Practice Characteristics of Pediatric Otolaryngology Same-Day Appointments

Abstract

Objectives

This study aims to assess characteristics of same-day clinic appointments in a pediatric population at an academic otolaryngology practice.

Methods

Retrospective chart review of patients aged 18 or younger who had same-day clinic appointments between January 1, 2016, and December 31, 2018, at a single academic institution. Demographic data, diagnosis(es), procedures, and operations completed were included in the analysis.

Results

There were 363 same-day visits by 322 patients in the 3-year study period. Two hundred sixty-nine (269) of these visits were from new patients. Otitis media and rhinosinusitis were the most frequently coded diagnoses. One hundred forty-four (144) procedures were completed the day of the visit and 169 operations were performed as a result of the same-day visit. If the patient had a procedure or operation performed, they were more likely to have been referred by another provider.

Conclusions

Providing same-day appointments can help provide timely and appropriate otolaryngology specialty care to pediatric patients. Further evaluation is needed to determine the effects on patient satisfaction as well as no-show rates.

Introduction

In the US general population, there are 9.1 visits per 100 persons per year to otolaryngologists. ¹ Of these visits, 15.6% of otolaryngology visits in 2015-2016 were for patients less than 15 years of age, and 7.4% were in patients aged 15-24. ¹ Access to otolaryngologyhead and neck specialty care can be difficult due to the estimated otolaryngology physician workforce shortage by 2025.^2,3 Same-day scheduling may be an option to improve patient access to otolaryngology care. Same-day appointment options may benefit the pediatric population as there is increased no-show rate of pediatric appointments scheduled more than 7 days from the initial contact. ⁴ It can also benefit a pediatric practice by providing potential procedures or operations. Characteristics of adult same-day visits have been assessed for common diagnoses along with resulting procedures and surgeries; however, this has not been completed for a pediatric population. ⁵ The goal of this study is to assess characteristics of same-day pediatric visits in an otolaryngology department at an academic institution.

Methods

The University of Nebraska Medical Center Institutional Review Board approved this study. A retrospective chart review of patients seen as a same-day appointment by any otolaryngologist or otolaryngology physician assistant in the Department of Otolaryngology-Head and Neck Surgery between January 1, 2016, and December 31, 2018, were included in this study. Same-day appointments were scheduled within the Epic^TM template as such; these appointments became available for scheduling 24 hours prior to the appointment. Charts of patients aged 19 years and older were excluded from review. The final dataset consisted of diagnosis by ICD-10 code(s), procedures performed on the day of the visit or as a result of the visit, operations performed as a result of the visit, and referring provider information. Procedures were defined by Current Procedural Terminology (CPT) codes in addition to the Evaluation and Management (E&M) code that were completed without necessitating general anesthesia. Operations were defined by CPT codes that required general anesthesia. Diagnoses were categorized into their respective groups and infrequent diagnoses not better characterized into one of the aforementioned groups were included within the “other” category (Tables 1a and 1b). Procedures and operations are categorized in Tables 2 and 3. The time period between date of visit and operation were recorded in days. Descriptive statistics including frequency, percentage and means, and data analysis were completed within Microsoft Excel.

Table 1a.

ICD-10 Diagnoses Sorted by Category.

Otitis Media/Externa	Other Ear Disorders	Rhinosinusitis/Nasal Obstruction	Trauma/Foreign Body
Acute otitis media Chronic otitis media Acute otitis externa Chronic otitis externa Otitis media (Serous, secretory, mucoid, suppurative)	Cerumen impaction Obstructed PE tube Hearing loss Cholesteatoma Tympanic membrane perforation Otalgia Otorrhea Eustachian tube dysfunction (uni/bilateral)	Viral upper respiratory illness Septal deviation Nasal obstruction/congestion Chronic sinusitis (with or without polyps) Adenoid hypertrophy Acute sinusitis Pott’s puffy tumor Allergic rhinitis	Nasal fracture Nasal contusion Ear canal trauma Orbital fracture Zygomatic fracture Foreign body nose/ear

Table 1b.

ICD-10 Diagnoses Sorted by Category (continued).

