Chapter 4. Timeliness
National Healthcare Quality Report, 2008
Timeliness is the health care system's capacity to provide health care quickly after a need is recognized. Timeliness 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.
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 also 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
- 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.10 Early 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 total hospitalization charges.12, 13
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.
- Emergency department visits in which patients left without being seen.
In addition, one noncore measure is presented:
- Time to initiation of thrombolytic therapy for heart attack patients.
Getting Care for Illness or Injury As Soon As Wanted
A patient's primary care provider should be the first point of contact for most illnesses and injuries. A patients' 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 age group, 2000-2005
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2000-2005.
Reference population: Civilian noninstitutionalized population age 18 and over.
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, 2001-2005
Source: Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2001-2005.
Reference population: Civilian noninstitutionalized population under age 18.
- From 2000 to 2005, the percentage of 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 did not significantly change (Figure 4.1). This was true for all age groups.
- In all 6 data years, the percentage of 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 was lower among those ages 45-64 and age 65 and over than among those ages 18-44.
- In 2005, among children who needed care right away for an illness, injury, or condition in the last 12 months, 8.1% sometimes or never got care as soon as wanted (Figure 4.2). This rate did not change significantly between 2001 and 2005.
- In all 5 data years, there was no significant difference on this measure between children under age 6 and children ages 6-17 (data not shown).
Emergency Department Visits in Which Patients Left Without Being Seen
In 2006, the median waiting time for patients to be seen by a physician during an emergency department (ED) visit in the United States was 31 minutes.14 In 2006, an estimated 119.2 million visits were made to hospital EDs (compared with 110.2 million in 2004).14-15 Between 1996 and 2006, the number of hospital EDs decreased from 4,019 to 3,833.14 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.
Figure 4.3. Emergency department (ED) visits in which patients left without being seen, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006
Source: Centers for Disease Control and Prevention, National Center for Health Statistics, National Hospital Ambulatory Medical Care Survey, 1997-1998, 1999-2000, 2001-2002, 2003-2004, and 2005-2006.
Denominator: Visits to EDs of general and short-stay hospitals.
Note: The 1997-1998 data for those age 65 and over are not shown because data did not meet tests for statistical reliability.
- From 1997-1998 to 2005-2006, the overall percentage of ED visits in which the patient left before being seen increased from 1.2% to 2.0% (Figure 4.3).
- In 2005-2006, patients ages 18-44 were more likely than those in other age groups to have an ED visit in which they left without being seen.
- During this period, patients age 65 and over were less likely than those in other age groups to have an ED visit in which they left without being seen.
Time to Initiation of Thrombolytic Therapy for Heart Attack Patients
The capacity to treat hospital patients in a timely fashion is especially important for emergency situations such as heart attacks. For patients suffering from a heart attack, early interventions—such as percutaneous coronary stenting and thrombolytic therapy— may reduce heart muscle damage and save lives.16
Figure 4.4. Median time in minutes from arrival of heart attack patients to initiation of thrombolytic therapy, 2005-2006
Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program, 2005 and 2006.
Denominator: Adult patients meeting all of the following criteria: (1) principal diagnosis of acute myocardial infarction; (2) ST segment elevation or left bundle branch block on the electrocardiogram performed closest to hospital arrival time; and (3) thrombolytic therapy during the hospital stay.
Notes: Beginning in 2005, the data collection method changed from the abstraction of randomly selected medical records for Medicare beneficiaries to the receipt of hospital self-reported data for all payer types.
- Among heart attack patients, the median time from hospital arrival to the initiation of thrombolytic therapy was 39 minutes in 2006. This is an apparent decrease in waiting time from 2005 (Figure 4.4).i
- The median time to the initiation of therapy with thrombolytic agents remains above the national target of 30 minutes set by the American College of Cardiology and the American Heart Association.17
- 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 Academy Press; 2001. p. 53-54.
- 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.
- 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.
- Schellinger PD, Warach S. Therapeutic time window of thrombolytic therapy following stroke. Curr Atheroscler Rep 2004 Jul; 6(4): 288-94.
- Kwan J, Hand P, Sandercock P. Improving the efficiency of delivery of thrombolysis for acute stroke: a systematic review. QJM 2004 May; 97(5):273-79.
- 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.
- Luman ET, Barker LE, Shaw KM, et al. Timeliness of childhood vaccinations in the United States: days under-vaccinated and number of vaccines delayed. JAMA 2005 Mar 9;293(10):1204-11.
- 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):151-56.
- 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.
- 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.
- 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.
- Mellon M, Parasuraman B. Pediatric asthma: improving management to reduce cost of care. J Manag Care Pharm 2004 Mar-Apr; 10(2):130-41.
- Calculated from: Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project. 2003 Kids' Inpatient Database. Available at: http://hcupnet.ahrq.gov/. Accessed October 30, 2007.
- Pitts SR, Niska RW, 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. DHHS Publication No. (PHS) 2008-1250. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr007.pdf.
- McCaig LF, Nawar EW. 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. DHHS Publication No. (PHS) 2006-1250. Available at: http://www.cdc.gov/nchs/data/ad/ad372.pdf.
- 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.
- Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). Circulation 2004 Aug; 110(5):588-636.