A Clinical Improvement Project

Abstract

Introduction. Patients seen at the emergency department (ED) with poor asthma control at a tertiary hospital in Singapore were fast-tracked to the asthma clinic to stabilize and optimize asthma control. However, the default rates at the fast track clinic (FTC) were high since its initiation, hence the need to initiate a quality improvement project to tackle the default rate as well as to reduce patients’ health care utilization and cost. Aim. The aims were to reduce the default rate of referred appointments from the ED to the FTC from the current 50% to less than 10%, to assess the demographic factors associated with patients canceling and defaulting appointments, and to assess short-term health care utilization and costs for patients who were referred to the FTC. Method. Quality improvement project using the clinical practice improvement methodology. Results. The default rates at the FTC were reduced from 50% to less than 10%. There were significant reductions in health care utilization in the 3-month post-FTC scheduled visits (P < .001) in terms of revisits to the ED, readmissions, and cost. Age and ethnicity were found to be significantly associated with cancellations and defaults in the univariate model. The ethnic Malays were 2.4 times (95% confidence interval [CI] = 1.1-5.2) more likely to default when compared with ethnic Chinese (P = .032). In terms of age, the relative risk ratio of default decreased by a factor of 0.96 (95% CI = 0.93-0.99) for every year increase in age (P = .003). Conclusion. The clinical practice improvement project aided in reducing default rates to less than 10%. There were reductions in the number of ED revisits, rehospitalization, and cost for patients who showed up at the FTC as well as for those who defaulted and cancelled appointments. However, it did not indicate that those who showed up at the FTCs were doing better than those who cancelled or defaulted in terms of cost and reduction in health care utilization.