October 20, 2021  •  15 min read

Patient backlog exposed and how to clear it.

Providing patients with care in a timely manner has been a long-standing and common challenge in healthcare,1 and the COVID-19 pandemic exacerbated the issue. At the start of the pandemic, cancelling elective (non-urgent) surgeries was among the first orders of business for healthcare providers. Those cancellations caused backlogs of patients whose appointments were pushed to future dates.2

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Purple and pink colored circles in a backlogged cluster, pink circles flow through two gray rectangles.

The importance of clearing patient backlogs.

Backlogs are problematic for many cardiac patients because conditions like heart disease can become worse over time if untreated.3 This can put added pressure on health systems as providers begin to work down backlogs of more severely ill patients. Research published in the Annals of Surgery confirms, “Delays in surgery will have real impacts on patient health outcomes, hospital finances and resources, as well as training and research programs.”4

“The surge after the surge: cardiac surgery post–COVID-19,” study published in May 2020, found the volume of cardiac surgeries dropped to 54% following the March 2020 state of emergency declaration.5 With estimates based on service being restored in July 2020, the study’s authors Salenger et al. calculated it would take up to eight months to clear the backlog if surgery volumes increased to 120% of monthly levels.6 Salenger et al. commented, “Cardiac surgical operating capacity during the COVID-19 recovery period will have a dramatic impact on the time to clear the deferred cases backlog. Inadequate operating capacity may cause substantial delays and increase morbidity and mortality. If only prepandemic capacity is available, the backlog will never clear.”7

As 2020 went on, the fear of contracting COVID-19, combined with healthcare staff shortages8 and drug supply disruption,9 created the perfect storm for patient backlog well beyond surgery. A TIME/Harris Poll found that 78% of Americans put off a least one medical service.10

Then, just as businesses were reopening this year, people were feeling safer and healthcare providers began to address the backlog caused by the pandemic, COVID-19 transmission flared again.11 As of June 2021, more than 100 hospitals were, once again, putting off nonemergency procedures, according to Becker’s Hospital Review.12 It remains to be seen how significantly this new resurgence will increase the existing backlog.

Backlog assessment, patient access evaluation, and waiting list management.

In order to begin resolving backlog, it may be beneficial to have a clear understanding of how backlog can be measured. Then, practices can set measurable goals based on industry standards for appointment availability. The MGMA provides benchmarks for patient access that, when met, often result in greater capacity.13 The organization believes the third next-available appointment (TNA) metric is the best indicator of success.14 TNA is measured in the average number of days between an appointment request with a provider and the appointment date.15 For context, the next-available appointment could be the same day due to a cancellation or no-show. The second-next available appointment could be a result of rearranging schedules to fit someone in. The TNA is seen as a better indicator of regular appointment access because it removes arbitrary events from the appointment-availability measurement.16

The ideal range for the TNA varies based on a medical practice’s area of specialization, according to MGMA.17 The Institute for Healthcare Improvement offers a backlog reduction worksheet18 to help practices calculate the TNA and understand what influences wait times. HealthTeamWorks suggests measuring the TNA consistently on a specific weekday and time.19 And MGMA recommends looking at “trends over time to find out if it is becoming more difficult for new patients” to get appointments.20

TNA is a key performance indicator (KPI) that can influence patient satisfaction.21 According to MGMA, primary care practices should aim for the TNA to be the same day, while specialty care should aim for the TNA to be no more than two days.22 Of course, these are best-case scenarios. Achieving the target TNA will likely take time, especially due to the extreme circumstances of the pandemic. When waiting lists are being used, “practices may want to consider the highest-priority issues and which patients may have potential for adverse outcomes from delays in care,” says MGMA.23

Recommendations to help clear patient backlog.

Backlog is fundamentally a supply and demand problem, there are more patients who need appointments than the number of appointments available.24 Extending hours and/or hiring more physicians are straightforward, traditional ways to increase the number of available appointments. However, today’s circumstances will likely require different mechanisms since healthcare institutions are experiencing staff shortages and providers are already stretched thin.25  The following actions may be applied and considered a foundational start to clearing backlog.

