title: Increasing access to specialty care: patient discharges from a gastroenterology clinic.
abstract: OBJECTIVE
  Access to specialty care among safety net patients in the United States is inadequate. Discharging appropriate patients to routine primary care follow-up may improve specialty care access. We sought to identify, by consensus, patients who could safely be discharged from a gastroenterology (GI) clinic, and to evaluate the impact of the discharges on GI clinic work flow.
  
  
  METHODS
  Pre- and post intervention.
  
  
  METHODS
  We developed and implemented a modified Delphi process. Gastroenterologists and primary care providers (PCPs) rated their comfort (using 5-point Likert scales) with discharging patients immediately post endoscopy for 24 clinical scenarios, assuming formal recommendations were communicated to the PCP. We examined the impact of implementing these criteria on clinic wait times and on the ratio of new to follow-up visits.
  
  
  RESULTS
  All gastroenterologists (100%; 7 of 7) and 71.0% of PCPs (130 of 183) participated. Consensus was achieved for 13 of the 24 clinical scenarios for which discharge criteria were developed. Post intervention, 403 patients were discharged from the GI clinic, compared with 0 patients in the same 4 calendar months pre-intervention. The ratio of new to follow-up appointments increased from 0.9:1 to 1:1 (P = .05). Median wait time for the third next available appointment at GI clinics decreased from 158 days to 74 days (P = .0001).
  
  
  CONCLUSIONS
  Discharging patients from specialty care back to primary care with consensus standards is one method to improve access to specialty care. Understanding the concerns of all stakeholders is necessary to refine and disseminate this process to other specialties and healthcare systems to ensure timely access to specialty services for all patients.
authors.affiliation: San Francisco General Hospital, 1001 Potrero Ave, Bldg 100, Rm 342, San Francisco, CA 94110. E-mail: Delphine.tuot@ucsf.edu.
authors.forename: Delphine S
authors.initials: DS
authors.lastname: Tuot
authors.forename: Justin L
authors.initials: JL
authors.lastname: Sewell
authors.forename: Lukejohn
authors.initials: L
authors.lastname: Day
authors.forename: Kiren
authors.initials: K
authors.lastname: Leeds
authors.forename: Alice Hm
authors.initials: AH
authors.lastname: Chen
mesh_terms: D003697:Delphi Technique; D016099:Endoscopy, Gastrointestinal / Q000379:methods; D005260:Female; D005762:Gastroenterology / Q000458:organization & administration* / Q000706:statistics & numerical data; D006297:Health Services Accessibility / Q000458:organization & administration; D006801:Humans; D008297:Male; D010351:Patient Discharge / Q000706:statistics & numerical data*; D064876:Safety-net Providers / Q000458:organization & administration / Q000706:statistics & numerical data