

Alternati-ve 1 Patients Time email consults Time telephone consults Time physical consults Time total consults Productivity (minutes per patient) Productivity (patient per hour) Physician 1 444 505 3584 14720 18809 42 1.42 Physician 2 466 1175 3423 15060 19658 42 1.42 Physician 3 337 410 1638 10640 12688 38 1.59 Total 1247 2090 8645 40420 51155 41 1.48 Table 6 source: Cognos-Businessview-Contacten (2013)

The productivity of the physicians increases from 1.39 patients per hour to 1.48 patients per hour. The productivity increase can then be computed by:

The productivity increase can be computed per physician as well:

Physician 1: Physician 2: Physician 3:

7.2 Computation productivity gain alternative 3 (no barriers)

(38)

38 Current situation Patients Time email consults Time telephone consults Time physical consults Time total consults Productivity (minutes per patient) Productivity (patients per hour) Physician 1 444 265 3584 15680 19529 44 1.36 Physician 2 466 700 3423 16960 21083 45 1.33 Physician 3 337 80 1638 11960 13678 41 1.48 Total 1247 1045 8645 44600 54290 43 1.39 Table 3 source: Cognos-Businessview-Contacten (2013)

Alternative 3 Patients Time email consults Time telephone consults Time physical consults Time total consults Productivity in minutes per patient Productivity (patients per hour) Physician 1 444 1585 3584 10400 15569 35.1 1.71 Physician 2 466 2235 3423 10820 16478 35.4 1.70 Physician 3 337 1475 1638 6380 9493 28.2 2.13 Total 1247 5295 8645 27600 41540 32.9 1.85

The productivity of the physicians increases from 1.39 patients per hour to 1.85 patients per hour. The productivity increase can then be computed by:

The productivity increase can be computed per physician as well:

Physician 1 Physician 1 Physician 1

7.3 Discussion productivity gain alternative 2 (barrier: physician/patient preference)

(39)

(40)

40

8. Conclusions

Concluding from this paper, clinical pathways can improve the productivity of physicians in outpatient clinics for Inflammatory Bowel Disease. The clinical pathways achieve this by targeting the patients in remission. The physical consults for patients in remission could (partially) be replaced by email consults, which reduces the average length of the consults, thereby reducing the average workload of physicians and increasing their productivity.

The research objective of that this paper aimed to answer was:

Developing clinical pathways for consult timing and consult type for outpatient clinics in order to increase the productivity of physicians.

The research objective has been achieved, how this has been achieved will be discussed by answering the research questions:

How does the outpatient clinic provide care to patients with Inflammatory Bowel Disease?

The patients that require care by the outpatient clinic have different characteristic. The care is provided by physicians with the support of nurses, using consults. These consults differ in type (physical, telephone, and email). The consult frequency that patients require depends on the medicine, state of disease, exacerbations of the disease, and number of medical tests. The precise implications for consult frequency and consult type have however not been agreed on, and can be developed in a clinical pathway.

What consult frequency and consult type has been used by physicians in the outpatient clinic?

(41)

41 the resulting average productivity for physicians is 1.39 patients per hour (Table 1, Table 3).

Which patients with Inflammatory Bowel Disease are most suitable to be targeted by clinical pathways?

The patient group that has been targeted by clinical pathways has been selected by homogeneity and impact. This led to the selection of patients in remission, which can be targeted by similar clinical pathways and have significant impact on the capacity.

How can clinical pathways plan consult timing and consult type most efficiently in order to enhance productivity of physicians?

The timing of consults depends on the medication of patients. Medicines require either one or two blood tests a year, which will be combined with a consult. The types of consults that will be used depend on the interests of stakeholders and the corresponding barriers. Therefore three alternative clinical pathways have been developed:

Alternative 1 (barrier: insurance companies): patients in remission will be consulted by one physical consult and one (possible) email consult.

Alternative 2 (barrier: physician/patient preference): patients in remission will be consulted by one physical consult or email consult, depending on the patient’s and physician’s preference. The other possible consult will be by email.

Alternative 3 (no barriers): patients in remission will be consulted by once or twice by email.

How much could implementing the clinical pathways increase the productivity for physicians?

(42)

42

8.1 Recommendations

The recommendation for the outpatient clinics is to implement one of the developed clinical pathways for patients in remission. This can lead to productivity gains for the physicians, and reduce the capacity problems for outpatient clinics. Which alternative should be implemented depends on the stakeholders and their interests.

Another recommendation is to attempt renegotiate the reimbursements for patients that have been consulted exclusively by email. This would remove a one of the barriers to see more patients by email consults, and therefore increase productivity. Furthermore, it would increase reimbursements for patients that currently exclusively receive email consults. The productivity increase for physicians is mutually beneficial for the clinic and the insurance company. Therefore this barrier is a result of a misalignment between the goals of the outpatient clinic and the insurance companies.

The patient preference is a barrier that evokes an ethical dilemma. The physicians in the outpatient clinic indicated not to be willing to refuse one physical per year to patients. Therefore this barrier should not be removed in order to prevent implementation issues.

8.2 Limitations

In order to narrow the scope of this research some assumptions have been made. These assumptions can lead to limitations of the research results.

In the theoretical framework the adherence to standards in healthcare has been discussed. Clinical pathways can increase the adherence to clinical guidelines by specifying

(43)

43

8.3 Further research

During the development of clinical pathways a misalignment between the goals of the outpatient clinics and the insurance companies has been identified. The alignment of goals between hospitals and insurance companies with respect to other reimbursements could be a very interesting research direction. Improving the alignment of goals between these two stakeholders would be mutual beneficial.