Mitigate no-shows: One major operational improvement to reduce patient backlog is more efficient management of no-shows. These typically untapped openings can begin to level the supply and demand balance. Marbouh et al. provide guidance for mitigating no-shows in their report, “Evaluating the impact of patient no-shows on service quality.” They recommend leveraging automated appointment reminders, which can be provided via phone calls, text messages, and emails.26 Creating a cancellation hotline and adopting no-show fees are other suggestions they recommend for improving attendance.27 Additionally, some healthcare providers offer self-serve appointment management by allowing patients to request and cancel appointments online, which could also lower no-show rates.

Expand access with telehealth: Virtual visits are also helping mitigate no-shows. Drerup et al. estimate the rate of no-shows for telehealth is 7.5% versus 36.1% for in-person appointments.28 These researchers deemed the reduction as “significant” and also noted high patient satisfaction for the virtual interactions.29

Telehealth adoption has accelerated due to COVID-19, CDC recommendations in favor of virtual healthcare, and reimbursement waivers from the Centers for Medicare & Medicaid Service (CMS).30,31 According to Demeke et al., based on 2019 Health Resources and Services Administration (HRSA) data and HRSA Health Center COVID-19 Survey results for July 11-17, 2020, “43% of health centers were capable of providing telemedicine, compared with 95% of the health centers that reported using telehealth during the COVID-19 pandemic.”32,33 They remark, the growth of telehealth “has facilitated care for a range of conditions and improved access for many underserved areas.”34,35

While digital health platforms have the potential to address deep-seated healthcare disparities, inequities must continually be addressed. Mahtta et al. caution, “Special attention should be paid to ensure that telehealth narrows, and not widens, the currently existing disparities in access to healthcare.”36

On the opposite end of the spectrum, a different section of the population expects telehealth to be a standard offering. Research from HIMSS shows that 47% of the millennials surveyed will continue to favor the option, and, within that percentage, nearly half say they would leave clinicians who don’t enable telehealth.37 There has been a change in perception from doctors as well — McKinsey also found that 58% of physicians surveyed think of virtual visits more positively now, and 57% would like to keep offering telehealth.38

In addition, Mahtta et al. confirm that telehealth has a track record “associated with improved healthcare outcomes while remaining a cost-effective mode of healthcare delivery.”39 For example, the researchers cite a 2017 paper from Lin et al. that found complementing in-person visits with telehealth care for heart failure patients resulted in lower rates of all-cause mortality, fewer hospital admissions for heart failure, and shorter hospital stays compared with those who utilized in-person visits alone.40

Standardize protocols to facilitate referrals: The primary evidentiary goals of the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality focus on increasing healthcare safety, making healthcare more equitable and affordable, as well as improving quality and accessibility.41 The agency advocates for a holistic approach to the delivery of primary care as outlined in its patient-centered medical home (PCMH) model.42,43 The scope of the PCMH model is as follows: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety.44 Taking a high-level view of the PCMH model, comprehensive care means multiple providers work as a team to support both the mental and physical health of patients.45 Patient-centered care refers to meeting the specific needs of each patient and including their families among their team.46 Coordinated care helps patients’ access services beyond the core support team.47 Accessible services provide extended hours of in-person access to care and offer telephone or email support that is always available.48 Quality and safety includes using metrics to continually improve the quality of healthcare services.49

The PCMH model helps reduce backlog insofar as the coordinated care component smooths the transition from primary to specialty care.50 The CMS Transforming Clinical Practice Initiative (TCPI) outlines a patient-centered process for coordinated referrals.51 It suggests primary care providers speak with each patient about the reason for the referral, create a “high value referral” that includes relevant information, ensure the specialist receives a clearly defined request, and follow up to see if the patient was seen.52,53 On the specialists end, the TCPI guidelines include a timely review of the referral, appointment scheduling within an appropriate time frame, supplying written recommendations, giving a “high value referral response,” and letting the referring physician know if the patient is not seen.54,55 Patrick Runnels, MD, chief medical officer of population health and behavioral health at University Hospitals, and vice chair of psychiatry at Case Western Reserve University, explains in a press release why care coordination is noteworthy: “Referrals from primary care to specialty care represent a critical pathway in the patient journey to wellness. As we move toward value-based payment models, high-reliability referral pathways will be of increasing importance in achieving better outcomes at lower cost.”56 He was also the lead author of the paper, “Designing for value in specialty referrals: A new framework for eliminating defects and wicked problems.” While the model presented in the paper was specific to psychiatric referrals, it could be expanded to other specialties.57

Backlog reduction success story at New Mexico Heart Institute.