Head and Neck Mass	Laryngeal Disease	Tonsillopharyngitis	Obstructive Sleep Apnea	Other
Tongue lesion	Laryngomalacia	Peritonsillar	Sleep-disordered breathing	Post-surgical follow-up
Mucocele/Ranula	Tracheal	Abscess	Obstructive	Dizziness/Vertigo
Thyroid nodule	Stenosis	Acute Tonsillitis	Sleep Apnea	Headache
Neck swelling	Tracheal	Recurrent tonsillitis	Tonsillar hypertrophy	Epistaxis
Dermoid cyst	Anomaly	Tonsil Stones	Mouth
Lymphadenopathy	Vocal Cord		breathing
Cervical adenit	Paresis		Snoring
Neck infection	Laryngopharyngeal reflux
	Cough/Dyspnea

Table 2.

Procedures Performed Sorted by Category. FB, foreign body; EAC, external auditory canal; I&D, incision and drainage.

Audiology	Control of Epistaxis	Removal of Foreign Body	Cerumen Removal	Endoscopy	Other
Audiogram	Chemical	FB nose	Cerumen removal	Nasal endoscopy	Ankyloglossia release
	Cautery	FB ears	EAC debridement	Flexible laryngoscopy	Ultrasound I&D
Tympanometry	Electrocautery	Attempted removal of FB

Results

Within the 3-year study period, there were a total of 363 visits by 322 patients (Table 4). These visits were conducted by 5 physicians and 4 physician assistants. Two hundred ninety-four (91.3%) patients completed one same-day appointment, 19 (5.9%) completed two same-day appointments, 7 (2.2%) patients had 3 same-day visits, and only 2 (.6%) patients had 4-6 same-day visits. Two hundred sixty-nine (83.5%) visits were new patients. Ninety-four (29.2%) visits were for established patients, 31 (9.6%) of which were for post-surgical follow-up. Patients referred from other medical providers including primary care (family medicine or pediatrics) (149), emergency department or urgent care (32), and otolaryngology (9) for a total of 202 (69%) patient referrals. Audiology referred 4 patients (1.2%), 2 (.6%) patients were referred by hematology/oncology and 1 (.3%) patient was referred each by neurosurgery, neurology, cardiology, ophthalmology, endocrinology, and transplant. The month of March had the most same-day visits scheduled (Figure 1).

Table 3.

Operations Performed, Sorted by Category. EUA, exam under anesthesia; FB, foreign body; T&A, tonsillectomy and adenoidectomy; FESS, functional endoscopic sinus surgery; I&D, incision and drainage; ORIF, open reduction internal fixation.

Removal of Foreign body	Ear procedures	T&A	Nasal Procedures	Airway	Neck Operation	Other
EUA FB removal Cerumen removal	Tympanostomy tube removal Myringotomy Tympanoplasty with or without canalplasty	T&A (separate or combined)	Nasal endoscopy FESS Septoplasty Rhinoplasty	Direct laryngoscopy Bronchoscopy Airway dilation with or without use of CO2 laser	Thyroidectomy I&D Lymphatic malformation resection Sistrunk	ORIF Frenectomy

Figure 1.

Distribution of same-day visits per months of the year (2016-2018).

Otitis media and rhinosinusitis were the most common category of primary diagnosis coded during the same-day visit (Table 5). Of all diagnoses coded, sinonasal (sinusitis, rhinitis, nasal obstruction, and epistaxis) and ear complaints (otitis media and externa, hearing loss, cerumen impaction, and Eustachian tube dysfunction) were the most common. Foreign bodies comprised 4% of diagnoses, with ear foreign bodies (20) being more common than nasal foreign bodies (8).

Table 4.

Demographic Data of Patients.

Total Number of Visits	363
New	269
Established	94
Total number of patients	322
Gender
Male	150
Female	172
Age
Average age	8.332298
Range	0-18 years old

Table 5.

Most Common Primary Diagnoses Coded During Same-Day Visits.

