Chapter 4. Timeliness

Timeliness is the health care system's capacity to provide health care quickly after a need is recognized. It is one of the six dimensions of quality the Institute of Medicine established as a priority for improvement in the health care system.¹ Measures of timeliness include time spent waiting in doctors' offices and emergency departments (EDs) and the interval between identifying a need for specific tests and treatments and actually receiving those services.

Importance

Morbidity and Mortality

• Lack of timeliness can result in emotional distress, physical harm, and higher treatment costs for patients.^2,3
• Stroke patients' mortality and long-term disability are largely influenced by the timeliness of therapy.^{4, 5}
• Timely delivery of appropriate care can help reduce mortality and morbidity for chronic conditions, such as kidney disease.⁶
• Timeliness in childhood immunizations helps maximize the protection from vaccine-preventable diseases while minimizing risks to the child and reducing the chance of disease outbreaks.⁷
• Timely antibiotic treatments are associated with improved clinical outcomes.⁸

Cost

• Early care for comorbid conditions has been shown to reduce hospitalization rates and costs for Medicare beneficiaries.⁹
• Some research suggests that, over the course of 30 years, the costs of treating diabetic complications can approach $50,000 per patient.¹⁰Early care for complications in patients with diabetes can reduce overall costs of the disease.¹¹
• Timely outpatient care can reduce admissions for pediatric asthma, which in 2003 accounted for more than $1.25 billion in hospitalization charges.^12,13

Measures

This report focuses on two core report measures related to timeliness of primary, emergency, and hospital care:

• Getting care for illness or injury as soon as wanted.
• ED visits in which patients left without being seen. In addition, one noncore measure is presented:
• Timeliness of cardiac reperfusion for heart attack patients.

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Findings

A patient's primary care provider should be the first point of contact for most illnesses and injuries. A patient's ability to receive timely treatment for illness and injury is a key element in a patient-centered health care system.

Figure 4.1. Adults who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by insurance, 2002-2006

             

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.
Denominator: Civilian noninstitutionalized population age 18 and over.

• From 2002 to 2006, there were no statistically significant changes in the percentages of adults ages 18 to 64 and age 65 and over who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted (Figure 4.1). This was also true for all insurance groups.
• In all years, the percentage of adults ages 18-64 who sometimes or never got care as soon as wanted was higher for those with public insurance or no insurance than for those with private insurance.

Figure 4.2. Children who needed care right away for an illness, injury, or condition in the last 12 months who sometimes or never got care as soon as wanted, by insurance, 2002-2006

Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2002-2006.
Denominator: Civilian noninstitutionalized population under age 18.

• In 2006, among children who needed care right away for an illness, injury, or condition in the last 12 months, 7.1% sometimes or never got care as soon as wanted (Figure 4.2). Between 2002 and 2006, there were no statistically significant changes in this percentage overall or for any insurance group.
• In all data years, children who had public insurance were more likely to sometimes or never get care as soon as wanted than those with private insurance.

Emergency Department Visits in Which Patients Left Without Being Seen

In 2006, an estimated 119.2 million visits were made to hospital EDs compared with 110.2 million visits in 2004.^14,15 The median waiting time for patients to be seen by a physician during an ED visit in the United States was 31 minutes.¹⁴

Not all patients seeking care in an ED need urgent care, and use of EDs for nonurgent care leads to longer waiting times. Although many factors may lead a patient seeking care in a hospital ED to leave without being seen, long waits tend to exacerbate the problem. Note that our measure of leaving an ED without being seen does not distinguish between appropriate and inappropriate use of the ED.

Figure 4.3. Emergency department visits in which patients left without being seen, by insurance, 2000-2007

Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 2000-2007.
Denominator: Visits to EDs of general and short-stay hospitals.

• From 2000-2001 to 2006-2007, the percentage of ED visits in which patients left without being seen did not change significantly overall or for any insurance group (Figure 4.3).
• In all years, patients with Medicaid and patients with no health insurance were more likely to leave without being seen than patients with private health insurance.

Timeliness of Cardiac Reperfusion for Heart Attack Patients

The capacity to treat hospital patients in a timely fashion is especially important for emergency situations, such as heart attacks. Some heart attacks are caused by blood clots. Early actions, such as percutaneous coronary intervention (PCI) or fibrinolytic medication, may open blockages caused by blood clots, reduce heart muscle damage, and save lives.¹⁶ To be effective, these actions need to be performed quickly after the start of a heart attack.