Technology modernization is another way to tackle backlog. New Mexico Heart Institute provides electrophysiology services for a vast geographic area covering nearly the entire state. The number of patients it cares for is large and some have to drive more than five hours to reach the facility. Dr. Yaw Adjei-Poku, device clinic medical director at the New Mexico Heart Institute explains in an iRhythm webinar, the older technology they were using for ambulatory cardiac monitoring created limited capacity. “Patients would come to our clinic, and they would need either a Holter monitor or an event monitor. But unfortunately, we didn't have the inventory to provide that. So patients would oftentimes have to come back to our clinic when the monitor was returned by a prior patient,”58 he says. Prior to the pandemic, the practice had an estimated six-week backlog.

Standardizing on newer, single-patient-use ambulatory cardiac monitoring technology solved their inventory problem — because patients no longer need to wait for a device return. Additionally, the monitors they now use take significantly less time to apply and educate patients on, allowing the practice to provide more patients with monitors each day. Dr. Adjei-Poku notes the impact of the change, “It removed the backlog, and we were able to accommodate walk-ins not only from the electrophysiology providers, but also our cardiac surgery partners and also our general cardiology partners.”59

For many months, due to COVID-19, New Mexico Heart Institute only used a telehealth model to see patients remotely. Doctors were able to continue to care for a high number of patients because the single-use monitors were easy-to-use and could be shipped to patients’ homes for self-application.

Gaining an awareness of their backlog and having the drive to resolve it has enabled New Mexico Heart Institute to go from monitoring an estimated 50 patients per month to over 800 patients per month, without adding any additional staff to their monitoring department. Dr. Adjei-Poku adds, their current monitoring solution allows the practice to “diagnose patients quickly and accurately and ultimately recommend the appropriate treatment.”60

Improve patient access.

The pandemic caused daunting backlogs that warrant a reexamination of patient access. As we’ve covered here, backlog can be addressed through a combination of people, process, and technology. Healthcare providers can take steps to improve patient access by evaluating their backlog, setting measurable goals, and following established guidelines as well as developing and implementing a backlog reduction strategy.

