Duration of Consultations in an Outpatient Ophthalmology Unit

A Retrospective Analysis of Potential Influencing Factors

Along with the aging of the population, eye diseases have increased by 15% to 34% in Germany over the last 15 years (1, 2). As the result, the number of patients seeking ophthalmology emergency care has risen. In the absence of sufficient capacity expansion, this causes a longer duration of consultations (including waiting time) in university hospital outpatient departments. To provide adequate care to a large number of patients, process optimization is vital. We therefore assessed the time spent by outpatients in the Department of Ophthalmology at the Medical Center—University of Freiburg and identified potential opportunities for improvement.

Methods

After receiving a positive opinion of the ethics committee (No. 21–1710-retro), an exploratory approach was used to retrieve all timestamps from electronic medical records in an anonymized manner. Timestamps were placed in the patient management system either manually by staff or automatically upon completion of an examination, depending on the ward/examination. Data points from 34 859 patient visits between 1 January 2018 and 31 December 2019 were extracted from selected outpatient clinics (Table 1) and unscheduled visits. Outpatient surgical procedures as well as specialty and private consultations were not included, because they did not use digital timestamps and thus could not be analyzed. Over the study period, a total of 108 200 outpatient clinic visits occurred and 36 491 outpatient surgical procedures were performed.

Table 1

Overview of median time to eye test, time to first physician contact, and median duration of consultations in the outpatient clinics with more than 1000 patient visits during the period studied

The start of the appointment, registration, start and end of all examination steps, and check-out were recorded. Examinations included eye test, tonometry, optical coherence tomography, corneal topography, and perimetry. Other data collected included the number of examinations, the type of outpatient clinic, the day of the week, the time of day, the age and sex of the patients, and the staffing (number of physicians and healthcare professionals) at the time of the visit. Multiple linear regression analysis was used to examine the influence of these latter factors on duration of consultations. For this purpose, estimates were calculated In addition, we determined the median and interquartile range of time between registration and eye test, registration and first physician contact, and the median duration of consultations at the outpatient clinic.

Results

A total of 34 859 patient visits were analyzed (52% female; median patient age, 63 years; interquartile range, 46–76). The median time between registration and eye test was 33 minutes (interquartile range, 20–55), and the median time between registration and first physician contact was 102 minutes (interquartile range, 67–150). The median duration of consultations was 149 minutes (interquartile range, 81–220; details [Table 1]).

Early arrival, morning appointments, a high number of examinations, a high number of patient visits on the day of the visit, utilization of unscheduled consultations, and appointments on Tuesday (compared to Monday) were all associated with a longer duration of consultations (Table 2). Higher medical staffing levels, late afternoon and evening visits, and Thursdays, as well as the outpatient clinics “Descemet Membrane Endothelial Keratoplasty (DMEK),” ”Uveitis,” “Glaucoma,” “Retina,” and “Cornea and Conjunctiva” all resulted in significantly shorter durations. Age and sex had no influence on the duration of consultations.

Table 2

Presentation of a selection of important factors influencing the duration of consultations at the outpatient clinic

Discussion

In our analysis, patients who arrived too early stayed longer at the outpatient clinic. Our findings confirm study results from Saudi-Arabia and the United States (3, 4). For this reason, patients should not be asked to arrive much earlier. Arriving too early prolongs the time when patients are only waiting and no examinations are performed due to the fact that the examination capacities are usually still occupied by the previous patients. In the same way, if examination capacities are limited both in terms of space and number of staff, it seems logical that on days with particularly high numbers of patient visits, the duration of consultations will be longer for the individual patient.

The longer duration on Tuesdays could be related to the fact that many patients with uveitic symptoms are referred unscheduled on this day of the week. These patients require additional time compared to less complex conditions and thus may have led to a longer duration of consultations.

Furthermore, an increased number of examinations also resulted in a long consultation duration. Thus, in the future appointments should be scheduled in such a way that staffing levels are sufficiently high when a large number of examinations is expected, because the more medical staff worked at the time of the appointments, the shorter the duration of consultations was. Thus, staffing levels adjusted to patient load could reduce the duration of consultations. By contrast, limited space and equipment resources translate into a cap on maximum patient capacity. Staffing should be kept dynamically adapted over the course of the day to what is appropriate, taking into account all available resources. The fact that the duration of consultations is shorter after noon, when there are fewer appointments overall, could also be the result of a lower patient load in the presence of with higher staffing levels.

Utilization of unscheduled appointments is associated with a longer duration of consultations compared to scheduled appointments, a finding that can be explained by the less predictable patient flow. In the case of unscheduled appointments, there is rather a risk of not having adequate staff resources available. Unscheduled patients in particular, whose treatment is considered less urgent, may have to wait significantly longer.

Our findings point to numerous opportunities to reduce the duration of consultations. The scheduling of appointments needs to be aligned with the projected duration of consultations. Another approach would be to make a longer duration of consultations more acceptable by providing information about the expected waiting time. (5). In conclusion, staggering of appointments according to the number of examinations and permanent optimization of staffing levels at peak times should be implemented to improve patient flow.

Conflict of interest statement
The authors declare no conflict of interest.

Translated from the original German by Ralf Thoene, MD.

Manuscript received on 22 October 2022, revised version accepted on 6 February 2023

Helena Siegel, Daniel Böhringer, Katrin Wacker, Peter Josef Lopez Niedenhoff, Hans Mittelviefhaus, Thomas Reinhard

Eye Center, Medical Center—University of Freiburg

Faculty of Medicine of the University of Freiburg, Freiburg, Germany
(Siegel, Böhringer, Wacker, Lopez Niedenhoff, Mittelviefhaus, Reinhard),

Cite this as:
Siegel H, Böhringer D, Wacker K, Lopez Niedenhoff PJ, Mittelviefhaus H, Reinhard T: Duration of consultations in an outpatient ophthalmology unit—a retrospective analysis of potential influencing factors. Dtsch Arztebl Int 2023; 120: 481–2. DOI: 10.3238/arztebl.m2023.0037

References

1. Wolfram C, Schuster AK, Elflein HM, et al.: The prevalence of visual impairment in the adult population. Dtsch Arztebl Int 2019; 116: 289–95

2. Schuster AK, Wolfram C, Pfeiffer N, Finger RP: Augenheilkunde 2019—Wo stehen wir? Eine Betrachtung der Versorgungssituation in Deutschland. Ophthalmologe 2019; 116: 829–37

3. Almomani I, AlSarheed A: Enhancing outpatient clinics management software by reducing patients’ waiting time. J Infect Public Health 2016; 9: 734–43

4. Medway AM, de Riese WTW, de Riese CS, Cordero J: Why patients should arrive late: the impact of arrival time on patient satisfaction in an academic clinic. Healthc (Amst) 2016; 4: 188–91

5. Mowen JC, Licata JW, McPhail J: Waiting in the emergency room: how to improve patient satisfaction. J Health Care Mark 1993; 13: 26–33.