During this research the assessments of the disease state has been identified as one of the possible causes for differences in consult frequency and consult type. These assessments of disease activity are subjective in practice, contrary to the scores that are used in clinical guidelines (Nederlandse Vereniging van Maag-Darm-Leverartsen (2008). Whether the judgments deviate significantly for IBD physicians could be an interesting question for further research.

(44)

44

References

Baker, R., Camosso-Stefinovic, J., Gillies, C. Shaw, E.J., Cheater, F., Flottorp, S., Robertson, N. (2010). Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes (review). The Cochrane Library, 3: 1-63

Bleser de, L., Deptreitere, R., Waele de, K., Vanhaecht. K., Vlayen, J., Sermeus, W. (2006). Defining pathways. Journal of Nursing Management, 14: 553–563

Bodenheimer, T., Chen, E., Bennett, H. D. (2009). Confronting the growing burden of chronic disease: can the U.S. health care workforce do the job? Health affairs (Project Hope), 28 (1): 139-146

Cabana, M.D., Rand, C.S., Powe, N.R., Wu, A.W., Wilson, M.H., Abboud, P.A.C., Rubin, H.R. (1999). Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA, 282:1458-1465

Campbell, H., Hotchkiss, R., Bradshaw, N., Porteous, M. (1998). Integrated care pathways. BMJ (Clinical research ed.), 316 (7125): 133-137

Dy, M.S., Garg, P., Nyberg, D.,Dawson, P.B.,Pronovost, P.J., Morlock, L.,Rubin, H., Wu, A.W. (2005). Critical Pathway Effectiveness: Assessing the Impact of Patient, 40(2): 499-516

Evans-Lacko, S., Jarrett, M., McCrone, P., Thornicroft, G. (2010). Facilitators and barriers to implementing clinical care pathways. BMC Health Services Research, 10 (182): 1-6

(45)

45 Hu, X. 2013. Improving Admission Time for Inflammatory Bowel Disease Outpatient Department through Resource Management. Internal report.

Grol R. (2001), Successes and Failures in the Implementation of Evidence-Based Guidelines for Clinical, Medical care, 39 (8): II46-54.

Karlsson, C. (2009). Researching Operations Management, Routledge, New York

Kinsman, L., Rotter, T., James, E., Snow, P., Willis, J. (2010). What is a clinical

pathway? Development of a definition to inform the debate. BMC Medicine, 8 (31): 1-3

Michie, S., and Johnston, M. (2004). Changing clinical behaviour by making guidelines specific.British Medical Journal, 328(7435): 343-345

Nederlandse Vereniging van Maag-Darm-Leverartsen (2008). Richtlijn diagnostiek en behandeling van inflammatoire darmziekten bij darmziekten bij volwassen, , De uitgave van deze richtlijn is mede tot stand gekomen via sponsoring door de Stichting Initiative on Crohn and Colitis, www.initiativeoncrohnandcolitis.nl

Panella, M., Marchisio, S., Di Stanislao, F (2003). Reducing clinical variations with clinical pathways: do pathways work? International journal for quality in health care : journal of the International Society for Quality in Health Care / ISQua, 15 (6): 509-521

(46)

46 Pearson, S.D., Goulart-Fisher, D., Lee, T.H. (1995). Critical Pathways as a Strategy for Improving Care: Problems and Potential. Annals of Internal Medicine, 123 (12): 941-948

Richens, Y., Rycroft-Malone. J., Morrell. C. (2004). Getting guidelines into practice: a literature review. Nursing Standard. 18 (50): 33-40

Scheffer, R. C. H. (2013) IBD presentation, available at

www.jeroenboschziekenhuis.nl/Website/Patient/presentaties%20Dokter%20op%20Dinsd ag/IBD_do_op_di_2013.pdf.

[Accessed May 27th 2014]

Vanhaecht, K., De Witte, K., Deptreitere, R., Sermeus, W. (2006). Clinical pathway audit tools: a systematic review. Journal of Nursing Management, 14: 529-537

Vissers, J. M. H., Bertrand, J. W. M., and De Vries, G. (2001). A framework for

production control in health care organizations. Production Planning & Control, 12 (6): 591–604.

Wieringa, R. (2007). Writing a report about design research, available at:

(47)

47

Appendices

Appendix 1 – Questionnaires physicians

Questionnaire for physicians

Questionnaire for physicians (overlapping answers have been removed)

- Are there standards for consult frequency and consult type that you use? Which standards do you use? Where have those standards been documented?

- Yes there are standards; these are protocols that regard the patients on new mediciation and the patients that are in remission. Those are national standards. Which can be found on the IBD website.

- There are national protocls (NICC from he initiative on crohn and colitis – the IBD workgroup). They indicate when a patients require blood tests and when they should be seen after the start on new specific medication. We want to organize a meeting on short notice with the phsycians of the IBD clinic to agree on the number of times we want/must to see certain patients.

- Do standards cover most decisions with regard to consult frequency and consult type? Is there room for differences within this standards?

- See the answer above

- There is a lot of room for own interpertation, we must harmonize this on short notice within our team.

(48)

48 - Yes: many reasons a) We do not remember standards b) We do not have capacity,

thus we use telephonic consults to replace physical consults c) Patient does not react on medication.

- Physician preference

- Discussing test results after medical testing

- A change in disease state between two planned visits.

Appendix 2 – Consult frequencies and consult types identified by Hu (2013)

Hu (2013) has found differences in consult frequency and consult type between the three physicians in the IBD clinic. However this data was from 2012 and was not checked for a different patient mix. Therefore data from 2013 was gathered and analyzed.

The results were similar, especially one of the three physicians saw his patients significantly more than the others:

Improving productivity of physicians in outpatient clinics for Inflammatory Bowel Disease by developing clinical pathways