  1. Savin S. Chapter 8: Managing patient appoints in primary care. In: Hall R. Patient flow: reducing delay in healthcare delivery. 2nd ed. Springer; 2013:172-196.
  2. Recalibrate the system by working down the backlog. Institute for Healthcare Improvement. Accessed September 27, 2021. http://www.ihi.org/resources/Pages/Changes/RecalibratetheSystembyWorkingDowntheBacklog.aspx
  3. The untold heartbreak. British Heart Foundation. Accessed September 27, 2021. https://www.bhf.org.uk/what-we-do/policy-and-public-affairs/legacy-of-covid
  4. Fu SJ, George EL, Maggio PM, et al. The consequences of delaying elective surgery: surgical perspective. Ann Surg. 2020;272(2):e79-e80. doi:10.1097/SLA.0000000000003998
  5. Salenger R, Etchill EW, Ad N, et al. The surge after the surge: cardiac surgery post-COVID-19. Ann Thorac Surg. 2020;110(6):2020-2025. doi:10.1016/j.athoracsur.2020.04.018
  6. ibid
  7. ibid
  8. Jacobs A. Nurising is in crisis: staff shortages put patients at risk. The New York Times. August 23, 2021. Accessed September 27, 2021. https://www.nytimes.com/2021/08/21/health/covid-nursing-shortage-delta.html
  9. Choe J, Crane M, Long J, et al. The pandemic and the supply chain. John Hopkins University. November 2020. Accessed on September 2, 2021. https://www.jhsph.edu/research/affiliated-programs/johns-hopkins-drug-access-and-affordability-initiative/publications/Pandemic_Supply_Chain.pdf
  10. Kluger J. You may be surprised by the type of American who Is postponing basic health care during the pandemic. Time. February 23, 2021. Accessed September 27, 2021. https://time.com/5941599/basic-health-care-postponed-covid-19/
  11. Previous COVID-19 Forecasts: Cases. Centers for Disease Control and Prevention. Updated daily. Accessed September 27, 2021. https://www.cdc.gov/coronavirus/2019-ncov/science/forecasting/forecasting-us-cases-previous.html
  12. Paavola A. 106 hospitals postponing elective procedures amid the COVID-19 resurgence. Beckers Hospital Review. Updated June 1, 2021. Accessed September 27, 2021. https://www.beckershospitalreview.com/patient-flow/8-hospitals-postponing-elective-procedures-amid-covid-19-resurgence.html
  13. Benchmarking for Patient Access in a Post-COVID-19 World. Medical Group Management Association. August 12, 2020. Accessed October 13, 2021. https://www.mgma.com/resources/quality-patient-experience/benchmarking-for-patient-access-in-a-post-covid-19
  14. Benchmarking for patient access in a post-COVID-19 world. Medical Group Management Association. August 2020. Accessed September 1, 2021. https://www.mgma.com/MGMA/media/files/pdf/DD-PracticeOps-2020-PatientAccess.pdf?ext=.pdf
  15. Third next available appointment. Institute for Healthcare Improvement. Updated November 2014. Accessed September 27, 2021. http://www.ihi.org/resources/Pages/Measures/ThirdNextAvailableAppointment.aspx
  16. ibid
  17. Benchmarking for patient access in a post-COVID-19 world. Medical Group Management Association. August 2020. Accessed September 1, 2021. https://www.mgma.com/MGMA/media/files/pdf/DD-PracticeOps-2020-PatientAccess.pdf?ext=.pdf
  18. Backlog reduction worksheet. Institute for Healthcare Improvement. Accessed September 27, 2021. http://www.ihi.org/resources/Pages/Tools/BacklogReductionWorksheet.aspx
  19. Third next available appointment: a reference guide. HealthTeamWorks. Updated November 2014. Accessed September 27, 2021. https://h1ccp.com/util/forms/Third_Next_Available_Appt_RG-fillable.pdf
  20. Moore N. Measures medical practices can take to improve patient access. MGMA. September 6, 2018. Accessed September 27, 2021. https://www.mgma.com/data/data-stories/measures-medical-practices-can-take-to-improve-pat
  21. ibid
  22. Hajde A, Good C. New patient appointments an ongoing struggle for practices amid COVID-19. MGMA. July 8, 2020. Accessed September 27, 2021. https://www.mgma.com/data/data-stories/new-patient-appointments-an-ongoing-struggle-for-p
  23. Benchmarking for patient access in a post-COVID-19 world. Medical Group Management Association. August 2020. Accessed September 1, 2021. https://www.mgma.com/MGMA/media/files/pdf/DD-PracticeOps-2020-PatientAccess.pdf?ext=.pdf
  24. Savin S. Chapter 8: Managing patient appoints in primary care. In: Hall R. Patient flow: reducing delay in healthcare delivery. 2nd ed. Springer; 2013:172-196.
  25. Jacobs A. Nurising is in crisis: staff shortages put patients at risk. The New York Times. August 23, 2021. Accessed September 27, 2021. https://www.nytimes.com/2021/08/21/health/covid-nursing-shortage-delta.html
  26. Marbouh D, Khaleel I, Al Shanqiti K, et al. Evaluating the impact of patient no-shows on service quality. Risk Manag Healthc Policy. 2020;13:509-517. doi:10.2147/RMHP.S232114