In this report, we introduce two new measures of timeliness of cardiac reperfusion:

• PCI within 90 minutes among appropriate patients.
• Fibrinolytic medication within 30 minutes among appropriate patients.

Figure 4.4. Hospital patients with heart attack who received PCI within 90 minutes or fibrinolytic medication within 30 minutes, 2005-2007

Key: PCI = percutaneous coronary intervention.
Source: Centers for Medicare & Medicaid Services, Medicare Quality Improvement Organization Program, 2005-2007.
Denominator: Patients hospitalized with a principal diagnosis of acute myocardial infarction who were appropriate candidates for PCI or fibrinolytic medication.

• Among heart attack patients, the percentage of patients receiving PCI within 90 minutes improved from 42.1% in 2005 to 71.8% in 2007 (Figure 4.4).
• The percentage of patients receiving fibrinolytic medication within 30 minutes improved from 37.9% to 50.0%.

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References

1. Institute of Medicine Committee on Quality of Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academies Press; 2001.

2. Leddy KM, Kaldenberg DO, Becker BW. Timeliness in ambulatory care treatment. An examination of patient satisfaction and wait times in medical practices and outpatient test and treatment facilities. J Ambul Care Manage 2003 Apr-Jun;26(2):138-49.

3. Boudreau RM, McNally C, Rensing EM, et al. Improving the timeliness of written patient notification of mammography results by mammography centers. Breast J 2004 Jan-Feb;10(1):10-19.

4. Schellinger PD, Warach S. Therapeutic time window of thrombolytic therapy following stroke. Curr Atheroscler Rep 2004 Jul;6(4):288-94.

5. Kwan J, Hand P, Sandercock P. Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review. QJM 2004 May;97(5):273-9.

6. Kinchen KS, Sadler J, Fink N, et al. The timing of specialist evaluation in chronic kidney disease and mortality. Ann Intern Med 2002 Sep 17;137(6):479-86.

7. Luman ET, Barker LE, Shaw KM, et al. Timeliness of childhood vaccinations in the United States: days undervaccinated and number of vaccines delayed. JAMA 2005 Mar 9;293(10):1204-11.

8. Houck PM, Bratzler DW. Administration of first hospital antibiotics for community-acquired pneumonia: does timeliness affect outcomes? Curr Opin Infect Dis 2005 Apr;18(2):151-6.

9. Himelhoch S, Weller WE, Wu AW, et al. Chronic medical illness, depression, and use of acute medical services among Medicare beneficiaries. Med Care 2004 Jun;42(6):512-21.

10. Caro JJ, Ward AJ, O'Brien JA. Lifetime costs of complications resulting from type 2 diabetes in the U.S. Diabetes Care 2002 Mar;25(3):476-81.

11. Ramsey SD, Newton K, Blough D, et al. Patient-level estimates of the cost of complications in diabetes in a managed-care population. Pharmacoeconomics 1999 Sep;16(3):285-95.

12. Mellon M, Parasuraman B. Pediatric asthma: improving management to reduce cost of care. J Manag Care Pharm 2004 Mar-Apr;10(2):130-41.

13. Calculated from Web site: Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project Kids' Inpatient Database. Available at: http://hcupnet.ahrq.gov/. Accessed on April 24, 2009.

14. Pitts S, Niska R, Xu J, et al. National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary. National Health Statistics Reports, No. 7. Hyattsville, MD: National Center for Health Statistics; 2008. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf [Plugin Software Help]. Accessed on July 7, 2009.

15. McCaig L, Nawar E. National Hospital Ambulatory Medical Care Survey: 2004 emergency department summary. Advance Data From Vital and Health Statistics, No 372. Hyattsville, MD: National Center for Health Statistics; 2006. Available at: http://www.cdc.gov/nchs/data/ad/ad372.pdf [Plugin Software Help]. Accessed on November 5, 2008.

16. Kloner RA, Rezkalla SH. Cardiac protection during acute myocardial infarction: where do we stand in 2004? J Am Coll Cardiol 2004 Jul 21;44(2):276-86.

 

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