Primary Diagnosis	Frequency Coded
Otitis media	62 (18%)
Rhinosinusitis	51 (15%)
Tonsillitis	34 (10%)
Foreign body	24 (7%)
Trauma	23 (7%)
Epistaxis	20 (6%)

Overall, there were 144 procedures completed on 129 patients. Thirty-eight (38%) percent of the same-day visits were directly associated with a procedure. The most common procedure was audiogram (36.2%) followed by nasal endoscopy (20.8%) (Figure 2). There were 19 foreign body removals attempted in the office, 9 (47.4%) of which were successful. There were 167 operations performed in 139 procedures dates on 119 patients (Figure 3). Of these 119 patients, 57% of visits resulted in a surgery within 30 days, and 91.6% of visits resulted in surgery within 60 days. Of the 202 patients that were referred from other providers, 83 patients (41%) had at least one procedure done, and 84 patients (42%) had at least one operation performed. The most common surgery was bilateral myringotomy with tube placement (29.3%), followed by tonsillectomy and adenoidectomy (15%) and foreign body removal (8.4%).

Figure 2.

Number of procedures completed as a result of same-day visit.

Figure 3.

Number of operations completed as a result of same-day visit.

Discussion

Providing a dedicated rapid access or emergency clinic, while shown to be helpful in improving timely patient care, is challenging to manage.^6,7 Reserving a few appointment slots, one in the morning and one in the afternoon that the electronic medical record releases the day prior, that are dedicated to same-day scheduling within 24 hours of the patient calling allows for improved rapid access while reducing the potential for overbooking providers. ⁵ This is the first study which assesses characteristics of otolaryngology same-day appointments for pediatric patients.

Our department was able to see 269 new pediatric patients during same-day visits in a 3-year period. Having same-day appointment scheduling is valuable for pediatric patients as it is often the parent schedule which dictates availability. Providing rapid care can potentially reduce missed school time for the patient and missed workdays for the parent/legal guardian. The vast majority of our patients had only one same-day appointment within a 3-year period and there was only a very small group of people that had between 4-6 same-day appointments. This is likely an indicator that these appointments are being utilized appropriately for same-day care.

The most common months for same-day appointments were February, March, April, and June. The months of February through April having a high rate of same-day appointment usage is consistent with otitis media and rhinosinusitis being the most frequently coded diagnoses.

There is an element of urgent care that was provided to patients for either trauma or foreign bodies. Fifty-four (54) of visits (14.9%) were related to trauma or foreign body, and 4% (29) and 4% (28) of all same-day diagnoses were due to trauma and foreign body, respectively.

The frequency of procedures and operations performed highlights the appropriateness of specialty care that was sought during the same-day appointment. While many patients were able to be medically managed, 39.6% of visits were associated with procedures and 36.9% with operations. Of those visits that resulted in an operation, 91.6% of the surgeries were done within 60 days of the appointment. If the patient needed a procedure or operation performed, it was more likely that they had been referred by another provider. Sixty-four (64%) percent of the patients who had procedures done were referred by another provider, and of the 119 patients that had operations done, 70.5% had a referral from another provider. This may be important for individual practices to consider from a business perspective if they are wishing to incorporate or maintain same-day appointments within their clinical schedules. It may be valuable to consider a scheduling preference from a referring provider or allowing self-referrals.

While the majority of patients were new patients to the practice, 29.2% of same-day scheduling was utilized by established patients and 9.6% by post-op patients. Since this appointment was pre-determined by the template for the providers, this appointment was not necessarily completed by the provider that had seen the patient initially or the surgeon who completed the surgery. This could create a challenge for continuity of care.

This retrospective study does have limitations. The authors categorized the diagnoses, procedures, and operations to summarize the dataset, and in many instances, there were multiple diagnoses coded for a single visit. The primary diagnosis for the visit is subjective to the provider who completed the visit. There is also provider variability amongst clinical assessments and ability or willingness to complete same-day procedures. This study was completed at an academic institution; therefore, implementation in a private practice setting may vary.

Same-day appointment scheduling is a valuable tool in an otolaryngology practice to provide timely care and manage urgent issues. No-show rates in pediatric otolaryngology clinics on average are between 23-33%.^4,8 While this study did not evaluate no-show rates in our clinics, there has been a previously demonstrated decrease in the no-show rates of pediatric otolaryngology clinics when appointments are scheduled between 0-7 days compared with those scheduled greater than 7 days after the call to schedule. ⁴

Further research can be considered on patient satisfaction with same-day appointments and the effect of same-day appointments on no-show clinic appointments.