  27. ibid
  28. Drerup B, Espenschied J, Wiedemer J, et al. Reduced no-show rates and sustained patient satisfaction of telehealth during the COVID-19 pandemic. Published online ahead of print, March 4, 2021. Telemed J E Health. 2021;10.1089/tmj.2021.0002. doi:10.1089/tmj.2021.0002
  29. ibid
  30. Koonin LM, Hoots B, Tsang CA, et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1595–1599. doi:10.15585/mmwr.mm6943a3external icon.
  31. Using telehealth to expand access to essential health services during the COVID-19 pandemic. Centers for Disease Control and Prevention. Updated June 10, 2020. Accessed September 7, 2021. https://www.cdc.gov/coronavirus/2019-ncov/hcp/telehealth.html
  32. Demeke HB, Merali S, Marks S, et al. Trends in use of telehealth among health centers during the COVID-19 pandemic — United States, June 26–November 6, 2020. MMWR Morb Mortal Wkly Rep 2021;70:240–244. doi:10.15585/mmwr.mm7007a3
  33. Demeke HB, Pao LZ, Clark H, et al. Telehealth practice among health centers during the COVID-19 pandemic — United States, July 11–17, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1902–5. doi:10.15585/mmwr.mm6950a4
  34. ibid
  35. Koonin LM, Hoots B, Tsang CA, et al. Trends in the use of telehealth during the emergence of the COVID-19 pandemic — United States, January–March 2020. MMWR Morb Mortal Wkly Rep. 2020;69:1595–1599. doi:10.15585/mmwr.mm6943a3
  36. Mahtta D, Daher M, Lee MT, et al. Promise and perils of telehealth in the current era. Curr Cardiol Rep 23. 2021;23(115). doi:10.1007/s11886-021-01544-w
  37. New data from HIMSS shows rapid digital health adoption necessitates personalized patient technology. HIMSS. June 15, 2021. Accessed September 27, 2021. https://www.himss.org/news/new-data-himss-shows-rapid-digital-health-adoption-necessitates-personalized-patient
  38. Bestsennyy O, Gilbert G, Harris A, et al. Telehealth: a quarter-trillion-dollar post-COVID-19 reality? McKinsey & Company. Updated July 9, 2021. Accessed September 27, 2021. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality
  39. Mahtta D, Daher M, Lee MT, et al. Promise and perils of telehealth in the current era. Curr Cardiol Rep 23. 2021;23(115). https://doi.org/10.1007/s11886-021-01544-w
  40. Lin MH, Yuan WL, Huang TC, et al. Clinical effectiveness of telemedicine for chronic heart failure: a systematic review and meta-analysis. J Investig Med. 2017;65(5):899–911.
  41. About AHRQ. Agency for Healthcare Research and Quality. Reviewed April 2021. Accessed September 27, 2021.
  42. Tools for implementing the PCMH. Agency for Healthcare Research and Quality. Accessed September 27, 2021. https://pcmh.ahrq.gov/page/tools-implementing-pcmh
  43. Defining the PCMH. Agency for Healthcare Research and Quality. Accessed September 27, 2021. https://pcmh.ahrq.gov/page/defining-pcmh
  44. ibid
  45. ibid
  46. ibid
  47. ibid
  48. ibid
  49. ibid
  50. ibid
  51. Managing referrals - providing a patient-centered referral experience. CMS.gov. Accessed September 27, 2021. https://innovation.cms.gov/files/x/tcpi-changepkgmod-referrals.pdf
  52. ibid
  53. Specialty out-patient referral request checklist. American College of Physicians. Accessed September 27, 2021. https://www.acponline.org/system/files/documents/clinical_information/high_value_care/clinician_resources/hvcc_toolkit/hvcc_project/generic-referral-to-subspecialist-practice.pdf
  54. Managing referrals - providing a patient-centered referral experience. CMS.gov. Accessed September 27, 2021. https://innovation.cms.gov/files/x/tcpi-changepkgmod-referrals.pdf
  55. Model specialty out-patient referral response checklist. American College of Physicians. Accessed September 27, 2021. https://www.acponline.org/system/files/documents/clinical_information/high_value_care/clinician_resources/hvcc_toolkit/hvcc_project/generic-referral-to-subspecialist-practice.pdf
  56. UH authors ‘design for value’ to improve patient and physician experience for referrals. University Hospitals Cleveland Medical Center. May 24, 2021. Accessed September 27, 2021. https://www.newswise.com/articles/uh-authors-design-for-value-to-improve-patient-and-physician-experience-for-referrals
  57. Runnels P, Wobbe H, Lee K, et al. Designing for value in specialty referrals: A new framework for eliminating defects and wicked problems. NEJM Catalyst. 2021;2(6). June 2021. doi:10.1056/CAT.21.0062
  58. Adjei-Poku Y. How New Mexico Heart Institute improves cardiac monitoring access and shortens time to treatment. iRhythm. August 11, 2021. Accessed September 27, 2021. https://www.irhythmtech.com/providers/webinars/poku
  59. ibid
  60. ibid

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